Full text of DOI:10.1080/10903120290938887

PREHOSPITAL FLUID RESUSCITATION OF THE PATIENT WITH MAJOR TRAUMA
Paul E. Pepe, MD, MPH, Vincent N. Mosesso, Jr., MD, Jay L. Falk, MD
ABSTRACT
trating, are candidates for immediate
support of blood pressure through
fluid infusions. However, the addition
of potential intra-abdominal, intra-
pelvic, or intrathoracic injuries with
uncontrolled hemorrhage confounds
the decision-making process. Although
conventional wisdom has been to pro-
vide aggressive blood pressure sup-
port under these circumstances
through judicious use of isotonic, or
perhaps hypertonic, fluid resuscita-
tion, recent experimental data chal-
lenge even this philosophy. Use of new
blood substitutes might help to resolve
some of these issues by providing oxy-
gen delivery with limited volume in
the face of uncontrolled hemorrhage.
Key words: blood substitute; blunt
injury; head injury; hemoglobin-based
oxygen carrier; hemorrhage; injury;
intravenous fluid; penetrating injury;
resuscitation; shock; trauma.
Researchers found that animals
receiving both blood and intra-
venous isotonic fluid as resuscita-
tive measures had a greater likeli-
hood of survival after severe hem-
orrhage when compared with ani-
mals receiving blood alone. The
animals left untreated usually died
or sustained irreversible organ
damage. In addition, restoring
blood pressure to normal or close
to normal was associated with an
improved outcome. The results of
these studies immediately affected
the standard treatment of wound-
ed soldiers in Vietnam by battle-
field medics, which contrasted
with previous battlefield ap-
proaches.11 In turn, the infusions of
intravenous fluids to normalize
blood pressure eventually was
transferred to the streets of the
United States and other western
societies by the 1970s with the
development of modern para-
medic services.
The PASG was developed as a
modification of the jet aviator’s G-
suit.4,12–18 It was designed to help
normalize blood pressure in the
face of post-traumatic hypo-
tension4,13,19 through its ability to
increase peripheral vascular resist-
ance. The PASG also had the theo-
retic advantage of providing a
potential tamponade effect for
underlying injuries with active
internal bleeding.20 By the 1980s,
the PASG and aggressive intra-
venous fluid resuscitation had
become the standard of care for all
trauma patients with potential
signs or symptoms of presumed
hemorrhagic shock.1–4,6,7
The most appropriate prehospital
approach to resuscitative fluid inter-
ventions for trauma patients involves:
determining the mechanism of injury
(i.e., blunt versus penetrating versus
thermal injury); identifying anatomic
involvement (i.e., truncal versus isolat-
ed head injury versus isolated extremi-
ty injury); and staging the condition
(i.e., hemodynamic stability versus
instability versus moribund state).
Based on available data, the liberal use
of fluid infusions for presumed uncon-
trolled internal hemorrhage, such as
that usually occurring after penetrating
abdominal and thoracic injuries, is no
longer advised. Although some infu-
sion might be appropriate in patients
with extremely severe hemorrhage
(i.e., no palpable blood pressure,
unconscious), the priority in such
patients is rapid evacuation to defini-
tive surgical intervention, with airway
control and intravenous access provid-
ed en route. The data are less clear for
patients with blunt injuries, particular-
ly those with closed head injury. Most
researchers would still recommend
that patients with isolated extremity
and head injuries, either blunt or pene-
PREHOSPITAL EMERGENCY CARE
2002;6:81–91
For more than three decades, the
traditional approach to prehospital
treatment of trauma patients with
low blood pressure resulting from
obvious or presumed hemorrhage
has been to attempt to restore nor-
mal systemic arterial blood pres-
sure.1–7 The rationale for this
approach has been to ensure and
maintain vital organ perfusion
while awaiting definitive surgical
intervention and hemostasis.1–3
The two modalities most often
used to achieve this goal are: 1)
rapid intravenous infusions of iso-
tonic crystalloid or colloid solu-
tions (normal saline, lactated
Ringer’s solution, albumin, or het-
astarch); and 2) use of the pneu-
matic antishock garment (PASG),
also known as military antishock
trousers (MAST).1–7
Received June 17, 2001, from the
Department of Surgery, University of Texas
Southwestern Medical Center, and The
Dallas Area Biotel (EMS) System (PEP),
Dallas, Texas; Department of Emergency
Medicine, UPMC Health System (VNM),
Pittsburgh, Pennsylvania; and Department
of Emergency Medicine, Orlando Regional
Healthcare (JLF), Orlando, Florida. Revision
received August 31, 2001; accepted for pub-
lication September 17, 2001.
Presented at the Turtle Creek Conference
III, Dallas, Texas, April 29–May 1, 2001.
Supported by an unrestricted educational
grant from Wyeth-Ayerst Laboratories.
