ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES

:: Management of Hypovolaemic Shock
in the Trauma Patient
b
l
o
o
d
O
-
n
e
g
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovaolaemicShock_FullRCvR.qxd 3/2/07 3:03 PM Page 1
Suggested citation:
Ms Sharene Pascoe, Ms Joan Lynch 2007, Adult Trauma Clinical Practice Guidelines,
Management of Hypovolaemic Shock in the Trauma Patient,
NSW Institute of Trauma and Injury Management.
Authors
Ms Sharene Pascoe (RN), Rural Critical Care Clinical Nurse Consultant
Ms Joan Lynch (RN), Project Manager, Trauma Service, Liverpool Hospital
Editorial team
NSW ITIM Clinical Practice Guidelines Committee
Mr Glenn Sisson (RN), Trauma Clinical Education Manager, NSW ITIM
Dr Michael Parr, Intensivist, Liverpool Hospital
Assoc. Prof. Michael Sugrue, Trauma Director, Trauma Service, Liverpool Hospital
This work is copyright. It may be reproduced in whole or in part for study
training purposes subject to the inclusion of an acknowledgement of the source.
It may not be reproduced for commercial usage or sale. Reproduction for purposes
other than those indicated above requires written permission from the NSW Insititute
of Trauma and Injury Management.
© NSW Institute of Trauma and Injury Management
SHPN (TI) 070024
ISBN 978-1-74187-102-9
For further copies contact:
NSW Institute of Trauma and Injury Management
PO Box 6314, North Ryde, NSW 2113
Ph: (02) 9887 5726
or can be downloaded from the NSW ITIM website
http://www.itim.nsw.gov.au
or the
NSW Health website http://www.health.nsw.gov.au
January 2007
HypovaolaemicShock_FullRCvR.qxd 3/2/07 3:03 PM Page 2
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE i
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Important notice!
blood
O-neg
'Management of Hypovolaemic Shock in the Trauma Patient’ clinical practice guidelines are
aimed at assisting clinicians in informed medical decision-making. They are not intended to
replace decision-making. The authors appreciate the heterogeneity of the patient population
and the signs and symptoms they may present with and the need to often modify
management in light of a patient's co-morbidities.
The guidelines are intended to provide a general guide to the management of specified
injuries. The guidelines are not a definitive statement on the correct procedures, rather they
constitute a general guide to be followed subject to the clinicians judgement in each case.
The information provided is based on the best available information at the time of writing,
which is December 2003. These guidelines will therefore be updated every five years and
consider new evidence as it becomes available.
These guidelines are intended for use in adults only.
All guidelines regarding pre-hospital care should be read and
considered in conjunction with NSW Ambulance Service protocols.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page i
::
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page ii
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE iii
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Contents
blood
O-neg
Algorithm 1 ::
The management of hypovolaemic
shock in the trauma patient ......................................1
Summary of guidelines.....................................3
1 Introduction................................................5
2 Methods.....................................................6
3 How do you know when the
patient is in hypovolaemic shock? ............8
4 How do you find the sources of bleeding
in a hypotensive trauma patient? ............10
5 What is the best management
of the bleeding patient?...........................12
6 If fluid resuscitation is indicated,
what type of fluid should be given? ........15
7 What are the endpoints of fluid
resuscitation in the trauma patient?........17
Evidence tables
Evidence Table 1. How do you know when
a trauma patient is in
hypovolaemic shock?...................22
Evidence Table 2. How do you find the sources
of bleeding in a hypotensive
trauma patient?...........................26
Evidence Table 3. What is the best management
of the bleeding patient? ..............27
Evidence Table 4. If fluid resucitation
is indicated, what type
of fluids should be used?.............31
Evidence Table 5. What are the endpoints
of fluid resuscitation in
the trauma patient?.....................37
Appendices
APPENDIX A ::
Search Terms used for the identificaion of studies ...44
References .....................................................46
List of tables
Table 1. Levels of evidence ......................................11
Table 2. Codes for the overall assessment
quality of study checklists ...........................11
Table 3. Complications of blood transfusions...........15
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page iii
::
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page iv
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 1
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Algorithm 1 :: The management of hypovolaemic shock in the trauma patient
The Management of Hypovolaemic Shock in the Trauma Patient
If definitive care is not available in your facility make early contact with retrieval services
Primary survey
Includes organising the trauma team, calling the surgeon and notifying the blood bank.
Also consider early call to Retrieval Services (AMRS 'formerly MRU' 1800 650 004).
REMEMBER – BP and HR will not identify all trauma patients who are in shock.
ASSESS – History and perfusion indices – ABG's, base deficit, lactate, Hb and HCT.
In the presence of uncontrolled haemorrhage and a delay of greater than 30 minutes to operative haemostasis,
infuse small aliquots (100-200mls) of fluid to maintain systolic blood pressure between 80-90mmHg. Use caution in
the elderly. Contraindicated in the unconscious patient without a palpable blood pressure. Maintain the systolic blood
pressure >90mmHg for those with a traumatic brain injury.
SIGNS OF SHOCK? Perform Secondary Survey
Identify the source of haemorrhage
Airway /
C-spine
1
Protect airway,
secure if
unstable.
1
Airway adjunct
as needed.
1
Control of
c-spine.
Circulation
1
Secure venous
access x 2
large bore
cannula.
1
Bloods:
– x-match
– FBC
– EUC's
– Creatinine
– ABG's
– Blood ETOH.
1
Control
external
bleeding.
Disability
1
Assess
neurological
status.
1
AVPU:
– alert
– responds
to vocal
stimuli
– responds
to painful
stimuli
– unresponsive.
Exposure /
Environment
1
Undress
patient.
1
Maintain
temperature.
Adjuncts
1
X-ray:
– chest
– pelvis
– lateral
c-spine.
Breathing
1
Definitive
control of
airway.
1
Oxygen.
1
Bag and
mask.
External
1
Careful visual
inspection.
Long bones
1
Careful visual
inspection.
Chest
1
Chest x-ray.
Abdomen
1
DPA* and
/ or FAST**.
Retroperitoneum
1
Pelvic x-ray.
External
1
Apply direct
pressure.
1
Suture
lacerations.
Interventions
Long bones
1
Splint + / -
reduce #.
Chest
1
Chest tube.
Abdomen
1
Emergency
Laparotomy.
Retroperitoneum
1
Externally
stabilise pelvis.
1
Emergency
angiogram.
* Diagnostic Peritoneal Aspiration (DPA). >10mls of frank blood = positive DPA.
** Focused Abdominal Sonography in Trauma (FAST). Free fluid = positive FAST.
NO
YES
N
S
W

I
n
s
t
it
u
t
e

o
f

T
r
a
u
m
a

a
n
d

I
n
ju
r
y

M
a
n
a
g
e
m
e
n
t

©

J
a
n
u
a
r
y

2
0
0
7



S
H
P
N
:

(
T
I
)

0
7
0
0
3
4
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 1
::
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 2
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 3
Summary of guidelines
blood
O-neg
When the haemodynamically unstable patient enters the resuscitation room, IV
a primary survey with full exposure takes place. Carefully inspect for external
bleeding sources and examine the long bones. If x-ray facilities are available,
a supine chest x-ray and pelvic x-ray should be obtained within 10 minutes
of arrival. The CXR will identify any large haemothorax. If the pelvic x-ray
shows a pelvic fracture, the remaining two sites of significant bleeding are
the abdomen and the pelvic retroperitoneum. The options for assessing
the abdomen are DPA and / or FAST.
GUIDELINE LEVEL OF EVIDENCE
Blood pressure and heart rate will not identify all trauma patients III-2
who are in shock. Assessment of the trauma patient should include:
:: arterial blood gases and assessment of base deficit
:: haemoglobin
:: lactate
:: haematocrit.
These tests are only of value when interpreted in a series,
therefore should be repeated.
GUIDELINE LEVEL OF EVIDENCE
How do you know when the patient is in hypovolaemic shock?
GUIDELINE LEVEL OF EVIDENCE
What is the best management of the bleeding patient?
:: Establish patent airway. III-2
:: Ensure adequate ventilation and oxygenation.
:: Secure venous access – large bore cannula x 2.
:: Control any external bleeding by applying direct pressure.
:: Rapidly identify patients requiring operative haemostasis.
:: Establish prompt contact with the major referral hospital and retrieval service.
In the presence of uncontrolled haemorrhage and a delay of greater than II
30 minutes to operative haemostasis, infuse small aliquots of fluid (100-200mls)
to maintain systolic blood pressure between 80-90mmHg. Use caution in the
elderly. Contraindicated in unconscious patients without a palpable blood
pressure and those with traumatic brain injury (see over leaf).
How do you find the sources of bleeding in a hypotensive trauma patient?
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 3
PAGE 4 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
Summary of guidelines
blood
O-neg
:: Early use of blood, if available, remains the optimal resuscitation fluid Consensus
for the hypovolaemic patient. Use with caution due to numerous complications.
:: Where blood is not available or delayed, Compound Sodium Lactate II
(Hartmanns) is the preferred alternative for the initial resuscitation of the
hypovolaemic trauma patient. Caution should be exercised in the trauma
patient with liver disease.
:: 0.9% Normal Saline is also an acceptable alternative. Large volumes,
however may result in metabolic acidosis.
GUIDELINE LEVEL OF EVIDENCE
If fluid resuscitation is indicated, what type of fluid should be given?
Traditional haemodynamic parameters do not adequately quantify the degree III-2
of physiological derangement in hypovolaemic trauma patients. If point of care
blood gas analysis is available base deficit and lactate levels should be used to
identify the magnitude of tissue oxygen debt and the adequacy of resuscitation.
These tests are only of value when interpreted in a series, therefore should
be repeated.
A persistently high or increasing base deficit indicates the presence of ongoing
blood loss or inadequate volume replacement.
In the absence of point of care blood gas analysis capability the restoration Consensus
of a normal mentation, heart rate, skin perfusion and urine output and maintain
ing the systolic blood pressure at 80-90 mmHg serve as the end point of
resuscitation.
GUIDELINE LEVEL OF EVIDENCE
What are the endpoints of fluid resuscitation in the trauma patient?
GUIDELINE LEVEL OF EVIDENCE
What is the best management of the bleeding patient? continued...
In the presence of uncontrolled haemorrhage in the patient with a concurrent I
traumatic brain injury, prevention of secondary brain injury from hypotension
is crucial as a systolic blood pressure <90mmHg is associated with poor outcomes.
Infuse small aliquots of fluid (100-200mls) to maintain systolic blood pressure
above 90mmHg.
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 4
Despite significant advances in the management
of trauma victims, traumatic injury remains
the fifth leading cause of death in Australia.
A significant number of these deaths are the result
of hypovolaemic shock. Acute blood loss following
injury leads to a depression of organ and immune
function that, if prolonged, progresses to the
sequential failure of multiple organ systems.
1
Timely diagnosis, surgical control of on-going loss
and physiologically directed fluid replacement remain
the cornerstones of management. In recent years,
however, the practice of rapid fluid replacement
has been questioned.
Early recognition of hypovolaemic shock is vital
for optimal care of the injured patient. Ongoing
controversy exists regarding the diagnosis of
occult shock and the ideal resuscitation scheme.
Advancement in technology and pharmacology
has added more treatment options to care for the
bleeding patient. This guideline aims to objectively
analyse the literature to provide the clinician with
evidence-based options. The guidelines will also seek
to establish the optimal care of the bleeding patient
in the rural setting where resources may be lacking
and access to definitive care is delayed.
This guideline has been developed to provide
evidence-based recommendations for the
management of hypovolaemic shock in
the trauma patient.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 5
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
1 Introduction
blood
O-neg
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 5
2.1 Scope of the guideline
This guideline is intended for use by all clinicians
who are involved in the initial care of patients with
hypovolaemic shock: ambulance officers, emergency
nurses, and physicians.
This guideline has been developed to assist clinicians
to provide a selective evidence based approach to the
management of trauma patients with hypovolaemic
shock. It is recognised that this guideline will not
suit all clinical situations.
These guidelines are not prescriptive, nor are
they rigid procedural paths. The guidelines rely
on individual clinicians to decipher the needs of
individuals. They aim to provide information on
what decisions can be made, rather than dictate
what decisions should be made.
2.2 Aims and objectives
of the guideline
This guideline aims to summarise the available
evidence to allow clinicians to make evidence-based
decisions in the diagnosis and management of trauma
patients with hypovolaemic shock.
A multidisciplinary team was consulted to aid in the
identification of the key clinical dilemmas that faced
clinicians when caring for patients with hypovolaemic
shock. By identifying the key clinical questions, the
guideline should facilitate:
:: early diagnosis of hypovolaemic shock
:: identification of the source(s) of bleeding
:: enhancement of tissue perfusion while minimising
ongoing haemorrhage.
PAGE 6 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
2 Methods
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
blood
O-neg
The clinician using this guideline can identify:
:: when the patient is in hypovolaemic shock
:: how to find the sources of bleeding
in a hypotensive trauma patient
:: what is the best management of the
bleeding patient
:: over what timeframe a hypovolaemic trauma
patient should be fluid resuscitated
:: what type of fluids should be used if required
:: what the endpoints of fluid resuscitation
in the hypovolaemic trauma patient.
2.3 Inclusion and exclusion
Inclusion criteria
Meta-analysis
Randomised control trials
Controlled clinical trials
Case series
Population aged >16 years
Traumatic hypovolaemic shock
Exclusion criteria
Case reports
Paediatric <15 years
Hypovolaemic shock secondary to burns
or non-traumatic (sepsis, dehydration)


HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 6
2.4 Strength of the evidence
2.4.1 Level of evidence
The articles were classified according to their general purpose and study type.
Table 1. Levels of evidence
2-4
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 7
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: METHODS
2.4.2 Quality appraisal
The included articles were appraised according to the NHMRC. The MERGE assessment tool.
5
The articles were rated for quality on a 4-point scale as follows:
Table 2. Codes for the overall assessment quality of study checklists
Level I Evidence obtained from a systematic review of all relevant randomised control trials
Level II Evidence obtained from at least one properly-designed randomised control trial.
Level III-1 Evidence obtained from well-designed pseudo-randomised controlled trials
(alternate allocation or some other method).
Level III-2 Evidence obtained from comparative studies (including systematic reviews of such studies) with concurrent controls
and allocation not randomised, cohort studies, case-control studies, or interrupted time series with a control group.
Level III-3 Evidence obtained from comparative studies with historical control, two or more
single arm studies or interrupted time series without a parallel control group.
Level IV Evidence obtained from a case-series, either post-test or pre-test / post-test
Low risk of bias A All or most evaluation criteria from the checklist are fulfilled,
the conclusions of the study or review are unlikely to alter.
Low-moderate risk of bias B1 Some evaluation criteria from the checklist are fulfilled. Where evaluation
criteria are not fulfilled or are not adequately described, the conclusions
of the study or review are thought unlikely to occur.
Moderate – High risk of bias B2 Some evaluation criteria from the checklist are fulfilled. Where evaluation criteria
are not fulfilled conclusions of the study or review are thought likely to alter.
High risk of bias C Few or no evaluation criteria fulfilled. Where evaluation criteria are not fulfilled
or adequately described, the conclusion of the study or review are thought
very likely to alter.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 7
Blood pressure and heart rate will not identify all trauma patients III-2
who are in shock. Assessment of the trauma patient should include:
:: arterial blood gases and assessment of base deficit
:: haemoglobin
:: lactate
:: haematocrit.
These tests are only of value when interpreted in a series,
therefore should be repeated.
GUIDELINE LEVEL OF EVIDENCE
PAGE 8 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
3 How do you know when the
patient is in hypovolaemic shock?
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
blood
O-neg
Acute blood loss or the redistribution of blood,
plasma, or other body fluid predisposes the
injured patient to hypovolaemic shock. Absolute
hypovolaemia refers to the actual loss of volume
that occurs in the presence of haemorrhage.
Relative hypovolaemia refers to the inappropriate
redistribution of body fluids such as that that
occurs following major burn trauma.
6
Acute blood loss is a very common problem following
traumatic injury. Rapid recognition and restoration of
homeostasis is the cornerstone of the initial care of
any seriously injured patient. Delay in recognising
and quickly treating a state of shock results in a
progression from compensated reversible shock to
widespread multiple system organ failure to death.
Morbidity may be widespread and can include renal
failure, brain damage, gut ischaemia, hepatic failure,
metabolic derangements, disseminated intravascular
coagulation (DIC), systemic inflammatory response
syndrome (SIRS), cardiac failure, and death.
The standard physiological classification of acute
blood loss has been promulgated through the
Advanced Trauma Life Support Course developed
by the American College of Surgeons.
7
While a
useful theoretical basis for understanding the stages
of shock, the physiological changes said to occur as
a patient progresses through the four stages are
not supported by evidence.
Lechleuthner et al in a study of blunt trauma found
that a systolic blood pressure (SBP) <90mmHg
will only identify 61% of patients with active
haemorrhage (sensitivity 61% and specificity 79%).
3.1% of patients with uncontrolled haemorrhage
had undisturbed physiological variables.
8
These
findings are supported by others.
9-11
Demetriades
examined the incidence and prognostic value of
tachycardia and bradycardia in the presence of
traumatic hypotension. The incidence of relative
bradycardia (SBP <90mmHg and HR <90 minute)
was present in 28.9% of hypotensive patients.
11
The results of these studies suggest that commonly
monitored variables, in and of themselves, do not
accurately reflect or predict the circulating volume of
injured patients.
9
The accuracy of circulatory values
(HR, BP, urine output and capillary return) in detecting
hypovolaemia in trauma patients is hampered by
complex neurohormonal mechanisms that can
successfully compensate for 15% loss of circulating
volume, particularly considering the majority of
trauma patients are young, fit males.
9
Confounders
such as traumatic brain injury also decreases the
sensitivity of SBP and HR to detect hypovolaemic
shock.
8
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 8
Detecting hypovolaemic shock in the trauma patient
with normal haemodynamics is reliant on history,
physical examination and pathology, including,
base deficit, lactate, haematocrit and haemoglobin.
However, these tests are only of value when
interpreted in a series. Initial haemoglobin (Hb)
of <=6g/l correlated well with mortality (48.4%)
and vital signs. A low level Hb (<8g/l) was found by
Knottenbelt, in a review of 1000 trauma patients, to
be an indicator of serious ongoing haemorrhage.
12
Lactate and base-deficit have also shown to correlate
well with vital signs and mortality.
13,14
The ability
and value of haemoglobin, lactate and base-deficit,
however, to predict blood loss in haemodynamically
stable patients is unknown.
Oman examined the predictive power of haematocrit
decrease of >5% as an indicator of ongoing
haemorrhage in trauma patients who receive IV
fluids. The study found that haematocrit was not
useful in identifying patients who were bleeding,
but was accurate 97% of the time for identifying
those who were not (sensitivity 94%, specificity
43%, PPV 26%, NPV 97%).
15
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 9
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: HOW DO YOU KNOW WHEN THE PATIENT IS IN HYPOVOLAEMIC SHOCK?
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 9
4.1 Probabilities and assessment
In a haemodynamically unstable trauma patient there
are five potential sites of major blood loss: externally,
long bones, the chest, the abdomen and the
retroperitoneum.
7
4.2 Externally and long bones
Blood loss from fractures and lacerations can result
in a significant amount of blood loss. The scalp is a
highly vascular region and may be associated with
significant blood loss. It is however, extremely difficult
to estimate the volume of bleeding from scalp and
other lacerations due to blood loss at the scene and
en route to the hospital. External blood loss requires
careful visual inspection.
Clarke reported that a single long-bone fracture may
result in 10-30% loss of total blood volume. Bleeding
from long bone fractures is present in approximately
40% of cases and is usually evident from swelling
due to haematoma formation. This is usually
a contribution, not a major ongoing cause of
blood loss.
16-18
4.3 The chest
Intrathoracic haemorrhage is to be expected in
4-29% of cases
16-19
and can be evaluated on a chest
x-ray, which should be performed within 10 minutes
of the patients arrival.
20
There are minor limitations to
first mobile supine chest x-ray. A small haemothorax
can be initially missed in 5% of surviving patients and
in up to 18% in non-surviving patients. However,
a large haemothorax contributing to haemodynamic
instability should not be missed.
4.4 The pelvis
The next part of the decision tree is crucial, trying
to decide whether the blood loss is in the abdomen
or in the pelvic retroperitoneum or in both. At this
point the AP pelvic radiograph should be reviewed.
If a pelvic fracture with possible disruption of the
pelvic ligaments causing an unstable fracture pattern
is seen or suspected, the probability of pelvic arterial
bleeding is 52%.
The initial AP pelvic radiograph is the only guide
to determine the probability of pelvic bleeding.
Disruptions involving only the pubic rami do not
vertically or rotationally unstabilise the pelvic ring,
but when recognising a fracture of the pubic bone,
posterior disruption and probability of arterial
bleeding must always be suspected. One must also
bear in mind that bilateral inferior/superior pubic
ramus fractures (butterfly type fracture from AP
compression mechanism), acetabular fractures and
even simple ramus fractures in the elderly can lead
to arterial bleeding causing hypotension.
PAGE 10 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
4 How do you find the
sources of bleeding in a
hypotensive trauma patient?
blood
O-neg
When the haemodynamically unstable patient enters the resuscitation room, IV
a primary survey with full exposure takes place. Carefully inspect for external
bleeding sources and examine the long bones. If x-ray facilities are available,
a supine chest x-ray and pelvic x-ray should be obtained within 10 minutes
of arrival. The CXR will identify any large haemothorax. If the pelvic x-ray
shows a pelvic fracture, the remaining two sites of significant bleeding are
the abdomen and the pelvic retroperitoneum. The options for assessing the
abdomen are DPA and / or FAST.
GUIDELINE LEVEL OF EVIDENCE
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 10
4.5 The abdomen
The abdomen is the most difficult to assess in the
rural and urban environment. Diagnostic Peritoneal
Aspiration (DPA) and Focused Abdominal Sonography
in Trauma (FAST) are the preferred diagnostic means
to determine if there is intra-abdominal bleeding.
Although the availability of FAST is increasing,
it is not available in all urban and rural emergency
departments. DPA is recommended if an EMST
accredited clinician is available. If neither FAST nor
DPA can be undertaken, the clinician should examine
the other four sources for blood loss, upon exclusion
of these it must be assumed that the patient has
intraabdominal bleeding until proven otherwise.
Seventy-eight per cent of intraperitoneal injuries
result in haemorrhage including; the spleen (22%),
the liver (20%), the bladder (15%), the bowel
mesentery (10%) and diaphragmatic lesions (4%).
Renal haemorrhage is found in 7% of cases.
The other 22% are intraperitoneal injuries
not associated with bleeding.
4.6 Decision-making
In the face of continuing haemodynamic instability
and in the absence of external blood loss, long bone
or pelvic fractures or any evidence of bleeding on
chest x-ray, immediate laparotomy is warranted.
If an unstable pelvic fracture is seen on x-ray
the chance of pelvic arterial bleeding is 52%.
The patient should have their pelvis externally
stabilised in the resuscitation room. Please refer to
the ‘Adult Trauma Clinical Practice Guidelines The
Management of Haemodynamically Unstable Patients
with a Pelvic Fracture’ (which is available from the
NSW Institute of Trauma and Injury Management,
contact details listed on the inside cover).
4.7 Timeframes
For every three minutes of haemodynamic
instability elapsed without haemorrhage control
in the emergency department, there is a 1%
increase in mortality. Therefore decision making
within pre-determined timeframes is crucial.
The haemodynamically unstable pelvic fracture
patient should leave the resuscitation room
within 45 minutes heading for either angiography
or laparotomy. Assessment of external bleeding
sources and long bone fractures should take place
within the first five minutes. The chest x-ray and
pelvic x-ray should be performed within 10 minutes
of the patients arrival. Assessment of the abdomen
with FAST / DPA if possible, should be completed
within 30 minutes.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 11
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: HOW DO YOU FIND THE SOURCES OF BLEEDING IN A HYPOTENSIVE TRAUMA PATIENT
Performance indicators
Assessment of external bleeding sources and long bone
fractures should take place within the first five minutes.
The chest x-ray and pelvic x-ray should be performed
within 10 minutes (if x-ray facilities are available).
FAST / DPA within 30 minutes.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 11
PAGE 12 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
5 What is the best management
of the bleeding patient?
blood
O-neg
Management priorities in the bleeding patient
include controlling blood loss, replenishing
intravascular volume and sustaining tissue perfusion.
1
When services are needed that exceed available
resources, it is of critical importance that early
consultation with a trauma specialist and rapid
transportation to definitive care occurs.
(Refer to NSW Department of Health Circular 2002/105
Early Notification of Severe Trauma in Rural NSW)
5.1 Controlling blood loss
After establishing a patent airway, ensuring adequate
ventilatory exchange and oxygenation and securing
venous access, the highest priority in the bleeding
patient is to control haemorrhage.
21
Because patients
may bleed from multiple sites, it is imperative that the
attending medical officer establish strategies to
address all sources of bleeding. Sources of bleeding
may be broadly classified as external or internal.
5.1.1 Controlling external bleeding
The Australian Resuscitation council advocates the
use of direct pressure to gain prompt control of
external bleeding.
22
The recommended method
involves approximating the wound edges if possible,
holding an absorbent dressing firmly over the area
with the heel of the hand, and elevating the bleeding
part. After bleeding is controlled the absorbent
dressing may be secured with a bandage. If bleeding
continues through the initial dressing, apply a second
dressing over the first and secure with a bandage.
Do NOT disturb the dressing once the bleeding has
been controlled. Arterial tourniquets are reserved for
life-threatening bleeding and when direct pressure to
the wound has failed to stop the bleeding or when
protruding objects prevent direct pressure.
GUIDELINE LEVEL OF EVIDENCE
What is the best management of the bleeding patient?
:: Establish patent airway. III-2
:: Ensure adequate ventilation and oxygenation.
:: Secure venous access – large bore cannula x 2.
:: Control any external bleeding by applying direct pressure.
:: Rapidly identify patients requiring operative haemostasis.
:: Establish prompt contact with the major referral hospital and retrieval service.
In the presence of uncontrolled haemorrhage and a delay of greater than II
30 minutes to operative haemostasis, infuse small aliquots of fluid (100-200mls)
to maintain systolic blood pressure between 80-90mmHg. Use caution in the
elderly. Contraindicated in unconscious patients without a palpable blood
pressure and those with traumatic brain injury (see below).
In the presence of uncontrolled haemorrhage in the patient with a concurrent I
traumatic brain injury, prevention of secondary brain injury from hypotension
is crucial as a systolic blood pressure <90mmHg is associated with poor outcomes.
Infuse small aliquots of fluid (100-200mls) to maintain systolic blood pressure
above 90mmHg.
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 12
5.1.2 Controlling internal bleeding
Evidence from numerous studies over the past
two decades indicates that immediate and definitive
operative haemostasis is the optimal treatment
for internal bleeding.
23
To delay leaves the patient
susceptible to multi organ dysfunction and other
complications. In the rural and remote setting
however, immediate operative haemostasis is limited
by a lack of surgical presence and or operating
facilities at the site, and or lengthy transport times
to institutions capable of providing definitive
operative haemostasis.
Given these limitations the challenge for the rural
and remote physician is to rapidly identify patients
who would benefit from early transfer based on
available local resources, manage any life-threatening
injuries, and establish prompt contact with the major
referral centre, and the transport /retrieval service.
Prolonged time spent in a local emergency
department poses a significant risk of mortality
for the internally bleeding patient.
24
In a prospective analysis of the interhospital
transfer of injured patients to a tertiary centre by
Martin et al, up to 60% of the time delay pertaining
to the transfer of injured patients was related to the
time taken to notify the retrieval team.
25
In some
cases this accounted for delays in excess of three
hours. Numerous other studies have suggested that
prompt early contact with the retrieval service and
subsequent timely transfer of severely injured patients
is associated with increased survival rates.
26-28
5.2 Repleting intravascular volume
It is generally recognised that a depleted intravascular
volume robs the cardiovascular system of the preload
required for adequate cardiac output and peripheral
oxygen delivery.
29
Inadequate perfusion, even in the
absence of overt hypotension can result in a
neurohumoral cascade that ultimately leads
to sequential organ failure.
30
Since the early 1900's the conventional approach
to restoring intravascular volume and subsequently
sustaining tissue perfusion in the bleeding patient
has focused on early aggressive fluid replacement
with large volumes of crystalloid and or blood
products.
31
There is a growing body of evidence,
however, that suggests that in the presence of
uncontrolled haemorrhage, fluid replacement may
result in increased haemorrhage and subsequent
greater mortality.
1;31-34
This is thought most likely
to be the result of increased blood pressure and the
subsequent reversal of vasoconstriction, dislodgement
of early thrombus and subsequent secondary
haemorrhage, and the dilutional coagulopathy that
occurs in the presence of large volumes of fluid.
1
Bickell et al studied the outcomes of swine that
were bled from a 5mm tear in the infrarenal aorta
and aggressively resuscitated with lactated ringers
solution. Control swine were not resuscitated.
33
A significant elevation of mean arterial pressure
(MAP) in the resuscitated swine was observed.
One-hundred per cent of resuscitated swine died
within 100 minutes. All of the control swine survived.
The follow-up interval, however was only two hours.
Kowalenko and his associates developed a more
severe model of aortic tear and similarly
demonstrated that animals aggressively resuscitated
with high volumes of crystalloid had significantly
lower survival rates than animals under-resuscitated.
35
Data from Capone et al
36
, and Stern et al
37
are
consistent with the study by Kowalenko.
35
Several solid organ injury animal models of
uncontrolled haemorrhage demonstrate results
that also support low volume fluid resuscitation
in the presence of uncontrolled haemorrhage
37;38
In Krausz et al
39
study of aggressive resuscitation
following moderate splenic injury in rats, untreated
controls sustained significantly less haemorrhage
volumes than treated animals. Similarly, Solomonov et
al
38
study of severe splenic injury in rats demonstrated
that animals aggressively resuscitated experienced
greater haemorrhage volumes and a significantly
lower survival time in comparison to untreated
animals.
Findings from the animal models are substantiated
by Bickell et al
40
prospective controlled study of
patients presenting with a penetrating torso injury
and a prehospital systolic blood pressure less than
90mmHg. Patients received either immediate or
delayed fluid resuscitation following penetrating torso
trauma. The delayed resuscitation group (n = 289)
had intravenous access secured, but received no fluid
resuscitation until admission to the operating theatre.
The immediate resuscitation group (n = 309) were
aggressively fluid resuscitated at the scene and during
transport. The volume of fluid infused was 2,478mls.
Survival to discharge rates was significantly higher in
the delayed resuscitation group compared to the
immediate resuscitation group (70% versus 62%;
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 13
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: WHAT IS THE BEST MANAGEMENT OF THE BLEEDING PATIENT?
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 13
p = 0.04). A number of methodological flaws,
however, have led some to question the study.
First the causes of death were not well defined.
Second, there were a number of protocol violations.
Eight per cent of the delayed resuscitation group
received fluids prior to operative intervention.
Finally there was wide variation in the severity of
shock across both groups.
31
Despite these limitations,
Bickell's paper has led us to question traditional fluid
resuscitation regimes.
A randomised study undertaken by Turner compared
early and delayed fluid administration in trauma
patients. Significant protocol violation (with only
31% of the fluid group actually receiving fluid)
resulted in the inability of this study to find any
treatment affect (10.4% mortality early fluid
