Table 4 Fluid resuscitation and adjuncts in haemorrhagic shock. AKI: acute kidney injury; CNS: central nervous system; HES: hydroxyethyl starch solution; ICU: intensive care unit; MA: metabolic acidosis; PRBCs: packed red blood cells; TBI: traumatic brain injury

CRYSTALLOIDS

0.9% Normal Saline (‘unbalanced’)

Readily available, familiar; compatible with most medications and blood products

Not ‘physiologic’ (high chloride load); excess administration leads to AKI and MA (2C)

Bolus to effect after bleeding controlled. (1A)

Ringer’s lactate/ acetate (‘balanced’); Plasmalyte

Readily available; ‘physiologic’

Slightly hypotonic; excess administration worsens TBI (1C)

May reduce incidence of AKI and mortality in ICU. Bolus with control of bleed (1A)

Hypertonic saline solution

Low weight and volume (easier to transport); thermal stability; safe

May interfere with coagulation in patients with severe TBI

NaCl concentration > 0.9%; may expand volume, no long term survival benefit or improved CNS outcome vs. NaCl 0.9%

COLLOIDS

Albumin, hydroxyethyl starch (HES), Dextran

Used as volume expander

Expensive; no proven mortality benefit. HES may increase harm in some subgroups.

Prehospital data still rare. HES may impair coagulation

PACKED RED BLOOD CELLS / PLASMA / WHOLE BLOOD

May improve survival or physiology, for Hb < 7 g/dL; lyophilised plasma is used in damage control

Inconvenient in out-of-hospital environment; ARDS/ transfusion reactions

Used by few centres; PRBCs:plasma: platelets 1:1:1 or 2:1:1 (1B), or fibrinogen 0.5 g per unit PRBCs (1C) in hospital

VASOPRESSORS

Use after adequate volume replacement (1C), Push-dose pressors simple; cardiac dysfunction: epinephrine

Does not treat cause; uncertain long-term benefit; dosing errors,; uncertain benefit (haemorrhage)

Constricts capacitance vessels; used in airway management / TBI with hypotension