Fluid resuscitation in haemorrhagic shock in combat casualties

Parli R. Ravi, Bipin Puri

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.