Despite these longstanding tradi-
tional management approaches,
recent experimental and clinical
data have indicated a modification
to this universal approach to the
trauma patient.11,21–31 Although rais-
ing blood pressure and restoring
Address correspondence and reprint re-
quests to: Paul E. Pepe, MD, MPH, Profess-
or and Chair, Emergency Medicine, Uni-
versity of Texas Southwestern Medical
Center at Dallas, Emergency Medicine, MC
8579, 5323 Harry Hines Boulevard, Dallas,
TX 75390-8579. e-mail: <paul.pepe@
utsouthwestern.edu>.
The basis for this approach was
largely established by the results of
several elegant animal studies per-
formed in the 1950s and 1960s.8–10
81

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PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1
perfusion to vital organs are clearly
believed to be beneficial after hemor-
rhage is controlled, growing evi-
dence indicates that raising blood
pressure before achieving adequate
hemostasis may be detrimental.21–33
While the original animal studies
that laid the groundwork for fluid
resuscitation more or less involved
controlled hemorrhage models with
fixed amounts of blood loss,8–10
more current studies have begun to
examine the effects of raising blood
pressure during uncontrolled hem-
orrhage.21–31 These studies and their
potential implications for clinical
epidemiology, research, and man-
agement are discussed in detail.34
ids only on arrival in the operating
quire surgical hemostasis. Al-
though large intravenous fluid
infusions may be necessary as soon
as bleeding is controlled, aggres-
sive fluid resuscitation in the pre-
hospital or emergency department
settings might still be detrimental
in such patients.28,33 In contrast, a
hypotensive trauma patient with
isolated severe hemorrhage from
an extremity probably would bene-
fit from immediate prehospital
fluid resuscitation because the
bleeding can be controlled outside
of the operating room setting.
The consideration that hemosta-
sis must be achieved before blood
pressure is raised might also
explain why antishock garments
have not provided the anticipated
benefit, particularly in patients
room (delayed group). Patients in
the immediate resuscitation group
had a higher mortality rate and a
higher rate of postoperative com-
plications compared with patients
in the delayed resuscitation group.
The authors of this study conclud-
ed that rapid administration of
intravenous fluids before hemor-
rhage is controllable results in
worse outcomes in this subpopula-
tion of hypotensive patients with
penetrating truncal injuries.
Despite some negative reaction
to this initial clinical effort to
resolve the question of when to
provide fluid resuscitation,35 the
study remains the strongest avail-
able evidence to date regarding the
issue. Also, counterarguments to
the initial critiques of the study
have noted that, at the very least,
there is no demonstrable advan-
tage to administering fluids in this
subpopulation of trauma pa-
tients.36 In addition, experimental
studies in multiple animal models
have all supported the concept of
the detrimental effect of fluid
resuscitation in uncontrolled hem-
orrhage.21–31 Furthermore, this
effect is found regardless of the
solution used (i.e., blood, lactated
Ringer’s solution, hypertonic
saline22,26,29). More importantly, in
other prehospital studies, fluid
resuscitation has yet to be correlat-
ed scientifically with improved
survival in the clinical setting, par-
ticularly in moribund patients who
intuitively would benefit the
most.37,38 The key factors in the sur-
vival of moribund patients appear
to be limited to rapid transport to
an appropriate trauma facility and
aggressive airway control.34,37,38
Therefore, the working hypothe-
sis at this time is that intravenous
fluid resuscitation should probably
be delayed until hemostasis is
achieved. Following this line of
thinking, if the anatomic site of
bleeding is a large vessel within the
thoracic or abdominal cavity,
bleeding control will usually re-
EVIDENCE AGAINST
PREOPERATIVE BLOOD
PRESSURE ELEVATION
with
penetrating
abdominal
injuries.39–44 In prospective trials,
one difference between PASG
patients and control patients has
been a marked elevation in systolic
blood pressure among the patients
who had prehospital PASG appli-
cation.39 This elevation in systolic
blood pressure is consistent with
findings of retrospective studies
and the initial anecdotal reports
that originally espoused the wide-
spread use of the PASG device.
Based on traditional wisdom, most
clinicians might anticipate that ele-
vating blood pressure in the face of
presumed hemorrhagic shock
Several animal studies performed
in the 1980s and 1990s found that
treatment with intravenous fluids
before hemorrhage is controlled
increases the mortality rate, espe-
cially if blood pressure is elevat-
ed.21–27 Possible mechanisms re-
sponsible for worse outcomes
include hydraulic acceleration of
ongoing hemorrhage as a result of
the elevated systemic blood pres-
sure, mechanical dislodgment of
active soft clot formation, and dilu-
tion of existing clotting factors
from administration of large vol-
umes of intravenous fluids.21,33
Research in humans, although
limited, has supported this con-
cept. A large, prospective, con-
trolled clinical trial comparing
immediate prehospital and emer-
gency department intravenous
fluid resuscitation with fluid resus-
citation delayed until arrival in the
operating room was conducted in
Houston, Texas, in the 1980s and
early 1990s.33 In this study,
hypotensive (systemic blood pres-
sure <90 mm Hg) patients with
penetrating torso injuries received
either aggressive isotonic fluid
resuscitation preoperatively (im-
mediate group) or were given flu-
(post-traumatic
hypotension)
would be beneficial and improve
patient outcome.4,12,13,17 In these
clinical trials, however, patients
with major vascular injuries, both
arterial and venous, were found to
trend toward decreased survival.39
Survival rates were approximately
90% for patients with solid organ,
abdominal wall, or bowel injuries,
with or without PASG application.
