Objectives

1. Understand the timing, extent, and the immediate goals for the initial fluid resuscitation in trauma victims, individualized to specific patients.

2. Review the factors influencing choice of fluid for the initial and ongoing resuscitation.

3. Discuss factors influencing the decision for initiating transfusion therapy, choice of blood products, immediate and delayed risks and benefits of transfusion therapy.

4. Become familiar with the current state of therapies intended for the most severely injured patients, including recombinant factor VIIa and massive blood transfusion protocols.

Initial evaluation of an acutely volume-depleted trauma patient will include a primary and secondary survey according to Advanced Trauma Life Support® protocol, an estimate of blood volume deficit (Table 6.1), rate of the ongoing blood loss, and an evaluation of cardiopulmonary reserve and coexisting hepatic or renal dysfunction [1]. The overriding priority of trauma management is to maintain or restore vital organ perfusion and oxygenation above critical levels at an early stage, and to restore perfusion and oxygenation to normal levels as soon as it becomes appropriate. This is best achieved by stopping the bleeding and repleting intravascular volume. Perfusion pressure and oxygenated blood flow to vital organs are important determinants of outcome.

Management priorities in an acutely bleeding trauma patient include ventilation and oxygenation (see Chapter 2), assessment of perfusion, estimation of volume replacement requirements, establishment or verification of adequate intravenous (IV) access (see Chapter 4), measurement of blood pressure, placement of electrocardiogram (ECG), pulse oximeter and capnograph, and laboratory studies.