Hemorrhage Control and Fluid Resuscitation

'25 refresher

What are the ABCs of hemorrhagic shock treatment?

• Airway

• Breathing

• Circulation

Is there a beneficial "shock position" for patients in hemorrhagic shock?

• Trendelenburg Position (originated in 1800s for surgical exposure)

• No evidence of benefit in shock patients

What are two mechanical methods to control hemorrhage?

1. Pelvic binders – reduce pelvic volume, create tamponade effect

2. Tourniquets – proven safe and effective, especially in combat trauma

What are hemostatic dressings made from, and how do they work?

• Made from volcanic rock, clay, or shells

• Mechanism:

  • Direct compression

  • Activation of clotting

  • Adhesion to wound

• Advantages: Pliable, fast to apply, and effective under fire

What are key principles for IV access in trauma?

• Use large-bore, short-length catheters (14–16G, 2 inches)

• Best site: Antecubital

• Simultaneous attempts by two providers

• Use 2–3 sites for major trauma

• Progression: Peripheral → Femoral → Subclavian

When should intraosseous (IO) access be considered?

• Use early as a rescue device if IV attempts fail or access is delayed

Where should IV access be avoided in trauma?

• Injured limb

• Distal to possible vascular injury

• Femoral access when there's trauma below the diaphragm

Is IV placement at the trauma scene supported by evidence?

• No evidence supports on-scene IVs

  • Preferred: En route placement

• Limit: 2 attempts → then use IO

• Use saline lock/keep open – avoid continuous fluids

• Use 250cc boluses titrated to palpable radial pulse

What are risks of too little fluid resuscitation?

• Ongoing shock

• Acidosis

• Coagulopathy

• Myocardial dysfunction

• Renal failure

• Death

What are risks of too much fluid?

• Increased bleeding

• Clot disruption

• Dilution of clotting factors

• Compartment syndrome

• Transfusion-related complications (e.g., TRALI, immunosuppression, inflammation)

How is total body water distributed?

• 60% of body weight = water

  • 2/3 Intracellular Fluid (ICF)

  • 1/3 Extracellular Fluid (ECF)

How do fluids distribute in IVS vs ISS? (CHECK SLIDE)

Fluid	IVS	ISS
D5W	~10%	~90%
NS	~25%	~75%
LR	~25%	~75%

What are key differences between Normal Saline (NS) and Lactated Ringers (LR)?

Solution	Contents	Pros	Cons
NS	Na, Cl	Fluid of choice for blood	Causes hyperchloremic acidosis
LR	Na, Cl, K, Ca, Lactate	Fluid of choice for ATLS	May modulate immune system

Why are isotonic crystalloids limited in effectiveness?

• Only 25% remains in the vascular space after 17 minutes

What is the concept of small volume resuscitation?

• Use hypertonic/hyperosmotic fluids to:

  • Remain in vascular space longer

  • Restore volume without overloading

• Originally used in military, now in civilian trauma

Examples:

• Hetastarch (Hespan/Hextend)

• Hypertonic Saline (3% to 7.5%)

What is hetastarch and how does it work?

• Plasma volume expander

• 500cc expands blood volume by ~800cc

• Effective and safe at 500cc dose

⚠ Cautions:

• Large doses (>2L) can cause Coagulopathy and renal dysfunction concern

What does hypertonic saline do in resuscitation?

(3%–7.5%) Sodium Chloride

• Pulls fluid into bloodstream rapidly

• Stabilizes BP, cardiac output (CO)

• Helps control intracranial pressure (ICP)

📌 Caveat:

• Large RCTs showed no clear survival benefit

What’s the equivalent volume effect of hypertonic solutions?

• 250ml Hypertonic Saline ≈ 1L NS or LR

What’s the golden rule regarding fluid use in trauma?

"If it doesn’t carry oxygen or it doesn’t clot – don’t give it to me."
→ Reflects the need to prioritize blood and clotting products over excess fluids.