When the subset of patients with
large-vessel involvement (e.g.,
inferior vena cava, renal vein,
hepatic artery) was examined, sur-
vival rates were 49% for the PASG
group and 65% for the control
group.39 Again, this observation is

Pepe et al. PREHOSPITAL FLUID RESUSCITATION
83
compatible with the evolving para-
digm that blood pressure elevation
before hemostasis may be detri-
mental. It must be kept in mind,
however, that through peripheral
vascular compression, the PASG
lowers total body cardiac output
and that other mechanisms may
also explain the disadvantages of
this device.
Conversely, hypotension might be
a marker for other factors that lead
to a bad outcome and in itself is not
necessarily detrimental.31
the same time, a retrospective sub-
analysis of all patients with injury
severity scores > 26 showed that
patients had worse outcomes with
early fluid resuscitation.33,36
Therefore, further clinical and
experimental studies are necessary
to better delineate the role of fluid
resuscitation in these complicated
patients. The type of injuries, their
anatomic location, and their severi-
ty must be kept in mind when such
research efforts are designed.34
Specifically, stratification of pa-
tients with and without head
injuries must be made clear, as
should stratification of those in
extremis conditions.32
Despite the animal data, statisti-
cally significant evidence from
prospective clinical trials is still
lacking regarding the value of fluid
resuscitation for the most severely
injured patients. Nevertheless, con-
sidering the animal data and grim
outlook for these patients, rapid
fluid infusions still might be
empirically reasonable in the ab-
sence of pulse and consciousness.
One consideration that might
help guide such therapy for severe-
ly compromised patients is the use
of end-tidal carbon dioxide
(ETCO2) measurements to detect
critical perfusion levels in which
total body oxygen consumption
and CO2 production begin to fall
significantly.54–56 End-tidal carbon
dioxide levels are affected primari-
ly by the level of pulmonary blood
flow.57 Thus in severely injured
patients whose cardiac output is
very low, little CO2 is delivered
from tissues to the pulmonary cir-
cuit and the exhalation of CO2 is
BLUNT VERSUS
PENETRATING TRAUMA
Although both experimental and
clinical studies supporting delay of
fluid resuscitation are somewhat
compelling, the clinical studies
generally involved patients with
penetrating injuries. The role of
fluid resuscitation in patients with
blunt trauma is less clear. For
example, after motor vehicle colli-
sions, patients with multisystem
injuries traditionally have been
provided blood pressure support
for major fractures and closed head
injury.45–52 However, a patient
trapped in a vehicle who has
altered mental status, left upper
quadrant pain, a closed femur frac-
ture, and hypotension presents a
challenging dilemma for clinicians.
Although aggressive preoperative
fluid resuscitation theoretically
could accelerate hemorrhage from
a major splenic rupture or avulsion
(a potential here), blood pressure
support for brain injury is also con-
sidered to be a key therapeutic
intervention. Also, a femur fracture
can result in massive blood loss
and fluid sequestration leading to
profound shock conditions.
Nevertheless, recent experimen-
tal models of head injury have
refuted the traditional universal
use of aggressive blood pressure
support in patients with head
injury.31 Although better outcomes
have been correlated with in-
creased systemic blood pressure in
patients with severe head in-
jury,46–52 a higher blood pressure
might simply be a marker for less
severe head and systemic injury.
FLUID RESUSCITATION IN
THE MORIBUND PATIENT
Although experimental evidence
has demonstrated the potential
detrimental effects of aggressive
fluid resuscitation in uncontrolled
hemorrhage, many animal studies
have suggested that blood or fluid
administration may be of value in
patients with “severe circulatory
compromise” (i.e., mean systemic
arterial blood pressure <40 mm
Hg).23–25 However, patients with
such a degree of hypotension typi-
cally present without a measurable
blood pressure and are usually
unconscious.
One retrospective study found
that patients with such severe cir-
culatory compromise might benefit
from application of the PASG.53
However, that conclusion may
have been limited by the study
design (selective retrospective
analysis, accuracy of prehospital
blood pressure measurements <70
mm Hg, and statistical power). In
the prospective clinical trial of
immediate versus delayed intra-
venous fluid resuscitation for pen-
etrating torso injury,33 patients
who had a systemic arterial blood
pressure of < 70 mm Hg were gen-
erally pulseless and clinically mori-
bund. These patients’ chance of
survival was very low regardless
of their prehospital treatment. At
minimal.57
Measurements
of
ETCO2 therefore reflect total body
cardiac output and can be used as
one noninvasive means of monitor-
ing directional changes in blood
flow during cardiopulmonary
resuscitation and fluid resuscita-
tion (Figs. 1 and 2).54,58 As shown in
Figure 2, ETCO2 can increase in
response to aggressive fluid resus-
citation in a patient with severe
trauma.58 However, the suggestion
to begin fluid resuscitation accord-
ing to ETCO2 measurement in
severe trauma is still only empiric
and unstudied, particularly in
those patients with uncontrolled
hemorrhage. It is still not known
whether ETCO2 levels should con-
stitute trigger points for fluid infu-
sions or how much or how fast the
fluids should be infused. Studies
examining these issues are strongly
encouraged.

