Fluid resuscitation in haemorrhagic shock in combat casualties
© The Author(s) 2017
Received: 23 November 2016
Accepted: 11 January 2017
Published: 17 January 2017
This brief update reviews the recent literature available on fluid resuscitation from hemorrhagic shock and considers the applicability of this evidence for use in resuscitation of combat casualties in the combat casualty care (CCC) environment. A number of changes need to be incorporated in the CCC guidelines: (1) dried plasma (DP) is added as an option when other blood components or whole blood are not available; (2) the wording is clarified to emphasize that Hetastarch is a less desirable option than whole blood, blood components, or DP and should be used only when these preferred options are not available; (3) the use of blood products in certain tactical field care settings where this option might be feasible (FSC, GH) is discussed; (4) 1:1:1 damage control resuscitation (DCR) with plasma: packed red blood cells (PRBC): platelets is preferred to 1:1 DCR with plasma: PRBC when platelets are available; and (5) the 30-min wait between increments of resuscitation fluid administered to achieve clinical improvement or target blood pressure has been eliminated. Also included is an order of precedence for resuscitation fluid options. There should be an emphasis on hypotensive resuscitation in order to minimize (1) interference with the body’s hemostatic response and (2) the risk of complications of over resuscitation. Hetastarch is retained as the preferred option over crystalloids when blood products are not available because of its smaller volume and the potential for long evacuations in the military setting.
KeywordsFluid resuscitation Warm fresh whole blood Coagulopathy Damage control resuscitation
A restricted increase in intravascular volume targeting a systolic blood pressure (SBP) up to 90 mmHg (improvement of mental status or a weakly palpable radial pulse as a surrogate marker) so as to minimizes adverse effects of edema and prevent dilutional coagulopathy caused by large volume crystalloid resuscitation, reduce the incidence of a re-bleed due to clot dislodgement (which increasingly occurs over systolic blood pressures of 90 mm Hg) while maintaining perfusion to vital organs
Enhance the body’s ability to form and retain a clot at bleeding sites
Optimize oxygen carrying capacity
This commentary reviews the available fluids used in resuscitation and correct recommendations in vogue in management of combat casualties.
Fluids used in resuscitation
Crystalloids in a ratio of 3:1 (3 ml of crystalloid for every ml of shed blood) are used commonly as the first line of fluid in haemmorghic shock. Crystalloids however, have no role in DCR as short term increase in intravascular volume are negated by risk of pulmonary oedema, displacement of forming clots at sites of vascular injury, abdominal compartment syndrome, acidosis, worsening of cerebral oedema, and dilutional coagulopathy . In fact there is Level B clinical evidence that large volume crystalloid resuscitation reduces survival . If the only available fluid is crystalloid then, ringer lactate is preferred over NS because it does not produce the hyperchloremic acidosis and the concern of lactate in RL causing acidosis is some what unfounded . Plasma-lyte A if available offers some benefit over RL [neutral ph of 7.4, osmolarity of 295 mosm/l and no calcium. RL is more acidic, slightly hypotonic and contains calcium which may cause blood to coagulate if used with packed red blood cells (PRBC) or whole blood]. Hypertonic saline dextran (HSD) and hypertonic saline (HS) improve hemodynamic and metabolic responses, modulate immune function and reduce brain oedema in a number of experimental injury models. However a cochrane study concluded that there is no evidence that hypertonic crystalloids are better than near isotonic crystalloids for fluid resuscitation in trauma .
Colloids [Gelatins, various Hydroxy ethyl starches (HES) and albumin] are more effective than crystalloids for expanding the plasma volume because they contain large, poorly diffusible solute molecules that create an osmotic pressure to keep water in the vascular space with less extravasation of fluid into the lung than RL with a resulting improvement in oxygenation . The smaller volume of colloids required for an equivalent and extended expansion of the intravascular space as compared to crystalloids offers a logistical advantage. However their propensity to cause renal damage is still controversial with some studies reporting no renal damage  while others did . The FIRST trial reported that hydroxyl ethyl starch improves the renal function and lactate clearance when used for resuscitation in patients of penetrating trauma . Additionally high molecular weight HES inhibits platelet function with the exception of Hextend (HES 130/0.75 in balanced electrolyte solution) which has a platelet stimulating effect which may be partially due to its solvent containing calcium chloride dehydrate . There is Level B evidence that Hextend used in two aliquots of 500 ml each to supplement fluid resuscitation in trauma patients is safe and does not result in a coagulopathy [11–13]. However, the FDA issued a safety communication on HESs (Hespan, Hextend, and Voluven) in November 2013. The warning noted an increased risk in mortality and renal replacement therapy associated with the use of these products as used to treat critically ill patients . However this communication did not mention the use of these products in the prehospital resuscitation of trauma patients, nor did it address the known increase in mortality and fluid overload complications resulting from the alternative use of large volume crystalloids in such patients Use of albumin for resuscitation in patients with associated traumatic brain injury (TBI) resulted in increased mortality . This fact precludes its use in combat casualty care as haemorrhagic shock and TBI often co-exist.
