Fluid Resuscitation In Trauma: What Are The Best Strategies And Fluids?

The repletion of patients' intravascular volume through the use of an intravenous (IV) electrolyte solution was first described by a young Irish physician, William Brooke O'Shaughnessy, in 1831. Immersing himself in the middle of a cholera outbreak in Sutherland, England, O'Shaughnessy observed that large amounts of water, sodium, chloride, and bicarbonate were being lost in these patients' stool. With only brain injury as a larger cause of overall mortality, hemorrhage is the leading cause of preventable trauma death. Rates of mortality in injured patients requiring a massive blood transfusion in the late 1980s were greater than 80%. Prehospital strategies considered standard of care at the time included early intravenous (IV) access with 2 large-bore cannulas and aggressive administration of crystalloid, regardless of patient physiology. Most hemorrhage-related deaths occur in the first 6 h after injury The most common reason given for administering resuscitation fluid was impaired tissue perfusion or low measured cardiac output. The next most common indication, was abnormal vital signs (blood pressure, heart rate, urine output or central venous pressure) in the absence of evidence of impaired tissue perfusion Fluids have classically been categorized as crystalloid or colloid, terms introduced by Thomas Graham (Professor of Chemistry, University College London, 1836-1855) long before intravenous fluids were widely used in clinical practice. The ideal fluids should provide a solution to the various components of the physiopathology of shock. Two strategies were proposed to avoid clot disruption and dilutional coagulopathy: delayed resuscitation strategy where fluid is given after bleeding is controlled and permissive hypotension strategy, where fluid is given to increase in systolic blood pressure without reaching normotension. In penetrating trauma patients with hypotension (prehospital Systolic blood pressure < 90 mmHg), delayed resuscitation shows better survival rates compared to immediate resuscitation THE BALANCED RESUSCITATION STRATEGY Ideally, this process begins in the prehospital setting, continues through early trauma bay/emergency room resuscitation, and is completed in the operating room or the ICU, as needed. To improve outcomes of patients undergoing an abbreviated laparotomy or other procedure because of grossly disturbed physiology. As an adjunct to the care of these critically injured patients, its early implementation focused on delivering higher ratios of plasma and platelets, along with other strategies to prevent "popping the clot." Its 3 basic tenets are permissive hypotension, minimizing the use of crystalloid before surgical control of bleeding, and transfusion of blood products in a ratio approximating whole blood