The need for optimized crystalloid-based resuscitation

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Hemorrhage remains the major cause of trauma mortality, responsible for over 90% of all battlefield deaths. Bleeding should be stopped as quickly as possible. However, data have shown that majority of the preventable deaths from hemorrhage involve the trunk—also known as noncompressible torso hemorrhages.1 Controlling such bleeding requires surgical interventions that are unavailable at the point of injury. To bridge this gap in capabilities and maintain end-organ perfusion and oxygenation, alternative and supplemental treatment methods are needed. Volume resuscitation using intravenous fluids is such a method, aimed at expanding the intravascular volume, increasing preload and thus cardiac output and ultimately improving tissue perfusion. These are, of course, needed regardless of whether the cause of shock is a compressible or noncompressible hemorrhage.
A decade's long, rigorous debate regarding the optimal resuscitation strategy has been raging continuously, probably since the invention of the second intravenous formula (lactated Ringer's [LR] solution).2 Numerous volume resuscitation protocols have been developed and updated during the last decades.3–6 Similarly, a variety of resuscitation fluids and medications are being used: crystalloids (isotonic or hypertonic), colloids, artificial oxygen carriers, blood substitutes, pharmacologic agents, and blood products—that have been falling in and out of favor over the years. Several leading professional organizations have recently been promoting the use of blood products as the resuscitation fluids of choice for the point of injury and prehospital care.5,6 Although probably offering important physiologic and scientific advantages, such recommendations are less relevant to most of the casualties and their care providers. The aim of this article is to assist providers in optimizing volume resuscitation using the available fluids and call for continuous efforts to close the gap between the scientific, ideal treatments and the practical reality.
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