Page 37 - Journal of Special Operations Medicine - Fall 2014

also produced good survival rates in a study that used a *HTS is not recommended as a resuscitation fluid, but is
180-minute observation period. 44 recommended to decrease ICP in casualties with severe
TBI who have physical findings suggestive of impending
There is animal evidence showing that fluid resusci- cerebral herniation.
tation with both Hextend and LR causes a dilutional
coagulopathy. Animals resuscitated with Hextend, how- 2. Blood products are becoming increasingly available
ever, exhibited return of base excess and lactate levels in the prehospital setting and are the resuscitation
to prehemorrhage levels by the end of 6 hours. The LR fluids of choice when feasible. The DoD should use
animals did not, indicating better tissue perfusion with whole blood or plasma and RBCs (in a 1:1 ratio)
Hextend resuscitation. 43 as far-forward as feasible, including evacuation plat-
forms and some selected TFC locations. Platelets
Hextend use has been seen in a Joint Trauma Ssystem should also be used should they become available in
performance improvement review to produce survival far-forward settings in the future.
equivalent to the group who did not receive Hextend, 3. Both fresh whole blood and apheresis platelets, as
despite the fact that the casualties in the Hextend group currently collected and screened in deployed medical
were more severely injured. treatment facilities, are not FDA compliant. Non–
FDA-compliant platelets should be used only when
Crystalloids have been shown in animal models to in- FDA-compliant platelets are not available (as is
crease the edema associated with TBI lesions. 134 currently the case in deployed MTFs). Non–FDA-
compliant whole blood should be used only when
Medby states that the lack of clinical evidence showing treatment with FDA-compliant blood components is
benefit from either crystalloids or colloids used in the not producing the desired clinical effect and FDA-
prehospital resuscitation of trauma victims in hemor- compliant whole blood is not available.
rhagic shock necessitates a search for alternative resus- 4. In order to administer blood components safely in
citation fluids. 179) the prehospital combat setting and to optimize the
benefit obtained from their use, a command or the-
NS causes hyperchloremic acidosis and should not be ater-approved protocol that has been coordinated
used for fluid resuscitation in hemorrhagic shock. with the appropriate clinical and blood and bank-
ing facilities should be in place. All medical person-
Although Plasma-Lyte A has not been widely used in nel who will be responsible for administering blood
the US military, it may be as good as or better than LR. products in the prehospital combat setting should
be trained in the approved protocol.
5. Hextend is less desirable than blood components for
Conclusions
fluid resuscitation. When available for point-of- injury
1. The preferred fluids for resuscitation of casualties in care, liquid (never-frozen) or thawed plasma, or recon-
hemorrhagic shock, in descending order of prefer- stituted DP is preferred over both crystalloids and col-
ence, are: loids. The French DP product is currently being used
– Whole blood by selected Special Operations units under a treat-
– 1:1:1 plasma, RBCs, and platelets ment protocol. The DoD should continue its aggres-
– 1:1 plasma and RBCs sive efforts to obtain an FDA-approved DP product
– Reconstituted DP, liquid plasma, or thawed so that the use of DP can expanded to all military
plasma alone or RBCs alone medical personnel who may care for combat casual-
– Hextend ties at or near the point of injury.
– LR or Plasma-Lyte A 6. The DoD and the FDA should move to establish a
Notes: Military Use Panel with a charter to grant military-
*Plasma is strongly preferred over Hextend. specific approval where appropriate for medications
*Plasma-Lyte A can be used with RBC transfusions. not labeled for trauma or other products not yet FDA
*NS is not recommended for hemorrhagic shock, but approved, but which are documented to be safe and
may be indicated for dehydration. effective and are of special interest to the military for
*NS has in the past been used as an adjunct to trans- use in battlefield trauma care.
fusing PRBCs (spun from WB – no additive solution 7. The volume of fluid used in the resuscitation of casu-
– hematocrit [Hct] 60–70), but the RBCs infused now alties in hemorrhagic shock is an important factor in
are RBCs in additive solution (spin – remove PRP – add determining outcomes and the optimal volume may
additive solution – final Hct 55 – much lower viscosity vary based on the type of injuries present.
than true PRBCs). These are the RBCs being transfused 8. Large-volume crystalloid fluid resuscitation for pa-
in theater at present. tients in shock caused by penetrating torso trauma

Fluid Resuscitation for Hemorrhagic Shock in TCCC 29