group vs 9.8% mortality in delayed group).
41
Dutton, in a randomised study evaluated fluid
resuscitation titrated to a SBP of 100mmHg or
70mmHg during a period of active haemorrhage
on mortality. There was no difference in mortality
between the two groups (7% vs 7%).
42
The low
pressure group appeared sicker than the higher
pressure group (ISS in the conventional-pressure
group was 19.65 ± 11.84, compared with 23.64
± 13.82 in the low-pressure group). This may have
had a negative affect on survival in the low pressure
group.
Evidence from retrospective studies further supports
the concept of delayed resuscitation. Sampalis et al
43
reviewed the outcomes of 217 trauma patients who
had received intravenous fluid and compared them
with 217 controls who received no fluid. Correction
was made for gender, age, mechanism of injury and
injury severity score. Patients who received on-site
fluid resuscitation had a higher mortality than the
control group, particularly when fluid resuscitation
was combined with prolonged prehospital times.
Another study by Hambly and Dutton
44
compared
patients given fluids using a rapid infusion device
with historical controls who had undergone standard
resuscitation. Patient resuscitated with the rapid
infusion device had a higher mortality than those
receiving standard resuscitation.
The advocates of early aggressive resuscitation
of hypotensive bleeding patients argue that the
trauma population is too heterogenous to rely solely
on animal studies, and limited clinical trials. It should
be noted, however, that a systematic review on the
effects of early or large volume intravenous fluid in
uncontrolled bleeding by Kwan et al
45
found no
evidence to support the conventional practise of
early aggressive fluid resuscitation in the presence
of uncontrolled haemorrhage.
From this data consensus opinion now recommends
a more discriminating approach to the conventional
practice of delivering liberal volumes of intravenous
fluids to patients with uncontrolled bleeding.
46
The emerging evidence demonstrates that aggressive
fluid resuscitation in the bleeding patient leads to
additional haemorrhage through soft clot dissolution,
hydraulic acceleration of bleeding and dilution of
clotting factors. While aggressive fluid resuscitation
it is still considered appropriate for unconscious
patients with no palpable blood pressure, the latest
recommendations are to limit or delay intravenous
fluid resuscitation preoperatively in those with
uncontrolled haemorrhage, even if they are hypo
perfusing, although caution should be used with
the elderly.
In the presence of uncontrolled haemorrhage in
the patient with a concurrent traumatic brain injury,
prevention of secondary brain injury from hypotension
is crucial as a systolic blood pressure <90mmHg is
associated with poor outcomes. Infuse small aliquots
of fluid (100-200mls) to maintain systolic blood
pressure above 90mmHg.
122
There is abundant data to suggest that hypotensive
or limited resuscitation may be preferable to
aggressive fluid resuscitation in the setting of
uncontrolled haemorrhage. There is, however, little
evidence suggesting the volume of fluid required to
maintain vital organ perfusion yet prevent thrombus
dislodgment and subsequent secondary haemorrhage
and coagulation dilution. At best the literature
suggests that small aliquots of fluid (100-200mls)
should be given to maintain the patients systolic
blood pressure between 80-90mmHg.
47;48
PAGE 14 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Performance indicators
Primary Survey completed.
Initial stabilisation of life threatening injuries.
Early transfer to definitive care..
Fluid administration <600mls/hr.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 14
Although a wide variety of options are currently available for fluid resuscitation, most agree that the best
resuscitation fluid is blood. It provides simultaneous volume expansion and oxygen carrying capacity.
49
However,
there are a number of disadvantages to blood as a resuscitation fluid (Table 1, p.7). In addition, issues regarding
compatibility, cost and storage requirements make blood and its derivates in the rural setting unlikely options as
a permanent solution for the rural physician. This limits the choice in the rural setting to crystalloid and or colloid.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 15
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
6 If fluid resuscitation is indicated,
what type of fluid should be given?
blood
O-neg
:: Early use of blood, if available, remains the optimal resuscitation fluid Consensus
for the hypovolaemic patient. Use with caution due to numerous complications.
:: Where blood is not available or delayed, Compound Sodium Lactate II
(Hartmanns)is the preferred alternative for the initial resuscitation of the
hypovolaemic trauma patient. Caution should be exercised in the trauma
patient with liver disease.
:: 0.9% Normal Saline is also an acceptable alternative. Large volumes,
however may result in metabolic acidosis.
GUIDELINE LEVEL OF EVIDENCE
Table 3. Complications of blood transfusions
Complication Mechanism
Impaired oxygen The ability of red blood cells to store and release oxygen is impaired after storage.
2,3
release from DPG levels fall rapidly resulting in a shift to the left of oxygen disassociation curve,
haemoglobin and subsequent impaired oxygen release.
Dilutional Stored blood contains all coagulation factors except factors V and VIII. Microvascular bleeding and
coagulopathy coagulopathy can occur in the setting of massive transfusion due to decreased levels of Factor V, VIII
and fibrinogen and associated increased prothrombin times.
Thrombocytopenia Dilutional thrombocytopenia is inevitable following massive transfusion as platelet function declines
to zero after a few days of storage.
Hypothermia Cold blood is associated with major coagulation derangements, peripheral vasoconstriction, metabolic acidosis,
and impaired immune response.
Citrate toxicity / Each unit of blood contains approximately 3g of citrate. Citrate toxicity is caused by acutely decreasing serum
Hypocalcaemia levels of ionised calcium, which occurs because citrate binds to calcium
Hyperkalaemia The plasma potassium concentration of stored blood increases during storage and may be over 30mmols/l.
The potential for Hyperkalaemia occurs with infusion rates of blood greater than 120ml/min and in patients
with severe acidosis.
Acid-base Lactic acid levels in the blood pack give stored blood an acid load of up to 30-40mmols/l. This along with
abnormalities citrate is metabolised rapidly. Citrate in turn is metabolised to bicarbonate, and a profound metabolic alkalosis
may result.
Haemolytic Reactions that result in destruction of the transfused cells may occur from errors involving ABO incompatibility,
transfusion or when the recipients antibody coats and immediately destroys the red blood cells.
reactions
Source: Adapted from Trauma.Org, Transfusion for Massive Blood Loss, http://www.trauma.org/resus/massive.html, accessed 27 April 2004
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 15
The debate regarding the relative effectiveness of
colloids compared to crystalloid continues several
decades after it began. Despite numerous publications
recommending specific fluids, there is no evidence
from randomised control trials that resuscitation with
colloids carries a reduced mortality in patients with
trauma, burns and following surgery.
50;51
Because
colloids are not associated with an increase in
survival and they carry a significant cost compared
to crystalloids there is no apparent benefit to their
use in the initial management of the hypovolaemic
patient.
50;51
A number of recent studies
52-54
have suggested that
the administration of hypertonic solutions, in the
absence of a head injury, allows for a more rapid
stabilisation of macro and micro-haemodynamics.
A recent systematic review by Alderson et al,
50
suggests that there is no evidence that hypertonic
crystalloid is better than isotonic crystalloid. Due to
the clinically different outcomes identified during the
review, however, Bunn et al recommends further
large-scale trials comparing hypertonic crystalloids
with isotonic crystalloids are required to inform
practice.
Wade and colleagues undertook a meta-analysis of
randomised trials examining the effects of Hypertonic
Saline (HS) and Hypertonic Saline/Dextran (HSD)
on survival of trauma patients until discharge or
for 30 days. The study found that HS alone does
not offer any benefit in terms of 30-day survival
over isotonic crystalloids. HSD may improve mortality
(OR 1.20 [95% CI 0.94-1.57]). The summary statistics
of the available data shows that HS does not provide
any benefit over current practices in terms of survival
and that HSD may be superior.
55
The optimal resuscitation fluid for the hypovolaemic
trauma patient remains the early use of blood.
In the absence of type specific blood, isotonic
crystalloids have an established safety record when
used appropriately.
42
Isotonic crystalloids produce
a relatively predictable increase in cardiac output and
are generally distributed throughout the extracellular
space. Where blood is not available or delayed,
Compound Sodium Lactate (Hartmanns) solution
is the preferred alternative for the initial resuscitation
of the hypovolaemic patient.
7;56
Compound Sodium
Lactate solution contains a bicarbonate precursor that
when metabolised helps to correct metabolic acidosis
and its attendant detrimental effects.
56
Compound
sodium lactate may need to be discontinued in the
presence of liver disease. Normal Saline 0.9% is
an acceptable alternative, however, large volumes
of 0.9% Normal Saline may result in metabolic
acidosis.
56
PAGE 16 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 16
Traditional haemodynamic parameters do not adequately quantify the degree III-2
of physiological derangement in hypovolaemic trauma patients. If point of care
blood gas analysis is available base deficit and lactate levels should be used to
identify the magnitude of tissue oxygen debt and the adequacy of resuscitation.
These tests are only of value when interpreted in a series, therefore should
be repeated.
A persistently high or increasing base deficit indicates the presence of ongoing
blood loss or inadequate volume replacement.
In the absence of point of care blood gas analysis capability the restoration Consensus
of a normal mentation, heart rate, skin perfusion and urine output and maintain
ing the systolic blood pressure at 80-90 mmHg serve as the end point of
resuscitation.
GUIDELINE LEVEL OF EVIDENCE
The challenge of caring for the hypovolaemic trauma
patient involves limiting cellular oxygen deficits,
anaerobic metabolism and resultant tissue acidosis.
57
Resuscitation is complete when the cellular oxygen
deficits have been corrected, tissue acidosis is
eliminated and normal aerobic metabolism is
restored.
58
Many patients may appear to be
adequately resuscitated, but have occult
hypoperfusion and ongoing tissue acidosis
(compensated shock).
57
Failure to recognise
this may result in organ dysfunction and death.
Traditionally it has been assumed that the restoration
of a normal mentation, blood pressure, heart rate,
skin perfusion and urine output signified the end
points of resuscitation.
59
Recent studies
60;61
however,
suggest that even after normalising these parameters,
up to 85% of severely injured patients have evidence
of compensated shock. Compensated shock is
defined as the presence of ongoing inadequate tissue
perfusion despite the normalisation of heart rate,
blood pressure, skin perfusion and urine output.
58
Recognition of compensated shock and its rapid
reversal are critical to minimise the risk of multi organ
dysfunction or death. Consequently, the traditional
end points of fluid resuscitation in the hypovolaemic
trauma patient need to be supplemented with global
and end organ markers that are sensitive to the
symptoms of compensated shock.
Global markers include: lactate levels and base
deficit.
54
Arterial pH is not as sensitive as it is
buffered by the body's compensatory mechanisms.
54
End organ markers include: monitoring of gut
perfusion with gastric tonometry, and direct
measures of tissue oxygen tension.
7.1 Base deficit
A recent study by Davis et al
62
found that the initial
base deficit was a reliable early indicator of the
magnitude of volume deficit. Patients were stratified
according to the level of base deficit as mild (base
deficit 2 to -5mmol/L), moderate (base deficit -6 to
-14) or severe (base deficit < -15). Patients with the
more severe base deficit required a greater volume
of fluid for resuscitation. Sixty-five per cent of patients
with an increasing base deficit had ongoing blood
loss. This is consistent with the findings of Canizaro
et al
63
, and James et al
64
.
Kincaid and his associates
65
, further found that
among trauma patients who normalised their lactate
levels, those with persistently higher base deficits
had a significantly increased risk of multi-organ
dysfunction and death. Patients with persistently
higher base deficits also demonstrated impaired
oxygen utilisation. In a similar study Rixen et al
13
found that an increase in base deficit between the
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 17
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
7 What are the endpoints of fluid
resuscitation in the trauma patient?
blood
O-neg
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 17
time the patient arrived at the hospital to the time
of admission to intensive care identified patients
who were haemodynamically unstable, had high
transfusion requirements, coagulation and metabolic
derangements, and an increased risk of death.
It is important to note that base deficit may
be confounded by a number of factors. Firstly,
approximately 12-16 hours following resuscitation,
base deficit may no longer correlate with lactate.
66
Secondly, the administration of bicarbonate may alter
the base deficit without correcting the oxygen debt.
57
Underestimation of base deficit may occur in
the hypocapnic or hypothermic trauma patient,
whereas an elevated base deficit may be present
in the presence of excess heparin in the blood.
Finally, alcohol intoxication can worsen base deficit
for similar levels of injury severity after trauma.
In summary, although base deficit has its limitations,
it is apparent that base deficit levels are a useful guide
for identifying the magnitude of tissue oxygen debt
and the adequacy of resuscitation. A persistently high
or increasing base deficit indicates the presence of
ongoing blood loss or inadequate volume
replacement.
57
7.2 Lactate levels
Recent evidence suggests that serum lactate levels
accurately reflect the degree of circulatory failure
and level of oxygen debt in trauma patients.
54
Abramson
67
studied patients with a moderate injury
severity score who were resuscitated to supranormal
values of O
2
transport. They found that patients who
had a normalised serum lactate level within 24 hours
had a significantly higher survival rate than those
whose lactate levels did not return to normal within
48 hours. Manikis and his associates
68
in a study on
the correlation of serial blood lactate levels to organ
and mortality after trauma reported similar results.
Sauaia et al
69
found that a serum lactate of more
than 2.5mmol/L 12 hours post injury accurately
predicted the onset of multiple organ failure.
When using lactate levels as an end point to
resuscitation it is important to note that as the oxygen
debt becomes normalised lactate maybe washed out
into the circulation, thus spuriously increasing lactate
levels. Nevertheless returning lactate levels to normal,
and in particular normalising them in a short time
period, has proved to be a useful goal in the
resuscitation of trauma patients.
57
7.3 Gastric pH
The gastrointestinal circulation appears to be
exquisitely sensitive to changes in perfusion.
Measuring gastric pH has been attributed to
detect intestinal hypoxia to determine both the
depth of shock and the adequacy of resuscitation.
The potential value of detecting intestinal hypoxia
is two-fold. Intestinal mucosal hypoxia may be an
early warning sign of inadequate global oxygen
delivery due to compensatory mechanism which
redistribute blood flow away from the gut, especially
the splenic bed and intestinal mucosa. The resulting
intestinal mucosal hypoxia may itself have deleterious
effects, playing a role in the development of
multi-organ failure as a result of increased intestinal
permeability and translocation of endotoxin and
bacteria across the intestinal wall. Thus, correction of
low pHi by treatment aimed at correction of mucosal
hypoxia should result in an improved outcome.
Ivatury and colleagues compared global oxygen
transport indices versus organ-specific gastric
mucosal pH as resuscitation endpoints in trauma
patients and found a large reduction in mortality
in patients resuscitated to achieve a gastric pH >7.3
(mortality 9.1% vs 31.3%, p = 0.27).
70
However in a
similar study undertaken by the same authors a year
later found inconsistent results with survival being
higher in the patients randomised to normalisation
of gastric ph (90% vs 74.1%, p = 0.16) but organ
failures also being higher (56.7% vs 29.6%).
71
Both studies, however were underpowered to
draw any conclusions. Larger studies are warranted.
7.4 Sublingual capnometry
One study was identified that included trauma
patients and evaluated the predictive power of
sublingual capnometry for identifying peripheral
hypoperfusion. Sublingual CO
2
correlated strongly
with haemodynamic parameters and lactate (r
2
=0.84,
p<0.01).
72
The application of this instrument may
serve to diagnose and estimate the severity of shock,
but does not appear to add any new information that
is not readily determined by standard monitoring of
heart, blood pressure and lactate.
PAGE 18 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 18
7.5 Supranormal circulatory values
Shoemaker, Bishop and colleagues have done
a number of studies examining and evaluating
supranormal circulatory values as resuscitation goals
(based on cardiac index, oxygen delivery and oxygen
consumption) in severely injured patients.
61;73-75
A quasi-randomised study compared global oxygen
indices as resuscitation goals to resuscitation based
on standard variables (HR, BP, U/O, BD, and Lactate).
Bishop and colleagues found a lower mortality
for patients who were resuscitated to achieve supra-
normal circulatory values (18% vs 37%, p<0.027)
and a lower incidence of organ failures per patient
(0.74 +/- 0.28 vs 1.62 +/- 0.28, p<0.002).
76
It is notable that predicted and observed mortality
between the two groups is different with 81%
observed survival vs 84% predicted survival in
the intervention group versus 63% observed vs
91% predicted in the control group. The observed
mortality is much lower than the predicted mortality
in the control group whilst the observed mortality is
similar to the predicted mortality for the intervention
group. Resuscitation to supranormal circulatory values
did not seem to improve survival when compared to
predicted survival for this group. It is concerning as
to why the observed mortality was 28% more than
predicted. In conclusion, this study highlights that
failure to achieve normal of supranormal circulatory
values is a predictor of a poor outcome, however
augmentation of survivor values in reducing mortality
is not conclusive from this study.
A randomised trial undertaken by Velmahos
and colleagues also evaluated the effect early
optimisation on the survival of severely injured
patients. However no difference in mortality
(15% vs 11%), organ failure, sepsis or length of
intensive care unit stay was observed between the
two groups. The authors conclude that patients who
can achieve optimal haemodynamic values are more
likely to survive than those who cannot, regardless of
resuscitation techniques.
77
Conclusion
Much controversy exists regarding the optimum end
points for resuscitation. What is agreed upon is that
vital signs are very poor indicators of the adequacy of
resuscitation. In recent times, ‘occult hypoperfusion’
has dominated the literature on highlighting that
current end points of resuscitation are inadequate.
This has fuelled the development of Gastric
Tonometry, Capnometry and goal directed therapies.
Application of these tools in resuscitation of trauma
patients has shown them to be powerful predictors
of mortality, however the research has failed to
consistently demonstrate an improvement in
outcomes when used to direct therapy in comparison
to standard endpoints such as HR, BP, urine output,
lactate and base deficit. There is compelling data for
the early recognition of compensated shock.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 19
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: WHAT ARE THE ENDPOINTS OF FLUID RESUSCITATION IN THE TRAUMA PATIENT?
Performance indicators
Arterial blood gases and lactate measured
to assess degree of shock.
Urinary catheter inserted to assess urine output.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 19
::
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 20
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 21
PAGE 22 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Evidence Table 1. How do you know when a trauma patient is in hypovolaemic shock?
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
V
i
c
t
o
r
i
n
o
,