Blood and blood products
Guidelines for blood collection and storage in combat areas
Develop a pre-deployment roster of pedigreed donors (screened every 90 days)
ABO and Rh
In emergency situations
Prefer previous and type O donor
Perform onsite ABO typing
Perform direct cross-match if possible
Use approved blood recipient set(contains anticoagulant)
Fill until 650-mL bag is nearly full (approx 450 mL blood)
Draw cross-match and transmissible disease blood tubes
Submit to supporting lab even after use of blood
Keep fresh warm blood no longer than 24 h
If less than 8 h old, may be refrigerated for 3 weeks
1:1:1 plasma, RBCs, and platelets
1:1 plasma and RBCs
Reconstituted DP (not available presently), liquid or thawed plasma, alone or RBCs alone
RL or Plasma-Lyte
Guidelines for fluid resuscitation at various field echleons
Fluid resuscitation at level of Combat Zone
Assess for hemorrhagic shock; altered mental status (in the absence of head injury) and weak or absent peripheral (radial)pulses are the best field indicators of shock
a. If not in shock:
No IV fluids necessary
PO fluids permissible if conscious and can swallow
b. If in shock:
Hextend, 500 mL IV bolus
Repeat once after 30 min if still in shock
No more than 1000 mL of Hextend
c. Continued efforts to resuscitate must be weighed against logistical and tactical considerations and the risk of incurring further casualties
d. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to maintain a palpable radial pulse
Fluid resuscitation at First Aid post
Reassess for hemorrhagic shock (altered mental status in the absence of brain injury and/or change in pulse character.) Maintain target systolic BP 80–90 mmHg
a. If not in shock:
No IV fluids necessary
PO fluids permissible if conscious and can swallow
b. If in shock and blood products are not available:
Resuscitate with Dried Plasma (DP) or if not available
Simultaneously give 1gm of tranaxemic acid in 100 ml saline
Hextend 500 mL IV bolus
Repeat after 30 min if still in shock
Continue resuscitation with Hextend or crystalloid solution as needed to maintain target
BP or clinical improvement
c. If in shock and blood products are available under an approved command or theater protocol:
Resuscitate with whole blood preferably FWWB. Continue resuscitation as needed to maintain target BP or clinical improvement
d. If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to maintain a palpable radial pulse. If BP monitoring is available, maintain target systolic BP of at least 90 mmHg
Fluid resuscitation at Field Surgical Centre
a. The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood*; plasma, RBCs and platelets in 1:1:1 ratio*; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (lactated Ringer’s or Plasma-Lyte A)
b. Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse)
1. If not in shock:
No IV fluids are immediately necessary
Fluids by mouth are permissible if the casualty is conscious and can swallow
2. If in shock and blood products are available under an approved blood product administration protocol:
Resuscitate with whole blood*, or, if not available
Plasma, RBCs, and platelets in a 1:1:1 ratio*, or, if not available
Plasma and RBCs in 1:1 ratio, or, if not available
Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone
Reassess the casualty after each unit. Continue resuscitation until a palpable radialpulse,improved mental status or systolic BP of 80–90 mmHg is present
3. If in shock and blood products are not available under an approved combat theater blood product administration protocol due to tactical or logistical constraints:
Resuscitate with Hextend, or if not available
Lactated Ringer’s or Plasma-Lyte A
Reassess the casualty after each 500 mL IV bolus;
Continue resuscitation until a palpable radial pulse, improved mental status, or systolic
BP of 80–90 mmHg is present
Discontinue fluid administration when one or more of the above end points has been achieved
4. Ongoing resuscitation to continue along with damage control surgery (DCS)
5. At any given time all possibilities of MEDEVAC should be considered
Fluid resuscitation strategies for combat casualties need to be urgently refined to keep pace with current recommendation. Large volume crystalloid resuscitation which is still in vogue in the most situations in combat need to be replaced with low volume colloid resuscitation and one of plasma or FWWB as forward in the field as possible to satisfy the arms of DCR namely the hypotensive resuscitation and haemostatic concerns. There should be a policy to outline planning parameters for blood supply to Forward medical echelons. The policy should specify zone wise responsibilities at various levels for ensuring availability of blood and blood products including collection, storage and transportation to meet operational requirements.
Both authors read and approved the final manuscript.
The authors declare that they have no competing interests.
Availability of data and materials
Authors have no problems to readily reproduce materials described in the manuscript, including new software, databases and all relevant raw data, freely available to any scientist wishing to use them, without breaching participant confidentiality.
Consent for publication
Not applicable for this section since no personal data or case report is involved.
Ethics approval and consent to participate
This article does not involve human participants, human data or human tissue neither animal. Hence ethic approval is not applicable for this article.
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