Table 4.

Fluid resuscitation and adjuncts in haemorrhagic shock. AKI: acute kidney injury; CNS: central nervous system; HES: hydroxyethyl starch solution; ICU: intensive care unit; MA: metabolic acidosis; PRBCs: packed red blood cells; TBI: traumatic brain injury

Agent	Advantages	Disadvantages	Notes
CRYSTALLOIDS 0.9% Normal Saline (‘unbalanced’)	Readily available, familiar; compatible with most medications and blood products	Not ‘physiologic’ (high chloride load); excess administration leads to AKI and MA (2C)	Bolus to effect after bleeding controlled. (1A)
Ringer’s lactate/ acetate (‘balanced’); Plasmalyte	Readily available; ‘physiologic’	Slightly hypotonic; excess administration worsens TBI (1C)	May reduce incidence of AKI and mortality in ICU. Bolus with control of bleed (1A)
Hypertonic saline solution	Low weight and volume (easier to transport); thermal stability; safe	May interfere with coagulation in patients with severe TBI	NaCl concentration > 0.9%; may expand volume, no long term survival benefit or improved CNS outcome vs. NaCl 0.9%
COLLOIDS Albumin, hydroxyethyl starch (HES), Dextran	Used as volume expander	Expensive; no proven mortality benefit. HES may increase harm in some subgroups.	Prehospital data still rare. HES may impair coagulation
PACKED RED BLOOD CELLS / PLASMA / WHOLE BLOOD	May improve survival or physiology, for Hb < 7 g/dL; lyophilised plasma is used in damage control	Inconvenient in out-of-hospital environment; ARDS/ transfusion reactions	Used by few centres; PRBCs:plasma: platelets 1:1:1 or 2:1:1 (1B), or fibrinogen 0.5 g per unit PRBCs (1C) in hospital
VASOPRESSORS	Use after adequate volume replacement (1C), Push-dose pressors simple; cardiac dysfunction: epinephrine	Does not treat cause; uncertain long-term benefit; dosing errors,; uncertain benefit (haemorrhage)	Constricts capacitance vessels; used in airway management / TBI with hypotension