G
P
.
B
a
t
t
i
s
t
e
l
l
a
,

F
D
.
W
i
s
n
e
r
,

D
H
.
2
0
0
3
7
8
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
t
e
s
t
B
2
T
o

d
e
t
e
r
m
i
n
e

t
h
e

c
o
r
r
e
l
a
t
i
o
n
b
e
t
w
e
e
n

t
a
c
h
y
c
a
r
d
i
a

a
n
d
h
y
p
o
t
e
n
s
i
o
n
.
H
e
a
r
t

r
a
t
e

w
a
s

n
o
t

f
o
u
n
d

t
o

b
e

a

g
o
o
d
p
r
e
d
i
c
t
o
r

o
f

h
y
p
o
t
e
n
s
i
o
n
,

b
u
t

i
t
s

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y

m
a
k
e

i
t

c
l
i
n
i
c
a
l
l
y

u
n
r
e
l
i
a
b
l
e

i
n

d
i
a
g
n
o
s
i
n
g

h
y
p
o
v
o
l
a
e
m
i
c

h
y
p
o
t
e
n
s
i
o
n
.
*
*
*
N
e
e
d

t
o

c
a
l
c
u
l
a
t
e

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y
.
T
a
c
h
y
c
a
r
d
i
a

w
a
s

n
o
t

f
o
u
n
d

t
o

b
e

a

r
e
l
i
a
b
l
e

i
n
d
i
c
a
t
o
r

o
f

h
y
p
o
t
e
n
s
i
o
n
.
H
o
w
e
v
e
r
,

t
h
e
r
e

a
r
e

s
o
m
e

l
i
m
i
t
a
t
i
o
n
s

o
f

t
h
i
s

s
t
u
d
y
.
H
y
p
o
t
e
n
s
i
o
n

i
s

a

s
u
r
r
o
g
a
t
e

o
r

l
a
t
e

o
u
t
c
o
m
e

f
o
r
h
y
p
o
v
o
l
a
e
m
i
a
.

P
e
r
h
a
p
s

t
h
e

a
u
t
h
o
r
s

s
h
o
u
l
d

h
a
v
e

m
e
a
s
u
r
e
d

c
i
r
c
u
l
a
t
i
n
g

v
o
l
u
m
e

a
n
d

c
a
r
d
i
a
c

o
u
t
p
u
t

t
o
d
e
t
e
r
m
i
n
e

t
h
e

u
s
e
f
u
l
n
e
s
s

o
f

t
a
c
h
y
c
a
r
d
i
a
.

A
s

s
o
m
e

p
a
t
i
e
n
t
s
m
a
y

b
e

h
y
p
o
v
o
l
a
e
m
i
c
,

t
a
c
h
y
c
a
r
d
i
c

b
u
t

h
a
v
e

a

n
o
r
m
a
l

b
l
o
o
d

p
r
e
s
s
u
r
e

d
u
e

t
o

c
o
m
p
e
n
s
a
t
o
r
y

m
e
c
h
a
n
i
s
m
s
.
L
e
c
h
l
e
u
t
h
n
e
r
,
A
.

L
e
f
e
r
i
n
g
,

R
.
O
u
i
l
l
o
n
,

B
.
1
9
9
4
8
I
I
I
-
2

D
i
a
g
n
o
s
t
i
c
t
e
s
t
A
T
o

e
v
a
l
u
a
t
e

s
y
s
t
o
l
i
c

b
l
o
o
d
p
r
e
s
s
u
r
e
,

c
a
p
i
l
l
a
r
y

r
e
f
i
l
l

a
n
d

t
r
a
u
m
a

s
c
o
r
e

i
n

i
d
e
n
t
i
f
y
i
n
g
u
n
c
o
n
t
r
o
l
l
e
d

h
a
e
m
o
r
r
h
a
g
e

i
n

p
a
t
i
e
n
t
s

w
i
t
h

b
l
u
n
t

t
r
a
u
m
a
.
S
y
s
t
o
l
i
c

b
l
o
o
d

p
r
e
s
s
u
r
e

<
9
0
m
m
H
g

w
a
s

t
h
e
m
o
s
t

s
e
n
s
i
t
i
v
e

p
a
r
a
m
e
t
e
r
,

h
o
w
e
v
e
r

o
n
l
y
i
d
e
n
t
i
f
i
e
d

5
0
%

o
f

b
l
u
n
t

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
i
t
h
u
n
c
o
n
t
r
o
l
l
e
d

h
a
e
m
o
r
r
h
a
g
e
.

T
h
e

s
e
n
s
i
t
i
v
i
t
y
i
m
p
r
o
v
e
d

t
o

6
6
%

w
i
t
h

a

S
B
P
<
6
0
m
m
H
g
.

A
n

a
c
c
o
m
p
a
n
y
i
n
g

t
r
a
u
m
a
t
i
c

b
r
a
i
n

i
n
j
u
r
y
i
m
p
a
i
r
e
d

t
h
e

a
b
i
l
i
t
y

o
f

S
B
P

t
o

d
e
t
e
c
t
u
n
c
o
n
t
r
o
l
l
e
d

h
a
e
m
o
r
r
h
a
g
e
.
T
h
e

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y

o
f

S
B
P
<
9
0
m
m
H
g
i
s

6
1
%

a
n
d

7
9
%

r
e
s
p
e
c
t
i
v
e
l
y
.
F
o
r

a

S
B
P
<
7
0
m
m
H
g

t
h
e

s
e
n
s
i
t
i
v
i
t
y

d
r
o
p
s

e
v
e
n

l
o
w
e
r

t
o

2
7
%

b
u
t

s
p
e
c
i
f
i
c
i
t
y

i
n
c
r
e
a
s
e
s

t
o

9
4
%
.
3
.
1
%

o
f

p
a
t
i
e
n
t
s

w
i
t
h

u
n
c
o
n
t
r
o
l
l
e
d

h
a
e
m
o
r
r
h
a
g
e

h
a
d

u
n
d
i
s
t
u
r
b
e
d

p
h
y
s
i
o
l
o
g
i
c
a
l

v
a
r
i
a
b
l
e
s
.
A

S
B
P
<
5
0
m
m
H
g
,

t
h
e

p
r
e
s
e
n
c
e

o
f

T
B
I

i
m
p
a
i
r
s

t
h
e

d
e
t
e
c
t
i
o
n

q
u
a
l
i
t
y
.
N
o

p
a
r
a
m
e
t
e
r

i
s

s
u
f
f
i
c
i
e
n
t
l
y

p
r
e
d
i
c
t
i
v
e

t
o

d
i
a
g
n
o
s
e

a
c
c
u
r
a
t
e
l
y
t
h
o
s
e

p
a
t
i
e
n
t
s

w
i
t
h

u
n
c
o
n
t
r
o
l
l
e
d

h
a
e
m
o
r
r
h
a
g
e
.
T
h
e

s
t
u
d
y

w
a
s

u
n
d
e
r
t
a
k
e
n

i
n

p
a
t
i
e
n
t
s

w
i
t
h

t
r
a
u
m
a

s
c
o
r
e
s

1
-
1
5
.
S
h
i
p
p
y
,

C
R
.
A
p
p
e
l
,

P
L
.
S
h
o
e
m
a
k
e
r
,
W
C
.

1
9
8
4
9
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
t
e
s
t
B
2
T
o

e
v
a
l
u
a
t
e

t
h
e

r
e
l
i
a
b
i
l
i
t
y

o
f

c
l
i
n
i
c
a
l
m
o
n
i
t
o
r
i
n
g

t
o

a
s
s
e
s
s

b
l
o
o
d

v
o
l
u
m
e
i
n

c
r
i
t
i
c
a
l
l
y

i
l
l

p
a
t
i
e
n
t
s
.
I
n

p
a
t
i
e
n
t
s

w
i
t
h

m
e
a
s
u
r
e
d

h
y
p
o
v
o
l
a
e
m
i
a
(
~
1
4
0
0
m
l
s
)

t
h
e
r
e

w
e
r
e

s
i
g
n
i
f
i
c
a
n
t

r
e
d
u
c
t
i
o
n
s
i
n

M
A
P
,

H
R
,

a
n
d

C
I
.

C
V
P

w
a
s

n
o
t

s
i
g
n
i
f
i
c
a
n
t
l
y
r
e
d
u
c
e
d
.

N
o
n
e

o
f

t
h
e

c
o
r
r
e
l
a
t
i
o
n

c
o
e
f
f
i
c
i
e
n
t
s
b
e
t
w
e
e
n

b
l
o
o
d

v
o
l
u
m
e

a
n
d

t
h
e
s
e

c
o
m
m
o
n
l
y
m
e
a
s
u
r
e
d

v
a
r
i
a
b
l
e
s

w
e
r
e

s
i
g
n
i
f
i
c
a
n
t
.
T
h
e

d
a
t
a

s
u
g
g
e
s
t

t
h
a
t

t
h
e

c
o
m
m
o
n
l
y

m
o
n
i
t
o
r
e
d

v
a
r
i
a
b
l
e
s
,

i
n

a
n
d

o
f

t
h
e
m
s
e
l
v
e
s
,

d
o

n
o
t

r
e
f
l
e
c
t

a
d
e
q
u
a
t
e
l
y

t
h
e

b
l
o
o
d
v
o
l
u
m
e

s
t
a
t
u
s

i
n

c
r
i
t
i
c
a
l
l
y

i
l
l

p
a
t
i
e
n
t
s
.

C
o
m
m
o
n
l
y

m
o
n
i
t
o
r
e
d
v
a
r
i
a
b
l
e
s

p
r
o
v
i
d
e
d

a
d
e
q
u
a
t
e

d
a
t
a

n
e
e
d
e
d

t
o

b
e
g
i
n
r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

s
h
o
c
k
,

b
u
t

t
h
e
r
e

a
b
s
o
l
u
t
e

v
a
l
u
e
s
i
n
d
e
p
e
n
d
e
n
t
l
y

a
r
e

n
o
t

a

r
e
l
i
a
b
l
e

e
s
t
i
m
a
t
i
o
n

o
f

b
l
o
o
d

v
o
l
u
m
e

s
t
a
t
u
s
.
C
l
i
n
i
c
i
a
n
s

n
e
e
d

t
o

b
e

m
i
n
d
f
u
l

o
f

t
h
e

c
o
m
p
l
e
x

n
e
u
r
o
h
o
r
m
o
n
a
l

m
e
c
h
a
n
i
s
m
s

w
h
i
c
h

p
r
o
f
o
u
n
d
l
y

e
f
f
e
c
t

t
h
e

c
i
r
c
u
l
a
t
i
o
n

i
n

g
e
n
e
r
a
l

w
h
i
c
h

c
o
u
l
d

l
e
a
d

c
l
i
n
i
c
i
a
n
s

d
o
w
n
t
h
e

g
a
r
d
e
n

p
a
t
h

o
f

t
h
i
n
k
i
n
g

t
h
a
t

m
a
n
y

p
a
t
i
e
n
t
s

a
r
e

f
u
l
l
y
r
e
s
u
s
c
i
t
a
t
e
d

a
l
t
h
o
u
g
h

t
h
e
y

m
a
y

s
t
i
l
l

b
e

h
y
p
o
v
o
l
a
e
m
i
c

a
n
d

a
t

r
i
s
k

o
f

d
e
v
e
l
o
p
i
n
g

t
h
e

s
e
q
u
e
l
a
e

o
f

s
h
o
c
k
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 22
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 23
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
K
n
o
t
t
e
n
b
e
l
t
,
J
D
.

1
9
9
1
1
2
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
t
e
s
t
B
1
T
o

e
v
a
l
u
a
t
e

t
h
e

i
m
p
o
r
t
a
n
c
e

o
f

a
l
o
w

i
n
i
t
i
a
l

h
a
e
m
o
g
l
o
b
i
n

a
n
d

i
t
s
c
o
r
r
e
l
a
t
i
o
n

w
i
t
h

s
h
o
c
k
.
I
n
i
t
i
a
l

h
a
e
m
o
g
l
o
b
i
n

c
o
r
r
e
l
a
t
e
d

w
i
t
h

v
i
t
a
l

s
i
g
n
s
a
n
d

m
o
r
t
a
l
i
t
y
.
I
n

3
1

p
a
t
i
e
n
t
s

w
i
t
h

i
n
i
t
i
a
l

H
b

l
e
v
e
l
s

o
f

l
e
s
s

t
h
a
n

8

g
/
d
L
,

t
h
e

o
v
e
r
a
l
l

m
o
r
t
a
l
i
t
y

w
a
s

4
8
.
4
%
,
c
o
m
p
a
r
e
d

w
i
t
h

2
.
6
%

i
n

9
6
9

p
a
t
i
e
n
t
s

w
h
o
s
e
i
n
i
t
i
a
l

H
b

l
e
v
e
l

w
a
s

8

g
/
d
L

o
r

m
o
r
e

(
p

<
0
.
0
0
0
0
1
)
.
A

l
o
w

H
b

l
e
v
e
l

o
b
s
e
r
v
e
d

s
o
o
n

a
f
t
e
r

i
n
j
u
r
y

i
s

u
s
u
a
l
l
y

a
n

i
n
d
i
c
a
t
o
r

o
f

s
e
r
i
o
u
s

o
n
g
o
i
n
g

h
a
e
m
o
r
r
h
a
g
e

a
n
d

h
a
s
i
m
p
o
r
t
a
n
t

i
m
p
l
i
c
a
t
i
o
n
s

f
o
r

m
a
n
a
g
e
m
e
n
t

a
n
d

p
r
o
g
n
o
s
i
s
.
W
o
,

C
C
J
.
S
h
o
e
m
a
k
e
r
,
W
C
.

