Fluid Therapy in Trauma

Abstract

Fluid therapy in trauma has been a controversial issue since it was first introduced on a major scale during the First World War. Initially, fluid resuscitation concentrated on the use of blood and blood products supported by colloids and saline-based crystalloid solutions. In the 1960s, experience from battlefield resuscitations, together with laboratory research led to the concept of the “third space” and the use of massive crystalloid resuscitation. The consequence of this was initially improved survival, but also the development of pulmonary oedema and abdominal compartment syndromes. More recently, aggressive pre-hospital resuscitation has been questioned and more conservative, hypotensive resuscitation has been advocated prior to the patient being transported to hospital. The role of hypotensive resuscitation in neurologically injured patients remains controversial. Military field data has suggested that the early use of blood products in addition to red blood cell concentrates may improve survival in battle casualties, but this has not been confirmed in civilian trauma. However, the emphasis on resuscitation of coagulation has placed increasing emphasis on the use of procoagulants, such as tranexamic acid early in severe trauma and, in hospital, on the appropriate monitoring of coagulation. The use viscoelastic coagulation assessment has allowed more precise management of trauma-induced coagulopathy with possibly improved outcomes. It has also been recognised that crystalloid overload is a major component of post-resuscitation morbidity and several studies have emphasised that the combined use of appropriate fluids including limited crystalloids, colloids and appropriate blood products may result in improved outcomes.