Page 25 - Journal of Special Operations Medicine - Fall 2014

found to cause increased morbidity (bacteremia, ARDS, authors have disputed the 1985 ATLS teaching (now
and renal failure). 4 discontinued) that the presence of a radial pulse indi-
cates a BP of 80 or higher, 35,36 the larger study of 342
In a swine model of uncontrolled hemorrhage using a trauma patients performed by McManus and colleagues
Grade V liver injury, Riha and colleagues found that found that a radial pulse character described as “weak”
the “no fluid” resuscitation option resulted in the least (mean SBP of 99.9mmHg) by prehospital providers was
postresuscitation bleeding. Other resuscitation fluids 26mmHg lower than a pulse described as “normal”
30
used in this study were LR, Hextend, hypertonic saline (mean SBP of 128.7mmHg). 37
(HTS), and NS. Although not statistically significant, all
animals in each arm of the study (n = 10) survived for Based on the above, for casualties with suspected uncon-
the 120-minute study period except for two animals in trolled hemorrhage and no TBI, the target SBP should be
the no-fluid arm. 30 80 to 90mmHg. If BP monitoring is not available, either
improved level of consciousness or a weakly palpable
In the combat setting, the unwarranted use of large- radial pulse may be used as a surrogate marker for SBP.
volume crystalloid has another negative impact. In the Future advances in prehospital monitoring capabilities
past, combat medical personnel often carried 10 to 20 may enable battlefield trauma care personnel to more
pounds of LR or NS in their combat medical packs. This precisely judge the adequacy of fluid resuscitation using
extra carriage weight has an unquantified but undoubt- such technologies as tissue oxygen saturation or the
38
edly detrimental effect on their combat effectiveness. In cardiovascular reserve index. 39
addition, time was wasted and lives were placed at risk
on the battlefield in order to perform an intervention of
dubious benefit. Resuscitation Volume—TBI
The TCCC Guidelines call for a modified fluid resusci-
Restricted fluid resuscitation is now used in many ci- tation regimen for casualties suffering from both hemor-
vilian trauma systems. 19,31–33 The Eastern Association rhagic shock and TBI. 13,14,40 In these casualties, decreased
for the Surgery of Trauma 2009 Practice Management level of consciousness may result from either the TBI or
Guidelines states that: “There is insufficient data to sug- hemorrhagic shock. Hypotension in the presence of TBI
gest that blunt or penetrating trauma patients benefit is associated with increased mortality.
41
from prehospital fluid resuscitation. In patients with
penetrating injuries and short transport times (less than Because of the need to maintain an adequate cerebral
30 minutes), fluids should be withheld in the prehospi- perfusion pressure, casualties with TBI should be resus-
tal setting in patients who are alert or have a palpable citated to an SBP of 90mmHg or greater even in the
radial pulse. Fluids (in the form of small boluses, ie, presence of possible uncontrolled hemorrhage. If BP
250mL) should be given to return the patient to a coher- monitoring is not available, resuscitate as needed to
ent mental status or palpable radial pulse. In the setting maintain a normal radial pulse, since altered mental sta-
of traumatic brain injury, however, fluids should be ti- tus in these casualties may be due to the TBI. 13,14
trated to maintain SBP greater than 90mm Hg (or MAP
greater than 60mmHg). HTS boluses of 250mL seem
equivalent in efficacy to 1000mL boluses of standard Resuscitation Fluid Volume—
solutions (LR, 0.9% sodium chloride). There is insuf- Controlled Hemorrhage
ficient evidence to show that injured patients with short Kragh et al.’s 2009 study on prehospital tourniquet use
transport times benefit from prehospital blood transfu- found that casualties with tourniquets applied before
sions. Finally, rapid infusion systems and or pressurized the onset of shock had a survival rate of 94%, while
devices (to deliver fluids more rapidly) should not be casualties who had tourniquets applied after shock was
used in the prehospital setting.” 33 already present had a survival rate of 17%. This study
42
did not describe what fluid resuscitation strategy, if any,
Beecher noted during World War II that, even when was used for these casualties.
blood products are being used, there was no need to
raise the SBP above 80mmHg. Strandenes and col- No prospective, randomized trials that focused spe-
22
leagues note that hypotensive resuscitation is the stan- cifically on prehospital fluid resuscitation for trauma
dard in resuscitating casualty from hemorrhagic shock. 34 patients in shock from hemorrhage that had been con-
trolled were found, but there have been animal mod-
For medics on the battlefield who typically do not els that address this question. In a recent study of fluid
have access to BP monitors, improvement in level of resuscitation in a swine model of uncontrolled hemor-
consciousness and the presence of a radial pulse have rhage, the animals were bled 60% of their total blood
been used as surrogate markers for BP. Although some volume—with a femur fracture superimposed on the

Fluid Resuscitation for Hemorrhagic Shock in TCCC 17