A
p
p
e
l
,

P
L
.
1
9
9
3
1
0
I
I
I
-
2
B
1
T
o

e
v
a
l
u
a
t
e

t
h
e

r
e
l
i
a
b
i
l
i
t
y

o
f

t
h
e

v
i
t
a
l

s
i
g
n
s

t
o

e
v
a
l
u
a
t
e

c
i
r
c
u
l
a
t
o
r
y
s
t
a
b
i
l
i
t
y

a
s

r
e
f
l
e
c
t
e
d

b
y

c
a
r
d
i
a
c
i
n
d
e
x
.
I
n

s
u
d
d
e
n

s
e
v
e
r
e

h
y
p
o
v
o
l
a
e
m
i
c

h
y
p
o
t
e
n
s
i
o
n
,
t
h
e

l
o
w
e
s
t

m
e
a
n

a
r
t
e
r
i
a
l

p
r
e
s
s
u
r
e

(
M
A
P
)
r
o
u
g
h
l
y

c
o
r
r
e
l
a
t
e
d

(
r
2
=

.
2
5
)

w
i
t
h

f
l
o
w
,

b
u
t

t
h
e
r
e

w
a
s

p
o
o
r

c
o
r
r
e
l
a
t
i
o
n

(
r
2
=

.
0
0
0
1
)

w
h
e
n

a
l
l

p
r
e
s
s
u
r
e

a
n
d

f
l
o
w

v
a
l
u
e
s

w
e
r
e

e
v
a
l
u
a
t
e
d
.
A
u
t
h
o
r
s

c
o
n
c
l
u
d
e

t
h
a
t

b
l
o
o
d

f
l
o
w

c
a
n
n
o
t

r
e
l
i
a
b
l
y

b
e

i
n
f
e
r
r
e
d

f
r
o
m

a
r
t
e
r
i
a
l

p
r
e
s
s
u
r
e

a
n
d

h
e
a
r
t

r
a
t
e

m
e
a
s
u
r
e
m
e
n
t
s
u
n
t
i
l

e
x
t
r
e
m
e

h
y
p
o
t
e
n
s
i
o
n

o
c
c
u
r
s
.
7
5
%

o
f

t
h
e

v
a
r
i
a
t
i
o
n

i
n

M
A
P

w
a
s

n
o
t

e
x
p
l
a
i
n
e
d

i
n

t
h
i
s

d
a
t
a
s
e
t

b
y

c
a
r
d
i
a
c

i
n
d
e
x
.
B
i
s
h
o
p
,

M
H
.
S
h
o
e
m
a
k
e
r
,
W
C
.

A
p
e
l
,

P
L
.
1
9
9
3
8
0
I
I
I
-
2
O
b
s
e
r
v
a
-
t
i
o
n
a
l

s
t
u
d
y
B
2
T
o

e
x
a
m
i
n
e

t
h
e

r
e
l
a
t
i
o
n
s
h
i
p
b
e
t
w
e
e
n

c
i
r
c
u
l
a
t
o
r
y

v
a
l
u
e
s

a
n
d
m
o
r
t
a
l
i
t
y

a
n
d

o
r
g
a
n

f
a
i
l
u
r
e
.
D
a
t
a

n
o
t

p
r
e
s
e
n
t
e
d
.
M
A
P

a
n
d

h
e
a
r
t

w
e
r
e

p
o
o
r
l
y

c
o
r
r
e
l
a
t
e
d

w
i
t
h

b
l
o
o
d

l
o
s
s

a
n
d
t
h
e

a
m
o
u
n
t

o
f

b
l
o
o
d

t
r
a
n
s
f
u
s
e
d
.

T
h
e

e
s
t
i
m
a
t
e
d

b
l
o
o
d

l
o
s
s
w
a
s

a

m
o
r
e

r
e
l
i
a
b
l
e

m
e
a
n
s

t
h
a
n

M
A
P

a
n
d

H
R

i
s

e
s
t
i
m
a
t
i
n
g
t
h
e

d
e
g
r
e
e

o
f

s
h
o
c
k
.

I
n

t
h
e

c
u
t
e
l
y

i
n
j
u
r
e
d

p
a
t
i
e
n
t
,

w
i
d
e
l
y
v
a
r
i
a
b
l
e

c
a
t
e
c
h
o
l
a
m
i
n
e

r
e
s
p
o
n
s
e
s

t
o

h
y
p
o
v
o
l
a
e
m
i
a
,

p
a
i
n
,

o
r

d
r
u
g
s

m
a
d
e

M
A
P

a
n
d

H
R

u
n
r
e
l
i
a
b
l
e

p
r
e
d
i
c
t
o
r
s

o
f

i
n
t
r
a
v
a
s
c
u
l
a
r

v
o
l
u
m
e
.
A
r
d
a
g
h
,

M
W
.
H
o
d
g
s
o
n
,

T
.
2
0
0
1
8
1
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
T
e
s
t
B
2
T
o

e
v
a
l
u
a
t
e

a

c
a
l
c
u
l
a
t
i
o
n

o
f

p
u
l
s
e

r
a
t
e

o
v
e
r

p
u
l
s
e

p
r
e
s
s
u
r
e

a
s

a

m
e
t
h
o
d

o
f

p
r
e
d
i
c
t
i
n
g
d
e
c
o
m
p
e
n
s
a
t
i
o
n

i
n

p
a
t
i
e
n
t
s

w
i
t
h

c
o
m
p
e
n
s
a
t
e
d

h
a
e
m
o
r
r
h
a
g
i
c
s
h
o
c
k

i
n

v
i
c
t
i
m
s

o
f

m
a
j
o
r

r
o
a
d

t
r
a
u
m
a
.
R
O
P
E

i
s

c
a
l
c
u
l
a
t
e
d

b
y
:

:
:

p
u
l
s
e

r
a
t
e
:
:

S
B
P
-
D
B
P
.
S
e
n
s
i
t
i
v
i
t
y

5
5
%
.
S
p
e
c
i
f
i
c
i
t
y

7
9
%
.
A

R
O
P
E

v
a
l
u
e

o
f

g
r
e
a
t
e
r

t
h
a
n

3
.
0

h
a
d

a

p
o
s
i
t
i
v
e

p
r
e
d
i
c
t
i
v
e

v
a
l
u
e

o
f

5
3
%

a
n
d

a

v
a
l
u
e

l
e
s
s

t
h
a
n

3
.
0

h
a
d

a

n
e
g
a
t
i
v
e

p
r
e
d
i
c
t
i
v
e

v
a
l
u
e

o
f

8
6
%

f
o
r

t
h
e

d
e
v
e
l
o
p
m
e
n
t

o
f

d
e
c
o
m
p
e
n
s
a
t
e
d

s
h
o
c
k
.
R
O
P
E

>
3
.
0

i
s

n
o
t

1
0
0
%

a
c
c
u
r
a
t
e

i
n

i
d
e
n
t
i
f
y
i
n
g

t
h
o
s
e

w
h
o
w
i
l
l

o
r

w
i
l
l

n
o
t

d
e
c
o
m
p
e
n
s
a
t
e

i
n

t
h
e

e
m
e
r
g
e
n
c
y

d
e
p
a
r
t
m
e
n
t
,
h
o
w
e
v
e
r

i
t

m
a
y

p
r
o
v
i
d
e

c
l
i
n
i
c
i
a
n
s

w
i
t
h

a

u
s
e
f
u
l

t
o
o
l

t
o
i
n
c
r
e
a
s
e

s
u
s
p
i
c
i
o
n

o
f

t
h
o
s
e

w
h
o

m
a
y
.

:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 23
PAGE 24 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
T
a
t
e
v
o
s
s
i
a
n
,
R
G
.

W
o
,

C
C
J
.
V
e
l
m
a
h
o
s
,

G
C
.
2
0
0
0
8
2
I
I
I
-
2
B
1
T
o

e
v
a
l
u
a
t
e

t
h
e

u
s
e
f
u
l
n
e
s
s

o
f
t
r
a
n
s
c
u
t
a
n
e
o
u
s

o
x
y
g
e
n

a
n
d

c
a
r
b
o
n

d
i
o
x
i
d
e

m
o
n
i
t
o
r
i
n
g

i
n
t
r
a
u
m
a

p
a
t
i
e
n
t
s

f
o
r

t
i
s
s
u
e

h
y
p
o
x
i
a

a
n
d

p
o
s
s
i
b
l
e

s
h
o
c
k
.
C
o
m
p
a
r
e
d

w
i
t
h

s
u
r
v
i
v
o
r
s
,

p
a
t
i
e
n
t
s

w
h
o

d
i
e
d

h
a
d

s
i
g
n
i
f
i
c
a
n
t
l
y

l
o
w
e
r

P
t
c
O
2
a
n
d

h
i
g
h
e
r
P
t
c
C
O
2
v
a
l
u
e
s

b
e
g
i
n
n
i
n
g

w
i
t
h

t
h
e

e
a
r
l
y

s
t
a
g
e

o
f

r
e
s
u
s
c
i
t
a
t
i
o
n
.
T
r
a
n
s
c
u
t
a
n
e
o
u
s

O
2
c
o
r
r
e
l
a
t
e
d

w
e
l
l

w
i
t
h

d
e
a
t
h
a
n
d

m
o
r
b
i
d
i
t
y
.
H
o
w
e
v
e
r

l
i
t
t
l
e

c
o
r
r
e
l
a
t
i
o
n

w
a
s

m
a
d
e

w
i
t
h
a
l
r
e
a
d
y

m
o
n
i
t
o
r
e
d

v
a
l
u
e
s

s
u
c
h

a
s

H
R

&

B
P

t
o
t
e
s
t

w
h
e
t
h
e
r

t
h
e
s
e

v
a
l
u
e
s

c
o
r
r
e
l
a
t
e
d

w
i
t
h

t
h
e
m
.

T
h
e
r
e

i
s

n
o

q
u
a
n
t
i
f
i
c
a
t
i
o
n

o
f

v
a
l
u
e
s

i
n

t
h
i
s

s
t
u
d
y

t
o

r
e
f
l
e
c
t
i
m
p
e
n
d
i
n
g

s
h
o
c
k

o
r

d
e
c
o
m
p
e
n
s
a
t
i
o
n
.

V
a
l
u
e
s

a
r
e

c
o
r
r
e
l
a
t
e
d
w
i
t
h

d
e
a
t
h

a
n
d

m
o
r
b
i
d
i
t
y
.
U
n
s
u
r
e

o
f

t
h
e

u
s
e
f
u
l
n
e
s
s

o
f

t
h
i
s

t
e
s
t

a
s

i
t

t
a
k
e

~
2
0

m
i
n
u
t
e
s
t
o

c
a
l
i
b
r
a
t
e

m
a
c
h
i
n
e
.
O
m
a
n
,

K
S
.
1
9
9
5
1
5
I
I
I
-
2
B
2
T
o

v
a
l
i
d
a
t
e

H
a
e
m
a
t
o
c
r
i
t

a
s

a
n
i
n
d
i
c
a
t
o
r

o
f

o
n
g
o
i
n
g

h
a
e
m
o
r
r
h
a
g
e
i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
h
o

r
e
c
e
i
v
e
I
V

f
l
u
i
d
s
.
T
h
e

m
e
a
n

h
a
e
m
a
t
o
c
r
i
t

c
h
a
n
g
e

w
a
s

-
5
.
3
%
;

i
n

g
r
o
u
p

2

(
h
a
e
m
o
r
r
h
a
g
e

g
r
o
u
p
)

t
h
e
h
a
e
m
a
t
o
c
r
i
t

c
h
a
n
g
e

w
a
s

-
8
.
3
%
.

(
p

<
0
.
0
5
)
.

A

h
a
e
m
a
t
o
c
r
i
t

d
e
c
r
e
a
s
e

o
f

5
%

h
a
s

a

s
e
n
s
i
t
i
v
i
t
y

o
f

9
4
%
,
s
p
e
c
i
f
i
c
i
t
y

4
3
%
,

P
P
V

2
6
%
,

N
P
V

9
7
%
.

M
e
a
n
i
n
g

t
h
a
t
h
a
e
m
a
t
o
c
r
i
t

c
h
a
n
g
e
s

a
r
e

n
o
t

u
s
e
f
u
l

i
n

i
d
e
n
t
i
f
y
i
n
g

p
a
t
i
e
n
t
s
w
h
o

a
r
e

h
a
e
m
o
r
r
h
a
g
i
n
g
,

b
u
t

a
r
e

a
c
c
u
r
a
t
e

9
7
%

o
f

t
h
e

t
i
m
e

i
n

i
d
e
n
t
i
f
y
i
n
g

p
a
t
i
e
n
t
s

w
h
o

a
r
e

n
o
t
.
R
i
x
e
n
,

D
.

R
a
u
m
,

M
.
B
o
u
i
l
l
o
n
,

B
.
L
e
f
e
r
i
n
g
,

R
.
2
0
0
1
1
3
I
I
I
-
2
G
e
r
m
a
n
A
b
s
t
r
a
c
t
o
n
l
y
N
/
A
T
o

e
v
a
l
u
a
t
e

t
h
e

p
r
o
g
n
o
s
t
i
c

v
a
l
u
e

o
f

b
a
s
e

d
e
f
i
c
i
t

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
I
n
c
r
e
a
s
i
n
g

b
a
s
e

d
e
f
i
c
i
t

w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

a

s
i
g
n
i
f
i
c
a
n
t

d
e
c
r
e
a
s
e

i
n

s
y
s
t
o
l
i
c

b
l
o
o
d
p
r
e
s
s
u
r
e

a
n
d

p
r
o
t
h
r
o
m
b
i
n

t
i
m
e

a
s

w
e
l
l

a
s
i
n
c
r
e
a
s
e
s

i
n

h
e
a
r
t

r
a
t
e
,

l
a
c
t
a
t
e

l
e
v
e
l

a
n
d
m
o
r
t
a
l
i
t
y

(
p

<
0
.
0
0
0
1
)
.
M
o
r
t
a
l
i
t
y

i
n
c
r
e
a
s
e
d

s
i
g
n
i
f
i
c
a
n
t
l
y

(
p

<
0
.
0
0
0
1
)
w
i
t
h

a

w
o
r
s
e
n
i
n
g

o
f

B
D

f
r
o
m

h
o
s
p
i
t
a
l

t
o

I
C
U
a
d
m
i
s
s
i
o
n
.
B
a
s
e

d
e
f
i
c
i
t

i
s

a
n

e
a
r
l
y

a
v
a
i
l
a
b
l
e

i
m
p
o
r
t
a
n
t

i
n
d
i
c
a
t
o
r

t
o
i
d
e
n
t
i
f
y

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
i
t
h

h
a
e
m
o
d
y
n
a
m
i
c

i
n
s
t
a
b
i
l
i
t
y
,

h
i
g
h

t
r
a
n
s
f
u
s
i
o
n

r
e
q
u
i
r
e
m
e
n
t
s
,

m
e
t
a
b
o
l
i
c

a
n
d

c
o
a
g
u
l
a
t
o
r
y
d
e
c
o
m
p
e
n
s
a
t
i
o
n
,

a
s

w
e
l
l

a
s

a

h
i
g
h

p
r
o
b
a
b
i
l
i
t
y

o
f

d
e
a
t
h
.
B
a
n
n
o
n

M
P
.
O
'
N
e
i
l
l

C
M
.
M
a
r
t
i
n

M
.
1
9
9
5
1
4
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
T
e
s
t
B
1
T
o

e
x
p
l
o
r
e

t
h
e

u
s
e
f
u
l
n
e
s
s

o
f

c
e
n
t
r
a
l

v
e
n
o
u
s

o
x
y
g
e
n

s
a
t
u
r
a
t
i
o
n
,
a
r
t
e
r
i
a
l

b
a
s
e

d
e
f
i
c
i
t
,

a
n
d

l
a
c
t
a
t
e
c
o
n
c
e
n
t
r
a
t
i
o
n

i
n

t
h
e

e
v
a
l
u
a
t
i
o
n

i
n

4
0

p
a
t
i
e
n
t
s

w
i
t
h

o
p
e
r
a
t
i
v
e
t
r
u
n
c
a
l

i
n
j
u
r
i
e
s
.
P
r
e
o
p
e
r
a
t
i
v
e

h
y
p
o
t
e
n
s
i
o
n

o
c
c
u
r
r
e
d

i
n

1
2
.
5
%

o
f

t
h
e
s
e

i
n
i
t
i
a
l
l
y

s
t
a
b
l
e

p
a
t
i
e
n
t
s
.