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PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1
The main alternative solutions
studied for trauma resuscitation in
the United States are hypertonic
saline and nonprotein plasma
expanders, such as dextran and
hetastarch.60–66 These fluids are less
antigenic and less expensive than
albumin but still may induce aller-
gic reactions, coagulopathies, and
seizures. Limiting the volumes
infused may avoid some of these
problems.28,62
Some clinical trials have specifi-
FIGURE 1. As total body oxygen (O2) delivery falls below an observed threshold, tissue O2
extraction is maximized and O2 consumption (and the corresponding carbon dioxide [CO2]
production) decreases linearly. However, CO2 production improves (point A to point B)
through saline infusions (25 mL/kg) in a closed cardiovascular system (i.e., no uncontrolled
hemorrhage). Based on data obtained from: Pepe PE, Culver BH. Independently measured
oxygen consumption during reduction of oxygen delivery by positive end-expiratory pres-
sure. Am Rev Respir Dis. 1985;132:788-92.
cally examined the efficacy of
hypertonic saline.61,62,64–66 Experi-
mentally, hypertonic saline in-
creases myocardial contractility,
induces vasodilation to precapil-
lary resistance vessels, and im-
proves redistribution of fluid from
the extravascular to the vascular
compartments. In addition, be-
cause considerably smaller vol-
umes are needed to restore intra-
vascular volume, hypertonic saline
solutions have been advocated as a
resuscitative agent for field use,
particularly for hypotensive pa-
tients with severe head injury.46,66
A prospective, multicenter trial
from 1991 compared the outcomes
of hypotensive trauma patients
treated with normal saline or
hypertonic saline in dextran (e.g.,
7.5% NaCl in 6% dextran 70).62 The
two groups received equal vol-
umes of fluid in the prehospital
phase, followed by standard iso-
tonic infusions in the emergency
department. Although the patients
in the hypertonic saline in dextran
group had higher systemic blood
pressures on arrival at the hospital,
no significant difference in overall
mortality was seen between the
two groups at 24 hours. There were
no clinically significant complica-
tions of hypernatremia or dextran-
related allergic reactions among
the patients who received hyper-
tonic saline in dextran. The authors
concluded that despite theoretic
concerns, hypertonic saline in dex-
tran was safe and further study
was warranted.
prehospital use.46,59-66 Although
isotonic crystalloids (e.g., normal
saline or lactated Ringer’s solution)
remain the principal choice today
in the United States, various types
of colloids (all very different in
themselves) are often the fluid of
choice in other countries, such as
Australia and European nations.
Obviously, this further complicates
the interpretation of meta-analysis
and cross-study comparisons.
Proponents of the use of colloids,
such as albumin, argue that fluids
given to replace blood loss from
the intravascular space should be
designed to remain in that space.67
The traditional teaching concern-
ing crystalloid infusions has been
the “3:1 rule,” whereby 1 liter of
crystalloid remains in the vascular
space for every 3 liters infused.1–3
This approach requires that large
volumes of balanced salt solutions
be administered to replace blood
loss. It could be further argued that
such infusions carry inherent risks.
For example, infusions of such
large volumes of crystalloid might
decrease intravascular colloid
osmotic pressure, potentially
increasing the risk of developing or
exacerbating pulmonary or cere-
bral edema. Nevertheless, most
analyses have not yet proven
definitively the advantage of albu-
min over crystalloids.67,68
One confounding factor to be
considered in these and any other
studies of severe circulatory com-
promise is the detrimental effects
of positive-pressure ventilation,
particularly in patients with pre-
sumed hemorrhagic shock and
severely depressed preload.32,56
This additional controversy de-
monstrates how stratification of
the severity (staging) of injuries is
important in future research
endeavors. Confounding the situa-
tion further is the recent experi-
mental evidence that bolus infu-
sions might be more detrimental
than slow infusions in near-fatal
models of uncontrolled hemor-
rhage.28 In addition, such investi-
gations have also used hypertonic
solutions.22,28 Therefore, the choice
of fluid may also have to be con-
sidered when analyzing the results
of these studies.
RESUSCITATION WITH
NONCRYSTALLOID FLUIDS
The type of fluid that should be
administered to trauma patients,
even those with controlled hemor-
rhage, has been the subject of con-
siderable debate. In North
America, crystalloids are typically
given to replace blood loss, but
several studies have examined the
use of fluid substitutes, such as col-
loids and hypertonic saline, for
However, one of the problems
with this study was that relatively

Pepe et al. PREHOSPITAL FLUID RESUSCITATION
85
small volumes of fluid were
administered in the prehospital
setting to a group of patients with
predominantly penetrating injur-
ies. Both groups of patients
received only 250 mL of either
fluid, and the two groups were
then given standard isotonic fluid
infusions in similar fashions, con-
founding the results.
