Trauma — Resuscitation Fluid in Haemorrhagic Shock
A 30-year-old man is brought in after a high-speed motor vehicle collision. Focused ultrasound shows free intraperitoneal fluid. After 1 L of warmed Ringer's lactate, his blood pressure rose briefly from 82/50 to 100/62 mm Hg but has fallen again to 84/52 mm Hg, with pulse 130 beats/min. Haemoglobin is 60 g/L. Which fluid should be given next?
- A.A further 2 L of normal saline
- B.Packed red blood cellsCorrect
- C.A further 2 L of Ringer's lactate
- D.Hydroxyethyl starch colloid
Explanation
This man has haemorrhagic shock from intra-abdominal bleeding and has responded only transiently to an initial crystalloid bolus, which signals ongoing blood loss. Advanced Trauma Life Support guidance limits initial crystalloid to about 1 L in adults and then moves early to blood products, ideally in a balanced ratio of plasma, platelets and red cells through a massive transfusion protocol, while arranging definitive haemorrhage control by laparotomy or angioembolisation. A haemoglobin of 60 g/L, which may still underestimate the true loss early after injury, confirms that oxygen-carrying capacity must be restored. Packed red cells, uncrossmatched group O if needed, are the right next fluid. More normal saline or Ringer's lactate dilutes clotting factors and red cells, worsens acidosis and hypothermia, and is linked to greater bleeding and mortality; large volumes of saline also cause hyperchloraemic acidosis. Synthetic starches raise the risk of kidney injury and coagulopathy and are not used in bleeding trauma patients. Tranexamic acid should also be given if within 3 hours of injury, and permissive hypotension is accepted until bleeding is controlled, except in head injury.
Why each option
- A.
- Further large-volume saline dilutes clotting factors and causes hyperchloraemic acidosis, worsening bleeding in a transient responder to crystalloid.
- B.
- Correct. Transient response to crystalloid with haemoglobin 60 g/L signals ongoing haemorrhage requiring early blood transfusion and haemorrhage control.
- C.
- Balanced crystalloid is the right initial fluid, but more than about 1 L worsens dilutional coagulopathy instead of restoring oxygen delivery.
- D.
- Hydroxyethyl starch increases acute kidney injury and coagulopathy and has no role in resuscitating bleeding trauma patients.
Reference: ATLS Advanced Trauma Life Support, 10th edition (American College of Surgeons, 2018); European guideline on management of major bleeding and coagulopathy following trauma, 6th edition (Rossaint et al., Crit Care 2023)
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