S
(
c
v
)
O
2
d
i
d

n
o
t

s
i
g
n
i
f
i
c
a
n
t
l
y

c
o
r
r
e
l
a
t
e

w
i
t
h

a
n
y
o
f

t
h
e

p
a
r
a
m
e
t
e
r
s

o
f

b
l
o
o
d

l
o
s
s

a
n
d

s
e
v
e
r
i
t
y

o
f

i
n
j
u
r
y

e
x
a
m
i
n
e
d
.

H
o
w
e
v
e
r
,

b
o
t
h

b
a
s
e

d
e
f
i
c
i
t
a
n
d

l
a
c
t
a
t
e

c
o
n
c
e
n
t
r
a
t
i
o
n

c
o
r
r
e
l
a
t
e
d

w
i
t
h
t
r
a
n
s
f
u
s
i
o
n

r
e
q
u
i
r
e
m
e
n
t
s
;

i
n

a
d
d
i
t
i
o
n
,

b
a
s
e
d
e
f
i
c
i
t

c
o
r
r
e
l
a
t
e
d

w
i
t
h

t
r
a
u
m
a

s
c
o
r
e
,

a
n
d
l
a
c
t
a
t
e

c
o
r
r
e
l
a
t
e
d

w
i
t
h

p
e
r
i
t
o
n
e
a
l

s
h
e
d

b
l
o
o
d

v
o
l
u
m
e
.
B
a
s
e

d
e
f
i
c
i
t

a
n
d

l
a
c
t
a
t
e

w
e
r
e

i
n
d
i
c
a
t
o
r
s

o
f

o
n
g
o
i
n
g

b
l
o
o
d

l
o
s
s

o
r

i
n
a
d
e
q
u
a
t
e

r
e
s
u
s
c
i
t
a
t
i
o
n
.
N
e
e
d

t
o

c
h
e
c
k

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y

i
n

f
u
l
l

t
e
x
t
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 24
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 25
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
D
e
m
e
t
r
i
a
d
e
s
,
D
.

C
h
a
n
,

L
S
.
B
h
a
s
i
,


P
.
B
e
r
n
e
,

T
V
.
1
9
9
8
1
1
I
I
I
-
2
B
1
T
o

e
x
a
m
i
n
e

t
h
e

i
n
c
i
d
e
n
c
e

a
n
d

p
r
o
g
n
o
s
t
i
c

s
i
g
n
i
f
i
c
a
n
c
e

o
f

t
a
c
h
y
c
a
r
d
i
a

a
n
d

r
e
l
a
t
i
v
e
b
r
a
d
y
c
a
r
d
i
a

i
n

p
a
t
i
e
n
t
s

w
i
t
h
t
r
a
u
m
a
t
i
c

h
y
p
o
t
e
n
s
i
o
n
.
(
R
e
l
a
t
i
v
e

b
r
a
d
y
c
a
r
d
i
a

i
s

d
e
f
i
n
e
d
S
B
P

<

o
r

=

9
0

m
m

H
g

a
n
d

a

H
R

<

o
r

=

9
0

b
e
a
t
s

p
e
r

m
i
n
u
t
e
)
.
T
h
e

i
n
c
i
d
e
n
c
e

o
f

r
e
l
a
t
i
v
e

b
r
a
d
y
c
a
r
d
i
a

i
n

t
h
i
s
s
t
u
d
y

w
a
s

2
8
.
9
%

o
f

h
y
p
o
t
e
n
s
i
v
e

p
a
t
i
e
n
t
s
.
P
a
t
i
e
n
t
s

w
i
t
h

r
e
l
a
t
i
v
e

b
r
a
d
y
c
a
r
d
i
a

i
n

t
h
e
s
u
b
g
r
o
u
p
s

w
i
t
h

I
S
S

>
1
6

s
i
g
n
i
f
i
c
a
n
t
l
y

b
e
t
t
e
r
s
u
r
v
i
v
a
l

t
h
a
n

p
a
t
i
e
n
t
s

w
i
t
h

s
i
m
i
l
a
r

i
n
j
u
r
i
e
s
p
r
e
s
e
n
t
i
n
g

w
i
t
h

t
a
c
h
y
c
a
r
d
i
a
.
R
e
l
a
t
i
v
e

b
r
a
d
y
c
a
r
d
i
a

i
n

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s
i
s

a

c
o
m
m
o
n

h
a
e
m
o
d
y
n
a
m
i
c

f
i
n
d
i
n
g
.

M
o
r
t
a
l
i
t
y

a
m
o
n
g
t
a
c
h
y
c
a
r
d
i
c

p
a
t
i
e
n
t
s

w
a
s

m
o
r
e

p
r
e
d
i
c
t
a
b
l
e

t
h
a
n

a
m
o
n
g
b
r
a
d
y
c
a
r
d
i
c

p
a
t
i
e
n
t
s

u
s
i
n
g

c
o
m
m
o
n
l
y

u
s
e
d

d
e
m
o
g
r
a
p
h
i
c
a
n
d

i
n
j
u
r
y

i
n
d
i
c
a
t
o
r
s
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 25
PAGE 26 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Evidence Table 2. How do you find the sources of bleeding in a hypotensive trauma patient?
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
G
i
t
h
a
i
g
a
,

J
W
.
A
d
w
o
k
,

J
A
.
2
0
0
2
8
3
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
B
1
T
o

d
e
t
e
r
m
i
n
e

t
h
e

a
c
c
u
r
a
c
y

a
n
d
s
e
n
s
i
t
i
v
i
t
y

o
f

d
i
a
g
n
o
s
t
i
c

p
e
r
i
t
o
n
e
a
l
l
a
v
a
g
e

i
n

t
h
e

a
s
s
e
s
s
m
e
n
t

o
f

i
n
t
r
a
-
a
b
d
o
m
i
n
a
l

i
n
j
u
r
y

u
s
i
n
g

t
h
e

d
i
p
s
t
i
c
k

m
e
t
h
o
d
.
D
P
L

u
s
i
n
g

t
h
e

d
i
p
s
t
i
c
k

m
e
t
h
o
d

h
a
d

a
n
a
c
c
u
r
a
c
y

a
n
d

s
e
n
s
i
t
i
v
i
t
y

o
f

9
3
%

a
n
d

s
p
e
c
i
f
i
c
i
t
y
o
f

9
8
%
.
D
i
a
g
n
o
s
t
i
c

p
e
r
i
t
o
n
e
a
l

l
a
v
a
g
e

i
s

a

c
h
e
a
p
,

s
a
f
e

a
n
d

r
e
l
i
a
b
l
e
m
e
t
h
o
d

f
o
r

a
s
s
e
s
s
m
e
n
t

o
f

a
b
d
o
m
i
n
a
l

t
r
a
u
m
a
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 26
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 27
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Evidence Table 3. What is the best management of the bleeding patient?
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
K
w
a
n
,

I
.
B
u
n
n
,

F
.
R
o
b
e
r
t
s
,

I
.
2
0
0
3
4
5
I
B
2
T
o

a
s
s
e
s
s

t
h
e

e
f
f
e
c
t
s

o
f

e
a
r
l
y
v
e
r
s
u
s

d
e
l
a
y
e
d
,

a
n
d

l
a
r
g
e
r

v
e
r
s
u
s

s
m
a
l
l
e
r

v
o
l
u
m
e

o
f

f
l
u
i
d
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
w
i
t
h

b
l
e
e
d
i
n
g
.
D
u
e

t
o

t
h
e
i
r

h
e
t
e
r
o
g
e
n
e
i
t
y
,

i
n

t
e
r
m
s

o
f

t
y
p
e
s
o
f

p
a
t
i
e
n
t
s

a
n
d

t
y
p
e
s

o
f

f
l
u
i
d
s

u
s
e
d
,

w
e

d
i
d

n
o
t

a
t
t
e
m
p
t

t
o

p
e
r
f
o
r
m

a

m
e
t
a
-
a
n
a
l
y
s
i
s

o
f

t
h
e

s
t
u
d
i
e
s
.
T
h
e
r
e

w
a
s

n
o

e
v
i
d
e
n
c
e

f
o
r

o
r

a
g
a
i
n
s
t

e
a
r
l
y

o
r

l
a
r
g
e
r
v
o
l
u
m
e

o
f

i
n
t
r
a
v
e
n
o
u
s

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
n

u
n
c
o
n
t
r
o
l
l
e
d
h
a
e
m
o
r
r
h
a
g
e
.

A

l
a
r
g
e
,

w
e
l
l
-
c
o
n
d
u
c
t
e
d

R
C
T

i
s

r
e
q
u
i
r
e
d

a
s

t
h
e

q
u
a
l
i
t
y

o
f

t
h
e

c
u
r
r
e
n
t

e
v
i
d
e
n
c
e

i
s

p
o
o
r
.
B
i
c
k
e
l
l
,

W
H
.
W
a
l
l
,

M
J

J
r
.
P
e
p
e
,

P
E
.
M
a
r
t
i
n
,

R
R
.
1
9
9
4
4
0
I
I
I
-
1
Q
u
a
s
i
r
a
n
d
o
m
i
s
e
d
t
r
i
a
l
B
2
5
9
8

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s
w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

t
o
r
s
o

i
n
j
u
r
i
e
s

w
e
r
e
q
u
a
s
i
-
r
a
n
d
o
m
i
s
e
d

(
a
l
t
e
r
n
a
t
e

d
a
y
a
l
l
o
c
a
t
i
o
n
)

t
o

e
a
r
l
y

v
e
r
s
u
s

d
e
l
a
y
e
d
f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
M
o
r
t
a
l
i
t
y

w
a
s

3
8
%

i
n

e
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
v
s
.

3
0
%

i
n

d
e
l
a
y
e
d
.
P
r
o
t
h
r
o
m
b
i
n

a
n
d

p
a
r
t
i
a
l

t
h
r
o
m
b
o
p
l
a
s
t
i
n

t
i
m
e

i
n

e
a
r
l
y

1
4
.
1

a
n
d

3
1
.
8

s
e
c
o
n
d
s

a
n
d

1
1
.
4

a
n
d

2
7
.
5

s
e
c
o
n
d
s

i
n

d
e
l
a
y
e
d

g
r
o
u
p
.
R
R

o
f

d
e
a
t
h

w
i
t
h

e
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
s

1
.
2
6

(
9
5
%

C
I

1
.
0
0
-
1
.
5
8
)
.
I
n
t
r
a
v
e
n
o
u
s

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

s
h
o
u
l
d

b
e

w
i
t
h
h
e
l
d

u
n
t
i
l
d
e
f
i
n
i
t
i
v
e

s
u
r
g
i
c
a
l

m
a
n
a
g
e
m
e
n
t

i
s

a
v
a
i
l
a
b
l
e

a
s

e
a
r
l
y

f
l
u
i
d
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

i
n
c
r
e
a
s
e
d

r
i
s
k

o
f

d
e
a
t
h

a
n
d

p
r
o
l
o
n
g
a
t
i
o
n

o
f

c
o
a
g
u
l
a
t
i
o
n

c
a
s
c
a
d
e
.
T
h
e

s
t
u
d
y

h
o
w
e
v
e
r

i
s

n
o
t

c
o
n
c
l
u
s
i
v
e
,

m
e
t
h
o
d
s

o
f

a
l
l
o
c
a
t
i
o
n
u
s
i
n
g

q
u
a
s
i
-
r
a
n
d
o
m
i
s
e
d

m
e
t
h
o
d
s

i
s

n
o
t

i
d
e
a
l
.

A

p
r
o
p
e
r
r
a
n
d
o
m
i
s
e
d

t
r
a
i
l

i
s

n
e
e
d
e
d

t
o

d
r
a
w

d
e
f
i
n
i
t
e

c
o
n
c
l
u
s
i
o
n
s
.




T
u
r
n
e
r
.
2
0
0
0
4
1
I
I
B
2
1
,
3
0
9

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s
r
a
n
d
o
m
i
s
e
d

t
o

r
e
c
e
i
v
e

f
l
u
i
d
s

o
r

n
o

f
l
u
i
d
s
.
E
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

m
o
r
t
a
l
i
t
y

1
0
.
4
%

v
s
.

9
.
8
%

i
n

d
e
l
a
y
e
d
/
n
o

f
l
u
i
d

g
r
o
u
p
.

R
e
l
a
t
i
v
e

r
i
s
k

f
o
r

d
e
a
t
h

w
a
s

1
.
0
6

(
9
5
%

C
I

0
.
7
7
-
1
.
4
7
)
.
T
h
e
r
e

w
a
s

s
i
g
n
i
f
i
c
a
n
t

n
o
n
-
c
o
m
p
l
i
a
n
c
e

t
o

s
t
u
d
y

p
r
o
t
o
c
o
l

w
i
t
h

3
1
%

o
f

f
l
u
i
d

g
r
o
u
p

r
e
c
e
i
v
i
n
g

f
l
u
i
d

a
n
d

8
0
%

o
f

n
o
n

f
l
u
i
d

g
r
o
u
p

n
o
t

r
e
c
e
i
v
i
n
g

f
l
u
i
d
.
K
a
w
e
s
k
i
,

S
M
.
S
i
s
,


M
J
.
V
i
r
g
i
l
i
o
,

R
W
.
1
9
9
0
8
4
I
I
I
-
2

c
a
s
e
c
o
n
t
r
o
l
B
2
T
h
e

o
u
t
c
o
m
e
s

o
f

6
,
8
5
5

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
e
r
e

s
t
u
d
i
e
d
r
e
t
r
o
s
p
e
c
t
i
v
e
l
y

t
o

e
v
a
l
u
a
t
e

t
h
e
i
m
p
a
c
t

o
f

p
r
e
-
h
o
s
p
i
t
a
l

i
n
t
r
a
v
e
n
o
u
s
f
l
u
i
d

o
n

m
o
r
t
a
l
i
t
y
.

M
o
r
t
a
l
i
t
y

w
a
s

s
i
m
i
l
a
r

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s
.

