Early Goal-directed Approach

In general, an aggressive early goal-directed approach to maximise oxygen delivery is indicated – as in sepsis and early management of sick surgical patients – although caution may need to be exercised in some situations. Penetrating chest trauma is such an example, where normalisation of blood pressure with fluid resuscitation prior to surgical haemostasis may worsen the outcome [10,31,33]. If presentation or recognition of the shock state occurs too late goal-directed therapy may be counterproductive [34-35].

In the majority of cases, the initial and critical element of therapy (together with high flow supplemental oxygen) will be fluid boluses. These should be small volumes (e.g. 250ml), given quickly (i.e. over 5–10 minutes) with reassessment after each. There is no evidence that ordinary crystalloid (normal saline or Hartmann’s) is inferior to colloid [36].

Given the key role of haemoglobin concentration in determining oxygen delivery it is important that it is maintained with judicious transfusion [31]. Excessive transfusion is unwise as it has been found to be of no benefit and possibly a risk in critically ill patients. A reasonable target is around 7–9g/dl in otherwise healthy non-trauma patients [37-38].