Fluid Resuscitation

Aggressive fluid resuscitation without adequate haemostasis has been demonstrated to dilute clotting factors and potentially dislodge clots. Maintaining a normal blood pressure may worsen bleeding. If there is ongoing and brisk bleeding, it may be impossible to adequately resuscitate a patient until the tap is switched off.

Examples of this situation would be a significant liver and spleen injury, or injury to one of the large intra-abdominal vessels. Continued fluid administration in this setting will eventually serve to haemodilute and impair coagulation. Immediate CT should be carried out and transfer from there to the angiographic suite if available or operating theatre depending on findings.

Table 1 outlines general guidelines for establishing the amount of fluid and blood likely required during resuscitation. If the amount of fluid required to restore or maintain adequate organ perfusion and tissue oxygenation greatly exceeds these estimates, carefully reassess the situation and search for unrecognized injuries and other causes of shock.

Table 1 responses to initial fluid resuscitation

Vital signs  Return to normal  Transient improvement, recurrence of decreased blood pressure and increased heart rate  Remain abnormal 
Estimated blood loss  Minimal (<15 % )  Moderate and ongoing (15%–40%)  Severe (>40%) 
Need for blood  Low  Moderate to high  Immediate 
Blood preparation  Type and crossmatch  Type-specific  Emergency blood release 
Need for operative intervention  Possibly  Likely  Highly likely 
Early presence of surgeon  Yes  Yes  Yes 

Learning Bite

Continuing abnormal physiology despite aggressive fluid resuscitation mandates early surgical intervention to turn off the tap.