Optimal Fluid Therapy for Traumatic Hemorrhagic Shock

Abstract

The resuscitation of traumatic hemorrhagic shock has undergone a paradigm shift in the last 20 years with the advent of damage control resuscitation (DCR). Major principles of DCR include minimization of crystalloid, permissive hypotension, transfusion of a balanced ratio of blood products, and goal-directed correction of coagulopathy. In particular, plasma has replaced crystalloid as the primary means for volume expansion for traumatic hemorrhagic shock. Predicting which patient will require DCR by prompt and accurate activation of a massive transfusion protocol, however, remains a challenge.

Keywords: Damage control resuscitation; Hemorrhagic shock; Massive transfusion protocol.

Figure 1

Proposed effect of hemorrhagic shock and crystalloid versus plasma resuscitation on the microvasculature. Panel A. Homeostasis prior to injury. Panel B. Hemorrhagic shock results in shedding of EGL components, resulting in endothelial injury, microvascular permeability, and leakage of fluid into the interstitial space. Panel C. Crystalloids increase hydrostatic pressure in the presence of persistent endothelial injury, resulting in edema. Panel D. Plasma restores intravascular volume while restoring the EGL and repairing endothelial injury, limiting edema. EGL, endothelial glycocalyx layer From Pati S, Matijevic N, Doursout MF. Protective effects of fresh frozen plasma on vascular endothelial permeability, coagulation, and resuscitation after hemorrhagic shock are time dependent and diminish between days 0 and 5 after thaw. J Trauma 2010;69(Suppl 1):S55–63. Used with permission.

Figure 2. Summary of treatment modalities for the bleeding trauma patient

From: Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: Fourth edition. Critical Care (2016):20:100.