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Table 2 Guidelines for fluid resuscitation at various field echleons

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