UPDATE IN FLUID

RESCUSITATION
IN CORRELATION WITH INITIAL RESUSCITATION IN COMBAT
SETTINGS
31 Augst-1 Sept 2006

Warko Karnadihardja
Department of Surgery, Hasan Sadikin Hospital
University of Padjadjaran
Bandung

A PROFILE OF COMBAT INJURY

Mechanism of
Site of Primary Injury
Wounding
Champion HR et al : J Trauma 2003, 54 : S13S19

A PROFILE OF COMBAT INJURY

Site of Fatal Injury

Mechanism of death
Champion HR et al : J Trauma 2003, 54 : in ground combat

ALGORITHM FOR THE INITIAL RESUSCITATION

OF COMBAT CASUALTIES

Rhee P, Koustova E & Alam HB. J Trauma, 2003,

54,559

INITIAL FLUID RESUSCITATION IN

COMBAT SETTINGS
1.
2.
3.
4.

5.

Reduce the evacuation time

Controlled bleeding and fluid infusion to stabilize
hemodynamic
In uncontrolled hemorrhagic shock, aggressive fluid
resuscitation is prohibited may induce re-bleeding and
mortality
SCOOP AND RUN:
When estimated evacuation time < 1 hour, immediate
evacuation after airway & breathing have been secured,
and IV line is instituted on the way to the surgical unit
HYPOTENSIVE RESUSCITATION
When evacuation time >1 hour, colloids should be added
to crystalloids, but the rate of infusion should be limited
in uncontrolled hemorrhagic shock to prevent re-bleeding
Kransz M.J Trauma, 2003,54. S39-S42

COMBAT CASUALTY
RESUSCITATION
CURRENT CONCEPTS
1. Limited or small volume
resuscitation
2. Permissive hypotension
3. Intraosseous infusion (IO)

SMALL-VOLUME RESUSCITATION
IN HYPOTENSIVE COMBAT
CASUALTY
To compensate for the logistic
problems
HSD: Hypertonic Saline Dextran (
7,5% NaCl / 6% Dextran-70)
Single dose, small-volume, in
short time 10-20 minutes
Intraosseous route

Majalah Defender 3 Mei 2006

Commando Vol II Edisi No.6, 2006

Majalah Defender 3 Mei 2006

PHYSIOLOGIC BENEFITS OF HSD

Rapid osmotic mobilization of cellular water into
the blood volume
Volume expansion of HSD is equal to 10 times that
of RL
Hyperosmotic vasodilatation of both systemic and
pulmonary vessels
cardiac effectiveness because of preload and
afterload (vasodilatation)
cardiac contractility
HSD has been shown to be effective and safe with
preexisting dehydration
Animal studies : osmolarity prevent T-cell
depression and neutrophil activation
survival in head and penetrating injury patient

PERMISSIVE HYPOTENSION
US Army: to improve field resuscitation, with
expecting delayed resuscitation and limited
availibility of resources
To avoid re-bleeding
Mostly in animal studies: BP 40-60 mm Hg
resulted in longer survival than MAP 80 mm Hg
Still in questions :
Late complication from incomplete
resuscitation?
BP 80 mm Hg would be inadequate to
improve cerebral perfusion after head injury

Hemodynamic responses to smallvolume hyperoncotic-hyperosmotic

resuscitation

Kramer GC. J. Trauma. 2003;54 :

Early and Long-Term

Survival

Cardiac output in 4 groups

Kramer GC. J. Trauma. 2003;54 :

S89-99

Early and Late Plasma volume

Expansion

Kramer GC. J. Trauma. 2003;54 :

S89-99

INTRAOSSEOUS INFUSION
(IO)

Easy and rapid to apply

Consistent with the concept of smallvolume resuscitation with HSD
Be careful with probability of local
complications

FAST package

FAST bone probe cluster,

infusion tube on the center
needle

FAST infusion tube in

position
Pyng medical, Calkins MD J. Trauma 2000 no.6,

The
BIG

The
JN

The SF

Calkins MD J. Trauma 2000

INTRAOSSEOUS INFUSION DEVICES

FDA approved
FAST : First Access for Shock and Trauma
(Pyng Medical)
BIG : Bone Injection Gun (Wais Medical)
SF : SurFast (Cook Crtical)
JN : Jamshidi Needle (Baxter)
Site of infusion:
FAST : Sternum-manubrium, midline, + 1,5
cm below sternal notch
BIG, SF, JN : Medial Proximal Tibia or Distal
Medial Tibia
Other sites : femur, iliac crest, humerus,
radius and clavicle