Future research could repeat this
protocol with a third study arm
that includes a group receiving no
fluid in the field, or even a fourth
group of patients who receive the
single dose of 250 mL of hyperton-
ic saline in dextran alone. This
would help to address the question
of whether any prehospital admin-
istration of fluids is warranted.
Another consideration would be a
comparison of preoperative versus
postoperative infusion of hyper-
tonic saline in dextran. Finally, use
of hypertonic saline in dextran in
patients with or without concomi-
tant head injury (without any addi-
tional isotonic fluid infusions)
should be examined more closely.
Although other data seem to sup-
port its efficacy,64–66 the general
consensus is that definitive clinical
trials are lacking.
In the meantime, most experts in
the United States generally hold
that limited crystalloid infusions
are preferable to most other colloid
infusions in the prehospital setting
and in the early resuscitative phas-
es of trauma care.5 The rationale is
that crystalloid is inexpensive,
readily available, and nonantigenic
and that administration of any iso-
tonic infusions might be followed
by plasma expanders or blood
products in the emergency depart-
ment or operating room. Also, no
firm data support the use of the
more expensive colloid solutions.67
Nevertheless, the potential anti-
inflammatory properties of some
colloids also create some appeal for
researchers and further study.68
The hetastarches, which are com-
monly used in Europe, and artifi-
cial hemoglobins are not as well
studied as crystalloids and other
FIGURE 2. Response of end-tidal carbon dioxide (ETCO2) to fluid resuscitation in a patient
with severe trauma. BP = blood pressure; HR = heart rate; PRSC = prehospital fluid resusci-
tation. Reprinted with permission from: Falk JL, O’Brien JF, Kerr R. Fluid resuscitation in
traumatic hemorrhagic shock. Crit Care Clin. 1992;8:323-40.
intravascular infusions.59,63,69–78
Although further research into
these types of resuscitative agents
can be anticipated, many of these
agents have been demonstrated to
have a potential for raising blood
pressure, a factor to consider in
patients with uncontrolled hemor-
rhage.79 For example, many of the
hemoglobin-based oxygen-carrier
products are thought to have
nitric-oxide scavenging effects that
lead to smooth-muscle constriction
and subsequent blood pressure ele-
vation.79 However, it is hoped that
the oxygen-carrying properties
will outweigh the risk of secondary
hemorrhage.70,71
One trial of the artificial hemo-
globin diaspirin cross-linked
hemoglobin (DCLHb) for trauma
patients was terminated prema-
turely because of an increased
number of deaths in the experi-
mental group.69 However, study
bias and other factors may have led
to this unexpected observation
with this particular product.69
model of trauma, Manning et al.70
demonstrated the successful resusci-
tation and survival of asanguinous
animals with uncontrolled hemor-
rhage that were given HBOC-201
compared with the high mortality
found in the control group given
standard crystalloid infusions.
In addition to improved oxygen-
carrying capacity, HBOC-201 is rel-
atively temperature stable75 and
could be stored in ambulances or in
military far-forward positions,
thus making it attractive to
researchers. In terms of human
data, HBOC-201 has been used
successfully as a short-term blood
substitute in hundreds of surgical
patients72–78 but has not yet been
tested in any of the various sub-
populations of trauma patients.
Nevertheless, the concept of pro-
viding improved oxygen transport
in the face of uncontrollable hem-
orrhage is appealing, and future
clinical trials of this new com-
pound would be worthwhile.
COMPLICATIONS OF
PREOPERATIVE FLUID
RESUSCITATION
The recent introduction of another
compound, HBOC-201, a purified
form of bovine hemoglobin, has
sparked renewed interest in artifi-
cial hemoglobin. HBOC-201 has
been shown to have some promise
in the laboratory.70,71 In a swine
Blood pressure alone is a poor pre-
dictor of shock (defined as inade-
quate perfusion of tissues). Despite

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PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1
the recently evolving paradigm
that limiting preoperative fluid is
preferable in most patients with
internal hemorrhage to prevent
secondary bleeding or acceleration
of ongoing hemorrhage, concern
still exists over the potential for
other sequelae of shock. The dura-
tion and degree of systemic
hypotension that a patient can
withstand are the issue.
