Page 36 - Journal of Special Operations Medicine - Fall 2014

HTS is currently recommended in the TCCC guidelines to be the reason for the increased survival. Use of pre-
to decrease intracranial pressure in casualties with se- hospital blood products is now in place in some civilian
vere TBI who have physical findings suggestive of im- trauma systems 175,176 and in the Royal Caribbean Cruise
pending cerebral herniation. 171 Line system. 64

Crystalloids—NS Unlike crystalloid, plasma does not cause coagulopa-
“Resuscitation with NS results in hyperchloremic aci- thy (and, in fact, is used to treat coagulopathy). Plasma
dosis. This acidosis may be associated with systemic does not promote cerebral edema and has not been as-
vasodilation, increased extravascular lung water, and sociated with increased mortality, acute kidney injury,
coagulopathy. The traditional indications for using NS or hypoxia, as crystalloid resuscitation has. There is,
to resuscitate trauma patients including traumatic head however, at present no mechanism or authority for
injury, the need to transfuse blood, and renal failure are most conventional medics, corpsmen, or PJs to admin-
not supported by randomized prospective trials. Rapid ister prehospital plasma to their casualties before the
infusion of LR for resuscitation of hemorrhagic shock TACEVAC phase of care. No DP product is currently
results in increased lactate levels that are not associated approved by the FDA.
with acidosis.” 152
There is no evidence for benefit from large volume crys-
NS is not an optimal choice for resuscitation from hem- talloid resuscitation in uncontrolled hemorrhage. There
orrhagic shock because of both hemodilution of clotting is Level B clinical evidence that this approach reduces
factors and the propensity of NS to cause hyperchlo- survival. 6
remic acidosis. 172,173 Aggressive resuscitation with sa-
line-based resuscitation strategies is associated with a There is Level B evidence that restricting fluid resuscita-
number of adverse effects, including increased bleeding, tion volume in patients with uncontrolled hemorrhage
ARDS, multiorgan failure, ACS, and increased mortal- is beneficial. 6
ity. 32,174 In an animal model of uncontrolled hemorrhage
resuscitated with various crystalloids and colloids, NS “Although the use of resuscitation fluids is one of the
produced more acidosis and secondary blood loss than most common interventions in medicine, no currently
the other fluid options and caused the authors to ques- available resuscitation fluid can be considered to be
tion the use of this fluid as a resuscitation choice in hem- ideal.” 177
orrhagic shock. As noted previously, in a large clinical
30
study, patients who received NS had more complica- There is Level B evidence that Hextend used in the vol-
tions, including renal failure, than patients who received ume recommended by TCCC to supplement fluid resus-
Plasma-Lyte A. 158 citation in trauma patients is safe and does not result in
a coagulopathy. 139,178

Prehospital Fluid Resuscitation: There are no definitive clinical trials to answer the ques-
Adding It All Up
tion of how combat medics, corpsmen, and PJs should
As with medications, selecting the right amount of re- resuscitate their casualties in hemorrhagic shock if
suscitation fluid to be administered as well as the right blood and plasma are not available, but Hextend has
fluid is critical to optimizing outcomes. the advantage of providing a prolonged (6- to 8-hour)
intravascular presence in the absence of ongoing hemor-
Fluid resuscitation studies performed in a nontrauma rhage. Crystalloid solutions rapidly redistribute through
patient population are not necessarily relevant to the the entire extravascular space after infusion and so must
resuscitation of trauma patients in hemorrhagic shock. be infused in three times the volumes of Hextend to pro-
vide an equivalent volume expansion for 6 hours. This
43
In uncontrolled hemorrhage, the resuscitation option of continues to be an important factor for combat medical
choice is whole blood or 1:1:1 plasma, RBC units, and personnel who have to carry resuscitation fluids for long
platelets, given at whatever rate is necessary to maintain distances.
tissue perfusion until bleeding can be controlled.
There is animal evidence showing that Hextend achieves
Advanced capability evacuation platforms that admin- 100% survival for 6 hours in a controlled hemorrhage
ister 1:1 plasma and RBC units en route are associated model (60% of estimated blood volume) using a vol-
with a higher survival rate in subsets of severely injured ume-for-volume replacement of shed blood with Hex-
casualties than evacuation platforms that do not have tend. Crystalloid resuscitation also produced 100%
the capability to use blood components for resuscita- survival, but required approximately three times the in-
tion. Blood products have not, however, been proved fused volume of Hextend. Smaller volumes of Hextend
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28 Journal of Special Operations Medicine Volume 14, Edition 3/Fall 2014