Preoperative resuscitation of the trauma patient

The traditional approach to trauma patients with presumed internal hemorrhage has been immediate, aggressive intravenous fluid resuscitation. Recent experimental and clinical data, however, suggest a more discriminating approach that first considers concurrent head injury, hemodynamic stability and the presence of potentially uncontrollable hemorrhage (e.g. deep truncal injury) versus a controllable source (e.g. distal extremity wound) as well as the use of new techniques to inhibit bleeding and better ways to monitor the patient's condition.

Evolving data suggest that while aggressive fluid infusions could be used for patients with isolated extremity, thermal or head injury, they should be limited in conditions with potentially uncontrollable internal hemorrhage, and particularly in patients with penetrating truncal injury being transported immediately to a trauma center. Likewise, the minute volume of positive pressure ventilatory support should be limited with potential severe hemorrhage due to the secondary reductions in venous return. For trauma patients with severe bleeding there is growing evidence for the increased use of plasma and factor VIIa, as well as tourniquets, intraosseus devices and evolving monitoring techniques.

Owing to the growing societal threat of trauma, further research, including studies already under way, will be critical to delineate the timing and technique of infusing advantageous resuscitative fluids such as hypertonic saline and hemoglobin-based oxygen carriers as well as the use of hemostatic agents and special blood products.