The clinical study comparing
immediate with delayed fluid
resuscitation showed a higher inci-
dence of postoperative complica-
tions in the immediate resuscita-
tion group (i.e., patients who
received aggressive fluid adminis-
tration in the prehospital and
emergency department settings).33
The incidence of acute respiratory
distress syndrome, sepsis, coagu-
lopathies, and renal failure was
greater in the immediate resuscita-
tion group compared with the
delayed resuscitation group.33
Several possible explanations have
been offered for this observation,
including decreased oxygen-carry-
ing capacity from accelerated hem-
orrhage. The statistically lower
hemoglobin levels on arrival in the
emergency department for patients
who received prehospital fluid
resuscitation was more pro-
nounced than those predicted by
simple hemodilution alone.33
Again, these findings suggest
that prehospital fluid might be
harmful in patients with penetrat-
ing injuries to the torso and pre-
sumed internal bleeding in an
urban emergency medical services
(EMS) system with rapid transport
intervals. Concern over more pro-
longed periods of hypovolemia
without fluid resuscitation still
exists, however, particularly in
patients with blunt injury. More
importantly, the definition of “pro-
longed” must be clarified. Above
all, the dilemma of maintaining
perfusion to the brain and other
vital organs in patients with closed
ment of trauma in the prehospital
setting paradoxically has been
complicated by well-intentioned
attempts to simplify it. Most EMS
systems worldwide have devel-
oped treatment algorithms that
often do not delineate between the
different mechanisms of injury or
anatomic location of wounds. The
result has been mistreatment or
misunderstanding of conflicting
study data. In that respect, the clas-
sic debate of “scoop and run” ver-
sus scene stabilization has by defi-
nition oversimplified prehospital
care strategies. Confounding the
discussion further, only a few
prospective controlled clinical tri-
als have been conducted to vali-
date or refute the prehospital inter-
ventions currently used for major
trauma patients. Future discus-
sions of the epidemiology,
research, and ultimately manage-
ment of trauma should include dis-
crimination of the mechanism of
injury (i.e., blunt versus penetrat-
ing versus thermal injury),
anatomic involvement (i.e., truncal
versus extremity versus isolated
head injury), and staging of the
condition (i.e., hemodynamic sta-
bility versus instability versus
moribund state). In particular, the
controversial issue of prehospital
care for trauma patients with
potential internal hemorrhage,
with or without head injury, needs
to be examined more closely.
Finally, the various types of colloid
and crystalloid fluids also need to
be examined more closely, as does
the development of oxygen-carry-
ing media. In all of these cases, the
confounding factor of current ven-
tilatory techniques for severely
injured patients must be consid-
ered as well.
head injury remains a significant
worry. Further study is required in
venues in which there are pro-
longed transport times and poten-
tially long delays until definitive
surgical hemostasis. Also, many
investigators consider blunt trau-
ma a disease of massive soft-tissue
injury and systemic inflammation,
making it much different from the
more focused penetrating injury
that primarily leads to more local-
ized injury and bleeding.80
CONCLUSION
The liberal use of fluid infusions
for patients with presumed uncon-
trolled internal hemorrhage, such
as that usually occurring after pen-
etrating abdominal and thoracic
injuries, is no longer advised. In
fact, this recommendation is not
new but actually long established,
if one considers the observations
made during past wars.11,81
Although some infusion may be
appropriate in patients with
extremely severe internal hemor-
rhage, the priority in such patients
is rapid transport to definitive sur-
gical hemostasis.
The use of fluid infusions in
patients with blunt trauma is not
always clear. For patients with iso-
lated extremity and head injuries
(blunt or penetrating), immediate
support of blood pressure through
fluid infusions is considered bene-
ficial when the bleeding is control-
lable. However, potential intra-
abdominal, intrapelvic, or intratho-
racic injuries and bleeding compli-
cate the picture. Although blood
pressure support through judi-
cious use of isotonic or hypertonic
fluid resuscitation generally has
seemed reasonable, some recent
experimental data even challenge
this approach.
The authors thank Carol W. Smith for her
dedicated assistance in preparing the manu-
script.
As implied in the preceding dis-
cussion, the traditional manage-

Pepe et al. PREHOSPITAL FLUID RESUSCITATION
87
CONSENSUS PRESENTATION
term might be controllable hemor-
rhage, which reflects the likelihood
that if bleeding were to occur, EMS
providers would probably be able
to control it. This generally applies
to extremity injuries or superficial
soft-tissue wounds of the trunk.
In the trauma patient with con-
trollable hemorrhage, the consen-
sus group recommended resuscita-
tion with intravenous fluids if the
patient shows clinical signs of
shock, such as altered mental sta-
tus or poor peripheral perfusion.
Use of capnography, if available,
was recommended as a potential
means of evaluating perfusion.
Adequate volume should be
infused to reverse clinical signs of
shock while ensuring continued
hemostasis. Fluid could be admin-
istered as intravenous boluses,
with the volume based on factors
such as the patient’s hemodynamic
status, age, and comorbidities and
the amount of the hemorrhage.
After each bolus, patients should
be reassessed and given additional
boluses as indicated. Reassessment
should include examination of
lung sounds and respiratory status
for evidence of pulmonary edema.
airway and ensuring adequate
ventilation and oxygenation are
the first priorities. Intravenous
access, preferably with large-bore
catheters, should be established en
route to the hospital.