T
h
i
s

s
t
u
d
y

f
a
i
l
e
d

t
o

s
h
o
w

a
n

i
n
f
l
u
e
n
c
e

o
f

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
o
n

s
u
r
v
i
v
a
l
.
H
a
m
b
l
y
,

P
R
.
D
u
t
t
o
n
,

R
P
.
1
9
9
6
4
4
I
I
I
-
3

H
i
s
t
o
r
i
c
a
l
c
o
n
t
r
o
l
T
o

a
d
d
r
e
s
s

t
h
e

i
m
p
a
c
t

o
f

r
a
p
i
d
i
n
f
u
s
i
o
n

d
e
v
i
c
e
s

o
n

p
a
t
i
e
n
t
o
u
t
c
o
m
e
.
C
o
m
p
a
r
e
d

t
o

m
a
t
c
h
e
d

c
o
n
t
r
o
l

p
a
t
i
e
n
t
s

i
n
j
u
r
e
d

t
o

t
h
e

s
a
m
e

e
x
t
e
n
t

d
u
r
i
n
g

t
h
e

s
a
m
e
t
i
m
e

p
e
r
i
o
d
,

p
a
t
i
e
n
t
s

w
h
o

r
e
c
e
i
v
e
d

f
l
u
i
d
s

v
i
a

t
h
e

R
I
S

h
a
d

a

4
.
8

t
i
m
e
s

g
r
e
a
t
e
r

c
h
a
n
c
e

o
f
d
y
i
n
g

(
9
5
%

c
o
n
f
i
d
e
n
c
e

i
n
t
e
r
v
a
l

2
.
4
-
7
.
1
)
.
A
c
t
u
a
l

v
e
r
s
u
s

e
x
p
e
c
t
e
d

m
o
r
t
a
l
i
t
y

w
a
s

a
l
s
o
h
i
g
h
e
r

t
h
a
n

e
x
p
e
c
t
e
d

m
o
r
t
a
l
i
t
y

(
5
2
.
9
%

v
s
.
6
1
.
8
%
,

p

<
0
.
0
0
1
)
.
B
2
T
h
i
s

s
t
u
d
y

r
a
i
s
e
s

t
h
e

q
u
e
s
t
i
o
n

o
f

t
h
e

s
a
f
e
t
y

o
f

r
a
p
i
d

i
n
f
u
s
i
n
g

d
e
v
i
c
e
s
.

T
h
i
s

a
n
e
c
d
o
t
a
l

e
v
i
d
e
n
c
e

s
u
g
g
e
s
t
s

t
h
e
n
e
e
d

f
o
r

a

p
r
o
s
p
e
c
t
i
v
e

r
a
n
d
o
m
i
s
e
d

t
r
i
a
l

t
o

d
e
t
e
r
m
i
n
e

i
t
s

t
r
u
e

i
m
p
a
c
t
.

H
o
w
e
v
e
r
,

i
n

t
h
e

l
i
g
h
t

o
f

c
u
r
r
e
n
t

e
v
i
d
e
n
c
e

t
h
a
t
s
u
g
g
e
s
t
s

s
m
a
l
l

v
o
l
u
m
e

h
y
p
o
t
e
n
s
i
v
e

r
e
s
u
s
c
i
t
a
t
i
o
n

t
h
i
s

i
s

u
n
l
i
k
e
l
y

t
o

o
c
c
u
r
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 27
PAGE 28 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
D
u
t
t
o
n
,

R
P
.
M
a
c
k
e
n
z
i
e
,

C
F
.
S
c
a
l
e
a
,

T
M
.
2
0
0
2
4
2
I
I
B
2
T
o

e
v
a
l
u
a
t
e

t
h
e

a
f
f
e
c
t

o
f

f
l
u
i
d
r
e
s
u
s
c
i
t
a
t
i
o
n

t
i
t
r
a
t
e
d

t
o

a

l
o
w
e
r
t
h
a
n

n
o
r
m
a
l

S
B
P

(
1
0
0
m
m
H
g

v
s
.
7
0
m
m
H
g
)

d
u
r
i
n
g

t
h
e

p
e
r
i
o
d

o
f
a
c
t
i
v
e

h
a
e
m
o
r
r
h
a
g
e

o
n

s
u
r
v
i
v
a
l

i
n
t
r
a
u
m
a

p
a
t
i
e
n
t
s

p
r
e
s
e
n
t
i
n
g

t
o

t
h
e
h
o
s
p
i
t
a
l

i
n

h
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k
.
M
o
r
t
a
l
i
t
y

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s

w
a
s

t
h
e
s
a
m
e

(
7
%

v
s
.

7
%
)
.
T
i
t
r
a
t
i
o
n

o
f

i
n
i
t
i
a
l

f
l
u
i
d

t
h
e
r
a
p
y

t
o

a

l
o
w
e
r

t
h
a
n

n
o
r
m
a
l

S
B
P

d
u
r
i
n
g

a
c
t
i
v
e

h
a
e
m
o
r
r
h
a
g
e

d
i
d

n
o
t

a
f
f
e
c
t

m
o
r
t
a
l
i
t
y

i
n

t
h
i
s

s
t
u
d
y
.
K
w
a
n
,

I
.

B
u
n
n
,

F
.
R
o
b
e
r
t
s
,

I
.
2
0
0
3
4
5
I
B
2
T
o

a
s
s
e
s
s

t
h
e

e
f
f
e
c
t
s

o
f

e
a
r
l
y
v
e
r
s
u
s

d
e
l
a
y
e
d
,

a
n
d

l
a
r
g
e
r

v
e
r
s
u
s

s
m
a
l
l
e
r

v
o
l
u
m
e

o
f

f
l
u
i
d
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
i
t
h

b
l
e
e
d
i
n
g
.
D
u
e

t
o

t
h
e
i
r

h
e
t
e
r
o
g
e
n
e
i
t
y
,

i
n

t
e
r
m
s

o
f

t
y
p
e
s

o
f

p
a
t
i
e
n
t
s

a
n
d

t
y
p
e
s

o
f

f
l
u
i
d
s

u
s
e
d
,

w
e

d
i
d

n
o
t

a
t
t
e
m
p
t

t
o

p
e
r
f
o
r
m

a

m
e
t
a
-
a
n
a
l
y
s
i
s

o
f

t
h
e

s
t
u
d
i
e
s
.
T
h
e
r
e

w
a
s

n
o

e
v
i
d
e
n
c
e

f
o
r

o
r

a
g
a
i
n
s
t

e
a
r
l
y

o
r

l
a
r
g
e
r

v
o
l
u
m
e

o
f

i
n
t
r
a
v
e
n
o
u
s

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
n

u
n
c
o
n
t
r
o
l
l
e
d
h
a
e
m
o
r
r
h
a
g
e
.

A

l
a
r
g
e
,

w
e
l
l
-
c
o
n
d
u
c
t
e
d

R
C
T

i
s

r
e
q
u
i
r
e
d

a
s

t
h
e

q
u
a
l
i
t
y

o
f

t
h
e

c
u
r
r
e
n
t

e
v
i
d
e
n
c
e

i
s

p
o
o
r
.
B
i
c
k
e
l
l
,

W
H
.
W
a
l
l
,

M
J

J
r
.
P
e
p
e
,

P
E
.
1
9
9
4
4
0
I
I
B
2
T
h
e

p
u
r
p
o
s
e

o
f

t
h
i
s

s
t
u
d
y

w
a
s

t
o
d
e
t
e
r
m
i
n
e

t
h
e

e
f
f
e
c
t
s

o
f

d
e
l
a
y
i
n
g
f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

u
n
t
i
l

t
h
e

t
i
m
e

o
f

o
p
e
r
a
t
i
v
e

i
n
t
e
r
v
e
n
t
i
o
n

i
n
h
y
p
o
t
e
n
s
i
v
e

p
a
t
i
e
n
t
s

w
i
t
h
p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s

t
o

t
h
e

t
o
r
s
o
.
5
9
8

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
i
t
h
p
e
n
e
t
r
a
t
i
n
g

t
o
r
s
o

i
n
j
u
r
i
e
s

w
e
r
e

q
u
a
s
i
-
r
a
n
d
o
m
i
s
e
d

(
a
l
t
e
r
n
a
t
e

d
a
y

a
l
l
o
c
a
t
i
o
n
)

t
o

e
a
r
l
y

v
e
r
s
u
s

d
e
l
a
y
e
d

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
M
o
r
t
a
l
i
t
y

w
a
s

3
8
%

i
n

e
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
v
s
.

3
0
%

i
n

d
e
l
a
y
e
d
.
P
r
o
t
h
r
o
m
b
i
n

a
n
d

p
a
r
t
i
a
l

t
h
r
o
m
b
o
p
l
a
s
t
i
n

t
i
m
e
i
n

e
a
r
l
y

1
4
.
1

a
n
d

3
1
.
8

s
e
c
o
n
d
s

a
n
d

1
1
.
4

a
n
d

2
7
.
5

s
e
c
o
n
d
s

i
n

d
e
l
a
y
e
d

g
r
o
u
p
.
R
R

o
f

d
e
a
t
h

w
i
t
h

e
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
s

1
.
2
6
(
9
5
%

C
I

1
.
0
0
-
1
.
5
8
)
I
n
t
r
a
v
e
n
o
u
s

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

s
h
o
u
l
d

b
e

w
i
t
h
h
e
l
d

u
n
t
i
l
d
e
f
i
n
i
t
i
v
e

s
u
r
g
i
c
a
l

m
a
n
a
g
e
m
e
n
t

i
s

a
v
a
i
l
a
b
l
e

a
s

e
a
r
l
y

f
l
u
i
d
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

i
n
c
r
e
a
s
e
d

r
i
s
k

o
f

d
e
a
t
h

a
n
d

p
r
o
l
o
n
g
a
t
i
o
n

o
f

c
o
a
g
u
l
a
t
i
o
n

c
a
s
c
a
d
e
.
T
u
r
n
e
r
.
2
0
0
0
4
1
I
I
B
2
E
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

v
s
.

n
o

f
l
u
i
d
.
E
a
r
l
y

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

m
o
r
t
a
l
i
t
y

1
0
.
4
%

v
s
.

9
.
8
%

i
n

d
e
l
a
y
e
d
/
n
o

f
l
u
i
d

g
r
o
u
p
.
R
e
l
a
t
i
v
e

r
i
s
k

f
o
r

d
e
a
t
h

w
a
s

1
.
0
6

(
9
5
%

C
I

0
.
7
7
-
1
.
4
7
)
.
T
h
e
r
e

w
a
s

h
u
g

n
o
n
-
c
o
m
p
l
i
a
n
c
e

t
o

s
t
u
d
y

p
r
o
t
o
c
o
l

w
i
t
h

3
1
%

o
f

f
l
u
i
d

g
r
o
u
p

r
e
c
e
i
v
i
n
g

f
l
u
i
d

a
n
d

8
0
%

o
f

n
o
n

f
l
u
i
d

g
r
o
u
p

n
o
t

r
e
c
e
i
v
i
n
g

f
l
u
i
d
.
K
a
w
e
s
k
i
,

S
M
.
S
i
s
e
,

M
J
.
V
i
r
g
i
l
i
o
,

R
W
.
1
9
9
0
8
4
I
I
T
h
e

o
u
t
c
o
m
e
s

o
f

6
,
8
5
5

t
r
a
u
m
a

p
a
t
i
e
n
t
s

w
e
r
e

s
t
u
d
i
e
d
r
e
t
r
o
s
p
e
c
t
i
v
e
l
y

t
o

e
v
a
l
u
a
t
e

t
h
e
i
m
p
a
c
t

o
f

p
r
e
-
h
o
s
p
i
t
a
l

i
n
t
r
a
v
e
n
o
u
s
f
l
u
i
d

o
n

m
o
r
t
a
l
i
t
y
.
M
o
r
t
a
l
i
t
y

w
a
s

s
i
m
i
l
a
r

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s
.
B
2
T
h
i
s

s
t
u
d
y

f
a
i
l
e
d

t
o

s
h
o
w

a
n

i
n
f
l
u
e
n
c
e

o
f

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n

o
n

s
u
r
v
i
v
a
l
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 28
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 29
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
B
l
a
i
r
,

S
D
.
J
a
n
v
r
i
n
,

S
B
.
M
c
C
o
l
l
u
m
,

C
.
1
9
8
6
8
6
I
I
B
1
E
a
r
l
y

v
e
r
s
u
s

d
e
l
a
y
e
d

b
l
o
o
d
t
r
a
n
s
f
u
s
i
o
n

f
o
r

p
a
t
i
e
n
t
s

w
i
t
h
g
a
s
t
r
o
i
n
t
e
s
t
i
n
a
l

b
l
e
e
d
i
n
g
.
M
o
r
t
a
l
i
t
y

w
a
s

8
%

i
n

t
h
e

e
a
r
l
y
v
e
r
s
u
s

0
%

i
n

t
h
e

l
a
t
e
.

T
h
e

e
a
r
l
y
b
l
o
o
d

t
r
a
n
s
f
u
s
i
o
n

g
r
o
u
p

w
a
s

5
.
4
(
9
5
%

C
I

0
.
3

t
o

1
0
7
.
1
)
.
T
h
e

w
e
r
e

n
i
n
e

p
a
t
i
e
n
t
s

i
n

t
h
e

t
r
a
n
s
f
u
s
e
d

g
r
o
u
p

t
h
a
t

r
e
-
b
l
e
d

c
o
m
p
a
r
e
d

w
i
t
h

o
n
l
y

o
n
e

i
n

t
h
e

n
o
n
-
t
r
a
n
s
f
u
s
e
d

g
r
o
u
p

(
p

<
0
.
0
1
)
.
T
h
e

a
u
t
h
o
r
s

c
o
n
c
l
u
d
e

t
h
a
t

e
a
r
l
y

b
l
o
o
d

t
r
a
n
s
f
u
s
i
o
n

a
p
p
e
a
r
s
t
o

r
e
v
e
r
s
e

t
h
e

h
y
p
e
r

c
o
a
g
u
l
a
b
l
e

r
e
s
p
o
n
s
e

t
o

h
a
e
m
o
r
r
h
a
g
e
t
h
e
r
e
b
y

e
n
c
o
u
r
a
g
i
n
g

r
e
-
b
l
e
e
d
i
n
g

a
n
d

h
e
n
c
e

t
h
e

n
e
e
d

f
o
r

a
n

o
p
e
r
a
t
i
o
n
.
D
u
n
h
a
m
,

C
M
.
B
e
l
z
b
e
r
g
,

H
.
L
y
l
e
s
,

R
.
W
e
i
r
e
t
e
r
,

L
.
1
9
9
1
8
7
I
I
C
R
a
p
i
d

i
n
f
u
s
i
n
g

d
e
v
i
c
e

v
s
.
c
o
n
v
e
n
t
i
o
n
a
l

f
l
u
i
d

a
d
m
i
n
i
s
t
r
a
t
i
o
n
T
h
e

r
e
l
a
t
i
v
e

r
i
s
k

f
o
r

d
e
a
t
h

i
s

0
.
8
0
(
9
5
%

C
I

0
.
2
8
-
2
.
2
9
)
.
L
a
c
t
a
t
e

l
e
v
e
l
s

w
e
r
e

l
o
w
e
r

i
n

t
h
e

R
I
S

g
r
o
u
p

a
t
v
i
r
t
u
a
l
l
y

a
l
l

t
i
m
e
s

f
r
o
m

h
o
u
r
s

1

t
o

2
4

(
4
.
3
/
5
.
3
m
M
/
l
,

t
-
v
a
l
u
e

=

3
.
3
,

D
F

=

2
7
9
,

p

=

0
.
0
0
1
)
.

P
o
s
t
-
a
d
m
i
s
s
i
o
n

h
y
p
o
t
h
e
r
m
i
a

w
a
s

g
r
e
a
t
e
r

i
n

t
h
e

C
F
A

g
r
o
u
p

a
t

a
l
l

t
i
m
e
s

d
u
r
i
n
g

t
h
e

f
i
r
s
t

2
4

h

(
3
5
.
2

/

3
6
.
4

d
e
g
r
e
e
s

C
,

t
-
v
a
l
u
e

=

5
.
6
,

D
F

=

2
5
0
,

P

=

0
.
0
0
1
)
.

T
h
e

m
e
a
n

p
a
r
t
i
a
l
t
h
r
o
m
b
o
p
l
a
s
t
i
n

t
i
m
e

w
a
s

s
i
g
n
i
f
i
c
a
n
t
l
y

h
i
g
h
e
r
i
n

t
h
e

C
F
A

g
r
o
u
p

(
4
7
.
3
/
3
5
.
1

s
,

t
-
v
a
l
u
e

=

3
.
1
,
D
F

=

2
7
9
,

P

=

0
.
0
0
2
)
.

