Fluid resuscitation of the patient with major trauma

Current reviews and consensus documents now recommend a more discriminating approach to the traditional practices of delivering liberal infusions of intravenous fluid to all major trauma patients with suspected or known major hemorrhage. The evolving evidence suggests that aggressive fluid resuscitation prior to hemostasis leads to additional bleeding through hydraulic acceleration of hemorrhage, soft clot dissolution, and dilution of clotting factors. Aggressive preoperative fluid infusion is still considered appropriate for unconscious patients without palpable blood pressure or for those with controllable hemorrhage (e.g. isolated extremity or head injury), However, the latest recommendations are to limit or delay intravenous fluid resuscitation preoperatively in those with uncontrollable hemorrhage (e.g. those with penetrating torso injuries), even if they are hypoperfusing. Although most clinicians still generally support fluid resuscitation for multisystem blunt trauma, particularly with head injury, the most recent experimental data have begun to challenge this traditional practice as well, suggesting a 'slow infusion' approach when there is risk for uncontrolled internal bleeding. By providing oxygen delivery with slow, limited infusion, new hemoglobin-based oxygen carriers might help to resolve the current dilemma of having to limit preoperative resuscitation when there is risk of uncontrolled hemorrhage.