What is the best approach to resuscitation in trauma?

Exsanguinating trauma is a major cause of death from trauma. Fluid resuscitation strategies have evolved remarkably since the 1980’s. Crystalloids, particularly lactated Ringer’s solution, were the initial fluids of choice before administering blood products. Subsequent studies have demonstrated that balanced crystalloids are likely better than normal saline and that hypertonic saline or colloids have little benefit. For patients with severe hemorrhagic shock, however, early administration of blood products, including packed red blood cells, plasma, and platelets, as part of a damage control resuscitation strategy, improves outcomes. Large amounts of crystalloids should be avoided. Monitoring thromboelastography may help. In select patients, this strategy may include administration of tranexamic acid or prothrombin complex concentrates. For patients with evidence of ongoing hemorrhage, hypotensive or limited fluid resuscitation is appropriate until hemostasis has been achieved. Details of optimal fluids or blood pressure goals still need to be determined. Once hemostasis has been achieved, fluid resuscitation should continue in order to achieve appropriate endpoints, which may include normalization of vital signs and urine output, decreasing lactate level or base deficit, or a minimization of additional fluid responsiveness based upon echocardiography or pulse waveform analysis.