The consensus group agreed that
both animal and human trials indi-
cate that patients respond differ-
ently to the various types of major
trauma. Trauma patients are not a
homogeneous group, and they
vary in their physiologic reactions
to the injury according to type and
severity of the injuries they sustain.
Some patients deteriorate into cir-
culatory arrest, others develop
severe shock states, and some
remain in a hemodynamically sta-
ble condition. The mechanism of
trauma and its anatomic involve-
ment can significantly affect these
responses and, in turn, influence
the appropriate approach to fluid
resuscitation. In addition, age and
comorbidities can be significant
factors. Children may have differ-
ent fluid replacement requirements
than do adults. Even among adults,
the fluid replacement requirements
of a younger person, both in terms
of rates and absolute amounts, may
differ from those of an elderly per-
son, who might have several
comorbid conditions. Thus no sin-
gle recommendation can be made
for prehospital fluid resuscitation
of trauma patients.
In addition to patient variables,
the resources and characteristics of
the EMS system influence prehospi-
tal fluid resuscitation decisions. For
example, the time it takes to trans-
port the patient from the scene to
the operating room may be a critical
factor in determining appropriate
fluid volumes and rates. Therefore,
the consensus participants suggest-
ed that EMS providers collaborate
with local and regional trauma
services to develop a coordinated
approach to fluid management in
the trauma patient.
Although the available data are
not definitive, for patients with
presumed uncontrollable hemor-
rhage who show some signs of
shock but are not near imminent
circulatory arrest (e.g., responsive
to verbal stimuli, palpable pulse),
the amount of fluid administered
should be limited. Intravenous
access with two large-bore
catheters should still be established
en route to the hospital, but fluids
should be limited to “keep vein
open” (KVO). Small titrated bolus-
es may be considered in some
patients with severe tachycardia
and those who show signs of fur-
ther hemodynamic deterioration.
However, there is insufficient clini-
cal research to define the role of
fluid administration more precise-
ly in these patients.
Moribund patients with near-
fatal injuries are reasonable candi-
dates for more immediate fluid
resuscitation. These patients typi-
cally have signs of extreme shock
(e.g., unresponsive to verbal stim-
uli, no palpable peripheral pulse).
As fluid is being administered, the
patient’s status should be continu-
ously assessed. Once signs of
improvement are noted, such as
return of pulses or improved men-
tal status, the rate of fluid adminis-
tration can be tempered. The over-
all goal is not to return patients to a
state of normal perfusion but
rather to achieve perfusion ade-
quate enough to maintain viability
of vital organs until the time of
definitive intervention.
UNCONTROLLABLE
HEMORRHAGE
Based on the best available data,
the appropriate approach to fluid
resuscitation of a trauma patient
with presumably uncontrollable
hemorrhage largely depends on
the mechanism of injury, be it pen-
etrating or blunt, the anatomic
involvement, and the severity of
the physiologic compromise.
Penetrating Trauma
For the patient with penetrating
trauma and presumed uncontrol-
lable hemorrhage, the goal is to
keep the out-of-hospital time as
short as possible. Along with rapid
evacuation, maintaining an open
CONTROLLABLE HEMORRHAGE
The consensus group noted that a
truly controlled hemorrhage is rare
in the prehospital setting. A better
Blunt Trauma
Although many trauma life sup-
port courses recommend that 2
liters of fluid be given to all

88
PREHOSPITAL EMERGENCY CARE JANUARY / MARCH 2002 VOLUME 6 / NUMBER 1
TABLE 1. Prehospital Fluid Resuscitation of Trauma Patients:
proper endpoints to be measured
that would guide such therapy.
Overall, the group generally would
err on the side of beginning to give
fluids en route to hypotensive
patients with blunt trauma, espe-
cially those with severe head trau-
ma and those with any clear clini-
cal signs of shock.
Summary of Consensus Group Recommendations
•
•
Discriminate between blunt, penetrating, and thermal injury or combinations thereof (e.g.,
blast injury).
If there are concerns about potential internal or other uncontrollable hemorrhage, rapidly
evacuate and transport the patient to definitive surgical facilities where hemostasis can be
achieved.
•
Manage the airway as indicated. Maintain airway patency, adequate oxygenation, and
adequate ventilation. Avoid hyperventilation with positive-pressure breaths (either high
respiratory rates or excessively large tidal volumes [>15 mL/kg]) because they can com-
promise cardiac output (due to decreased venous return) and cerebral perfusion (due to
cerebral vasoconstriction). Respiratory rates of 8 to 10 breaths/min are generally adequate
for patients with shock and even fewer (6 to 8 breaths/min) for those with circulatory or
near-circulatory arrest.