ADVANCED TRAUMA LIFE SUPPORT

ATLS
Systemic standardized approach to the
treatment of trauma casualties that has
been successful in civilian trauma
Medical training for Arm Forces in many
countries is currently based on the
principles taught in ATLS course, which
was applied to the combat environment
and termed Military Life Support

INITIAL FLUID RESUSCITATION OF

COMBAT CASUALTIES -1
The single major cause of death in
potentially salvageable battlefield
casualties is hemorrhage
Approximately 20% of these death
are preventable if the bleeding can be
quickly controlled or minimized and
treated by appropriate resuscitation
fluids

INITIAL FLUID RESUSCITATION OF

COMBAT CASUALTIES -2
Resuscitation with isotonic crystalloids,
including RL and artificial colloids, elicit
severe immune activation and an upregulation of cellular injury markers.
This effect is not seen with plasma, natural
colloids (albumin) and fresh whole blood
Hypertonic fluids cause suppression of
neutrophil activation and a milder increase
in the expression of cell injury markers

ENDOTHELIAL-LEUKOCYTE
INTERACTION

Rhee P, Koustova E and Alam H.B, J Trauma

2003; 54 : S52-S62

Chaudry IH etal J Trauma, 2003;54 : S118-

PASSAGE OF NEUTROPHILS FROM THE

VASCULATURE TO THE AREA OF INJURY
OR INFECTION

Pascual J.L etal, J Trauma 2003 ;54 : S133-S140

MICROVASCULAR DISTURBANCES
IN SIRS

Pascual J.L etal, J Trauma 2003 ;54 : S133-S140

INTRAVITAL
VIDEOMICROSCOPY 90
MINUTES AFTER RL
RESUSCITATION
The Rolling
Adherent
Leucocytes

LEUCOCYTE ADHESION WITH

DIFFERENT FLUID
RESUSCITATION

Pascual J.L etal, J Trauma 2003 ;54 :

PROLONGED SHOCK AND

MODS
Shock is a syndrome of hypotension of
sufficient severity to elicit signs and
symptoms of end-organ hypoperfusion
Profound vasoconstrictor response is
typical of acute hemorrhagic shock and
acute cardiogenic shock.
Prolonged hemorrhage or cardiogenic
shock may evolve into a late
irreversible phase caracterized by
vasodilatation

VASCULAR SMOOTH MUSCLE TONE IN

ACUTE HEMORRHAGIC SHOCKVASOCONSTRICTION

Rabin J K et al, J Trauma 2003, 54: S149-

VASCULAR SMOOTH MUSCLE TONE IN

IRREVERSIBLE HEMORRHAGIC SHOCKVASODILATATION

Rabin J K etal, J Trauma 2003, 54: S149-

VASOPRESSIN BLOCKADE OF
VASODILATATION

Rabin J K etal, J Trauma 2003, 54: S149-

Van Way III C.W et al , J Trauma 2003, 54 :

Algorithm for restoration of

oxygen transport
Clinical hypermetabolism
Control hemorrhage
Yes
Drain abscess
Adequate source control
No
Debride dead tissue
and
Flow-dependent oxygen consumption
Flow-dependent lactate production
No Yes
Metabolic support Preload assessment
add volume
Adequate
Afterload assessment add vasodilator
Adequate
Inotropic assessment add inotrope
Adequate
Consider vasopressor add vasopressor

Hypotension
Pasquale et al. Critical Care. In: Basic Surgery 1995. P.198

CONCLUSIONS
1. The current practice of using largevolume isotonic crystalloid infusion
alone for combat resuscitation is not
optimal
2. Fluid resuscitation of controlled
hemorrhage in the battle field, should
be an initial 250 ml infusion of HSD,
administered slowly 10-15 minutes,
followed by a second 250 ml at HSD
only in these pts who fail to stabilize

CONCLUSIONS
3. The infusion of HSD may be followed by
isotonic crystalloid alone as care progresses
4. Permissive hypotensive resuscitation has
been introduce to avoid re-bleeding and
worsen outcome of severe hemodilution
5. I.V. catheter placement remains the gold
standard for vascular access and should not
be replace, but in situations such as shock,
intraosseous (IO) infusion may provide an
alternative route of vascular approach