From: Fluid resuscitation in haemorrhagic shock in combat casualties
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 |