PREHOSPITAL FACTORS
The consensus group considered
how EMS providers can determine
the patient’s perfusion and meta-
bolic status using available tech-
niques. Checking pulses and blood
pressure can be difficult in the
trauma patient, and these measure-
ments are crude estimates of actual
perfusion. Assessment of mental
status as a sign of shock can be con-
founded by the presence of head
injury, drugs, or alcohol. The par-
ticipants agreed that ETCO2 can be
a useful adjunct, particularly in
patients who have already been
intubated, to assess perfusion in
low-flow states. End-tidal carbon
dioxide measurements provide an
indication of changes in cardiac
output and tissue perfusion. If a
patient is in severe shock, ETCO2
levels will be very low. Ventilation
generally should be kept constant
when using capnometry to assess
perfusion. However, positive-pres-
sure breaths can be detrimental in
patients with severely compro-
mised circulation, serving to con-
found the shock state even further.
Therefore, in trauma patients with
presumed hypovolemia and severe
circulatory compromise, infre-
quent breaths, using 10 to 15
mL/kg tidal volume, are recom-
mended as the constant. In EMS
systems that have capnometry
available, EMS providers should
receive specific training in its use.
In some EMS systems, transport
to the hospital may be prolonged,
particularly if air medic units are
unavailable or the system is locat-
ed in a rural setting. This extended
prehospital phase places an even
greater burden on EMS personnel.
•
•
Establish intravenous access with large-bore catheters.
If bleeding can be controlled (e.g., an isolated extremity injury), provide rapid intravenous
fluid infusions for patients with blunt or penetrating trauma who show signs or symp-
toms of compromised circulation.
•
•
In patients with penetrating trauma, infuse isotonic intravenous fluids if the patient is
moribund (unconscious, no palpable pulses); otherwise, restrict fluid infusions, particu-
larly in patients with penetrating torso injuries.
In patients with blunt trauma, especially those with severe head injury, provide enough
intravenous fluid infusion to maintain perfusion using clinical judgment but avoid exces-
sive fluid administration (because of the theoretical risks of cerebral and pulmonary
edema and secondary hemorrhage). Recognize that proper endpoints for determining
adequacy of fluid resuscitation are still unknown.
•
•
Consider end-tidal carbon dioxide (ETCO2) monitoring as an adjunct to identify patients
with severe circulatory compromise.
Establish a coordinated prehospital treatment protocol with local and regional trauma
services.
patients with blunt trauma, partic-
ularly those with signs of shock,
the consensus group recommend-
ed that intravenous fluid adminis-
tration be based more on the
patient’s clinical condition. Al-
though underresuscitation must be
avoided, providers should recog-
nize that overresuscitation can also
be harmful. The group agreed that
the cookbook approach of at least 2
liters of fluid to all trauma patients
and the approach that volume can
be administered copiously without
consequence should be discour-
aged.
Although the consensus was that
fluid administration generally
should be more liberal in patients
with blunt injury than in those
with penetrating injury, most
patients with blunt trauma still
should receive just enough prehos-
pital fluid to maintain perfusion.
Volume overload should be avoid-
ed to prevent complications such
as pulmonary edema and the
potential for worsening hemor-
rhage. The difficulty remains in
terms of understanding how much
and how fast to infuse, if at all.
Patients with closed head injury
present a particular challenge.
Intravascular volume support may
be necessary to maintain cerebral
perfusion and prevent secondary
cerebral injury, but excess volume
can increase cerebral edema and
intracranial pressure. Pending fur-
ther research to determine best
clinical practices, EMS providers
should consider these concerns
when assessing and treating indi-
vidual patients.
Again, the principal difficulty
faced by the consensus group in
discussing fluid resuscitation in
blunt trauma is that the proper vol-
ume and rate for initial resuscita-
tion in such patients, using current
techniques, are unknown. More
importantly, just as elusive are the

Pepe et al. PREHOSPITAL FLUID RESUSCITATION
89
Surgeons, 1981, p 17.
2. American College
rospective analysis of five years of expe-
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The risks to the patient become
greater, and prehospital providers
must be more rigorous and careful
in their assessment and manage-
ment. Because patients may be in
severe shock for an extended peri-
od, the possibility of underresusci-
tating with fluids may be greater.
Paradoxically, these patients are at
higher risk for overresuscitation
with fluids as well. Therefore, the
recommendation for those experi-
encing extended prehospital phas-
es of care is to limit intravenous
fluids to the amount needed to
reverse severe shock and to pre-
vent the possible risk of excess
fluid. Rescuers should also keep in
mind that patients with crush syn-
drome may have a greater need for
fluids than those without crush
syndrome.
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Surgeons
Committee on Trauma. Advanced
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IL: American College of Surgeons, 1984,
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CONCLUSION
Because trauma patients are not a
homogeneous group, fluid resusci-
tation in the field must be individ-
ualized according to the mecha-
nism, anatomic involvement, and
severity of the injury, as well as
certain patient characteristics and
estimated transport time to defini-
tive surgical intervention. The con-
sensus group agreed on certain
points for prehospital fluid resusci-
tation, as summarized in Table 1.
However, they also agreed that
many questions remain unan-
swered regarding optimal prehos-
pital fluid management. For exam-
ple, proper clinical endpoints for
the optimal type, amount, and rate
of fluid to be administered are
unknown. Clinical markers of ade-
quate perfusion also are subopti-
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mendations can be made as to
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