Chapter 26

Acute hemorrhage after a traumatic injury carries an ED mortality rate of 30% to 40%.1 The initial goals of therapy are control of bleeding and intravascular volume resuscitation. Resuscitation starts in the prehospital setting and continues in the ED. Crystalloid solutions, colloids, and blood products are the primary volume expanders for intravascular volume depletion. Acute hemorrhage is the main cause of acute intravascular volume loss, requiring aggressive fluid resuscitation (Table 26-1). Fluid and blood resuscitation is the bridge for maintaining survival and limiting morbidity until the underlying cause can be corrected. Other processes that cause loss of plasma fluid and electrolytes (e.g., dehydration, burns) may require aggressive fluid therapy, but blood replacement is usually not an immediate concern. This chapter focuses on the issues related to fluid and blood resuscitation in acute hemorrhagic shock. Burn resuscitation is discussed in Chapter 210, Thermal Burns, and resuscitation for sepsis is discussed in Chapter 145, Toxic Shock Syndrome and Streptococcal Toxic Shock Syndrome, and Chapter 146, Septic Shock.

Table 26-1 Causes of Intravascular Volume Loss

The long-held axiom that the goal of fluid resuscitation is to “refill the tank” and to rapidly restore normovolemia has been progressively challenged over the past decade or so. This challenge is based on concern that restoring normovolemia and normalizing blood pressure in the setting of ongoing hemorrhage can lead to accelerated loss of native red blood cells (RBCs) and, thus, further loss of oxygen-carrying capacity. Several laboratory investigations and clinical studies support limited volume resuscitation to a target blood pressure lower than normal range (e.g., mean arterial pressure of 60 mm Hg). This hypotensive resuscitation or permissive hypotension may be a better strategy in the initial phase of resuscitation. The approach of limited fluid resuscitation (or even no fluid at all) in certain clinical scenarios may be appropriate, but as of this writing the clinical evidence for this is still quite limited.

The principal objectives of fluid and blood resuscitation are: (1) to restore intravascular volume sufficient for critical organ perfusion, (2) to maintain oxygen-carrying capacity for adequate cellular oxygen delivery, and (3) to correct derangements in coagulation. Achieving these objectives requires attention to the dynamic changes that occur during hemorrhage and the ability to accurately monitor, as best as possible, the physiologic state of the patient. The goal of fluid ...

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