T
h
e

P
T
T

a
n
d

P
T

w
e
r
e

r
e
l
a
t
e
d

t
o

t
h
e

d
e
g
r
e
e

o
f

l
a
c
t
i
c

a
c
i
d
o
s
i
s

(
p

=

0
.
0
0
0
1
)

a
n
d

h
y
p
o
t
h
e
r
m
i
a

(
p

=

0
.
0
0
1
)

b
u
t

n
o
t

t
o

t
h
e

a
m
o
u
n
t

o
f

F
F
P

g
i
v
e
n

(
p

=

0
.
1
4
)
.
H
y
p
o
v
o
l
a
e
m
i
c

t
r
a
u
m
a

p
a
t
i
e
n
t
s

r
e
s
u
s
c
i
t
a
t
e
d

w
i
t
h

t
h
e

R
I
S

l
e
s
s

c
o
a
g
u
l
o
p
a
t
h
y
;

m
o
r
e

r
a
p
i
d

r
e
s
o
l
u
t
i
o
n

o
f
h
y
p
o
p
e
r
f
u
s
i
o
n

a
c
i
d
o
s
i
s
;

b
e
t
t
e
r

t
e
m
p
e
r
a
t
u
r
e

p
r
e
s
e
r
v
a
t
i
o
n
;

a
n
d

f
e
w
e
r

h
o
s
p
i
t
a
l

c
o
m
p
l
i
c
a
t
i
o
n
s

t
h
a
n

t
h
o
s
e

r
e
s
u
s
c
i
t
a
t
e
d
w
i
t
h

c
o
n
v
e
n
t
i
o
n
a
l

m
e
t
h
o
d
s

o
f

f
l
u
i
d

/

b
l
o
o
d

p
r
o
d
u
c
t
a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
D
u
t
t
o
n
,

R
P
.
M
a
c
k
e
n
z
i
e
,

C
F
.
2
0
0
2
4
2
I
I
B
2
L
a
r
g
e

v
s

s
m
a
l
l

f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n
.
M
o
r
t
a
l
i
t
y

w
a
s

4
/
5
5

(
7
.
3
%
)

i
n

t
h
e

g
r
o
u
p
a
d
m
i
n
i
s
t
e
r
e
d

a

l
a
r
g
e
r

v
o
l
u
m
e

a
n
d

4
/
5
5

(
7
.
3
%
)
i
n

t
h
e

g
r
o
u
p

a
d
m
i
n
i
s
t
e
r
e
d

a

s
m
a
l
l
e
r

v
o
l
u
m
e
(
1
0
0
0
m
l

l
e
s
s

t
h
a
n

i
n

t
h
e

i
n
t
e
r
v
e
n
t
i
o
n

g
r
o
u
p
)
.
T
h
e

r
e
l
a
t
i
v
e

r
i
s
k

f
o
r

d
e
a
t
h

i
s

1
.
0
0

(
9
5
%

C
I

0
.
2
6
-
3
.
8
1
)
.
T
h
e
r
e

w
a
s

n
o

e
v
i
d
e
n
c
e

f
o
r

o
r

a
g
a
i
n
s
t

l
a
r
g
e

v
o
l
u
m
e
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
n

p
a
t
i
e
n
t
s

w
i
t
h

t
r
a
u
m
a
t
i
c

h
y
p
o
t
e
n
s
i
o
n
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 29
PAGE 30 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
N
e
f
f
,

T
A
.
D
o
e
l
b
e
r
g
,

M
.
J
u
n
g
h
e
i
n
r
i
c
h
C
.

2
0
0
3
8
8
I
I
B
1
T
o

i
n
v
e
s
t
i
g
a
t
e

t
h
e

s
a
f
e
t
y

o
f
r
e
p
e
t
i
t
i
v
e

l
a
r
g
e
-
d
o
s
e

i
n
f
u
s
i
o
n

o
f

a

n
o
v
e
l

h
y
d
r
o
x
y
e
t
h
y
l

s
t
a
r
c
h
s
o
l
u
t
i
o
n

(
6
%

H
E
S

1
3
0
/
0
.
4
)

i
n
c
r
a
n
i
o
-
c
e
r
e
b
r
a
l

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
e
r
e

n
o

d
i
f
f
e
r
e
n
c
e
s

b
e
t
w
e
e
n

g
r
o
u
p
s

i
n

m
o
r
t
a
l
i
t
y
,

r
e
n
a
l

f
u
n
c
t
i
o
n
,

b
l
e
e
d
i
n
g
c
o
m
p
l
i
c
a
t
i
o
n
s
,

a
n
d

u
s
e

o
f

b
l
o
o
d

p
r
o
d
u
c
t
s
.
T
h
e
r
e

w
e
r
e

a
l
s
o

n
o

m
a
j
o
r

d
i
f
f
e
r
e
n
c
e
s

i
n
c
o
a
g
u
l
a
t
i
o
n

v
a
r
i
a
b
l
e
s
.
P
r
e
v
i
o
u
s
l
y
,

t
h
e

e
f
f
e
c
t

o
f

h
y
d
r
o
x
y
e
t
h
y
l

s
t
a
r
c
h

(
H
E
S
)

t
y
p
e
s
f
o
r

p
l
a
s
m
a

v
o
l
u
m
e

e
x
p
a
n
s
i
o
n

o
n

c
o
a
g
u
l
a
t
i
o
n

a
n
d

r
e
n
a
l
f
u
n
c
t
i
o
n
.

H
o
w
e
v
e
r
,

t
h
i
s

s
t
u
d
y

s
u
g
g
e
s
t
s

t
h
a
t

H
E
S

1
3
0
/
0
.
4
c
a
n

s
a
f
e
l
y

b
e

u
s
e
d

i
n

c
r
i
t
i
c
a
l
l
y

i
l
l

h
e
a
d

t
r
a
u
m
a

p
a
t
i
e
n
t
s

o
v
e
r
s
e
v
e
r
a
l

d
a
y
s

a
t

d
o
s
e
s

o
f

u
p

t
o

7
0

m
L

x

k
g
(
-
1
)

x

d
(
-
1
)
.
B
u
c
h
m
a
n
,

T
G
.
M
e
n
k
e
r
,

J
B
.
L
i
p
s
e
t
t
,

P
A
.
1
9
9
1
8
9
I
V
C
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
e
c
t

o
f

r
a
p
i
d
i
n
f
u
s
e
r

o
n

u
n
s
u
s
p
e
c
t
e
d

s
u
r
v
i
v
a
l
r
a
t
e
s

i
n

h
y
p
o
t
e
n
s
i
v
e

p
e
n
e
t
r
a
t
i
n
g
t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
a
s

a

s
t
a
t
i
s
t
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t
i
m
p
r
o
v
e
m
e
n
t

i
n

c
l
i
n
i
c
a
l

f
l
o
w

r
a
t
e
s
,

d
e
c
r
e
m
e
n
t

i
n

r
e
s
u
s
c
i
t
a
t
i
o
n

t
i
m
e
s

a
n
d

u
n
e
x
p
e
c
t
e
d

s
u
r
v
i
v
a
l
.
S
t
a
t
i
s
t
i
c
a
l

s
u
m
m
a
r
y

n
o
t

p
r
e
s
e
n
t
e
d

i
n

p
a
p
e
r
,
u
n
a
b
l
e

t
o

d
e
t
e
r
m
i
n
e
.
U
s
e

o
f

r
a
p
i
d

i
n
f
u
s
i
o
n

d
e
v
i
c
e

i
n

t
h
i
s

s
m
a
l
l

s
e
r
i
e
s

o
f

p
a
t
i
e
n
t
s

i
s

h
y
p
o
t
h
e
s
i
s
e
d

b
y

t
h
e

a
u
t
h
o
r
s

t
o

i
m
p
r
o
v
e
d
u
n
e
x
p
e
c
t
e
d

s
u
r
v
i
v
a
l
.
R
e
m
m
e
r
s
,

D
E
.
W
a
n
g
,

P
.

C
i
o
f
f
i
,

W
G
.
1
9
9
8
9
0
S
c
i
e
n
t
i
f
i
c
A
n
i
m
a
l
N
/
A
T
o

d
e
t
e
r
m
i
n
e

w
h
e
t
h
e
r

p
r
o
l
o
n
g
e
d
(
c
h
r
o
n
i
c
)

r
e
s
u
s
c
i
t
a
t
i
o
n

h
a
s

a
n
y
b
e
n
e
f
i
c
i
a
l

e
f
f
e
c
t
s

o
n

c
a
r
d
i
a
c

o
u
t
p
u
t
a
n
d

h
e
p
a
t
o
c
e
l
l
u
l
a
r

f
u
n
c
t
i
o
n

a
f
t
e
r
t
r
a
u
m
a
-
h
a
e
m
o
r
r
h
a
g
e

a
n
d

a
c
u
t
e
f
l
u
i
d

r
e
p
l
a
c
e
m
e
n
t
.
C
h
r
o
n
i
c

r
e
s
u
s
c
i
t
a
t
i
o
n

w
i
t
h

5

m
L
/
k
g
/
h
r

r
e
s
t
o
r
e
d
c
a
r
d
i
a
c

o
u
t
p
u
t
,

h
e
p
a
t
o
c
e
l
l
u
l
a
r

f
u
n
c
t
i
o
n
,

a
n
d
h
e
p
a
t
i
c

m
i
c
r
o
v
a
s
c
u
l
a
r

b
l
o
o
d

f
l
o
w

a
t

2
0

h
o
u
r
s
a
f
t
e
r

h
a
e
m
o
r
r
h
a
g
e
.

T
h
e

r
e
g
i
m
e
n

a
b
o
v
e

a
l
s
o
r
e
d
u
c
e
d

p
l
a
s
m
a

I
L
-
6

l
e
v
e
l
s
.
C
h
r
o
n
i
c

f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

a
d
d
i
t
i
o
n

t
o

a
c
u
t
e

f
l
u
i
d
r
e
p
l
a
c
e
m
e
n
t

s
h
o
u
l
d

b
e

r
o
u
t
i
n
e
l
y

u
s
e
d

i
n

e
x
p
e
r
i
m
e
n
t
a
l
s
t
u
d
i
e
s

o
f

t
r
a
u
m
a
-

h
a
e
m
o
r
r
h
a
g
e
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 30
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 31
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Evidence Table 4. If fluid resucitation is indicated, what type of fluids should be used?
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
A
l
d
e
r
s
o
n
,

P
.
S
c
h
i
e
r
h
o
u
t
,

G
.
R
o
b
e
r
t
s
,

I
.
B
u
n
n
,

F
.

2
0
0
4
5
0
IN
o
t
s
p
e
c
i
f
i
c
a
l
l
y
t
r
a
u
m
a
p
a
t
i
e
n
t
s
,
b
u
t
i
n
c
l
u
d
e
s
s
t
u
d
i
e
s

o
n
t
r
a
u
m
a
p
a
t
i
e
n
t
s
.
A
T
o

a
s
s
e
s
s

t
h
e

e
f
f
e
c
t
s

o
n

m
o
r
t
a
l
i
t
y
o
f

c
o
l
l
o
i
d
s

c
o
m
p
a
r
e
d

t
o

c
r
y
s
t
a
l
l
o
i
d
s
f
o
r

f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

c
r
i
t
i
c
a
l
l
y
i
l
l

p
a
t
i
e
n
t
s
.


C
o
l
l
o
i
d
s

c
o
m
p
a
r
e
d

t
o

c
r
y
s
t
a
l
l
o
i
d
s
:

R
R
1
.
5
2
(
9
5
%

c
o
n
f
i
d
e
n
c
e

i
n
t
e
r
v
a
l

1
.
0
8

t
o

2
.
1
3
)
.


H
y
d
r
o
x
y
e
t
h
y
l
s
t
a
r
c
h
:

R
R
1
.
1
6

(
0
.
6
8

t
o

1
.
9
6
)
.


M
o
d
i
f
i
e
d

g
e
l
a
t
i
n
:

R
R
0
.
5
0

(
0
.
0
8

t
o

3
.
0
3
)
.


D
e
x
t
r
a
n
:

R
R
1
.
2
4

(
0
.
9
4

t
o

1
.
6
5
)
.


C
o
l
l
o
i
d
s

i
n

h
y
p
e
r
t
o
n
i
c

c
r
y
s
t
a
l
l
o
i
d

c
o
m
p
a
r
e
d
t
o

i
s
o
t
o
n
i
c

c
r
y
s
t
a
l
l
o
i
d
:

R
R
0
.
8
8

(
0
.
7
4

t
o

1
.
0
5
)
.
T
h
e
r
e

i
s

n
o

e
v
i
d
e
n
c
e

f
r
o
m

r
a
n
d
o
m
i
s
e
d

c
o
n
t
r
o
l
l
e
d

t
r
i
a
l
s

t
h
a
t

r
e
s
u
s
c
i
t
a
t
i
o
n

w
i
t
h

c
o
l
l
o
i
d
s

r
e
d
u
c
e
s

t
h
e

r
i
s
k

o
f

d
e
a
t
h
c
o
m
p
a
r
e
d

t
o

c
r
y
s
t
a
l
l
o
i
d
s

i
n

p
a
t
i
e
n
t
s

w
i
t
h

t
r
a
u
m
a
,

b
u
r
n
s

a
n
d

f
o
l
l
o
w
i
n
g

s
u
r
g
e
r
y
.

A
s

c
o
l
l
o
i
d
s

a
r
e

n
o
t

a
s
s
o
c
i
a
t
e
d

w
i
t
h

a
n

i
m
p
r
o
v
e
m
e
n
t

i
n

s
u
r
v
i
v
a
l
,

a
n
d

a
s

t
h
e
y

a
r
e

m
o
r
e

e
x
p
e
n
s
i
v
e
t
h
a
n

c
r
y
s
t
a
l
l
o
i
d
s
,

i
t

i
s

h
a
r
d

t
o

s
e
e

h
o
w

t
h
e
i
r

c
o
n
t
i
n
u
e
d

u
s
e

i
n

t
h
e
s
e

p
a
t
i
e
n
t

t
y
p
e
s

c
a
n

b
e

j
u
s
t
i
f
i
e
d

o
u
t
s
i
d
e

t
h
e

c
o
n
t
e
x
t

o
f

r
a
n
d
o
m
i
s
e
d

c
o
n
t
r
o
l
l
e
d

t
r
i
a
l
s
.
W
i
l
k
e
s
,

M
M
.
N
a
v
i
c
k
i
s
,

R
J
.
2
0
0
1
9
1
IN
o
t
s
p
e
c
i
f
i
c
a
l
l
y
t
r
a
u
m
a
p
a
t
i
e
n
t
s
,
b
u
t
i
n
c
l
u
d
e
s
s
t
u
d
i
e
s

o
n
t
r
a
u
m
a
p
a
t
i
e
n
t
s
.
B
2
T
o

t
e
s
t

t
h
e

h
y
p
o
t
h
e
s
i
s

t
h
a
t

a
l
b
u
m
i
n
a
d
m
i
n
i
s
t
r
a
t
i
o
n

i
s

n
o
t

a
s
s
o
c
i
a
t
e
d
w
i
t
h

e
x
c
e
s
s

m
o
r
t
a
l
i
t
y
.
A
l
b
u
m
i
n

a
d
m
i
n
i
s
t
r
a
t
i
o
n

d
i
d

n
o
t

s
i
g
n
i
f
i
c
a
n
t
l
y
a
f
f
e
c
t

m
o
r
t
a
l
i
t
y

i
n

a
n
y

c
a
t
e
g
o
r
y

o
f

i
n
d
i
c
a
t
i
o
n
s
.
F
o
r

a
l
l

t
r
i
a
l
s
,

t
h
e

r
e
l
a
t
i
v
e

r
i
s
k

f
o
r

d
e
a
t
h

w
a
s

1
.
1
1
(
9
5
%

C
l
,

0
.
9
5

t
o

1
.
2
8
)
.
N
o

e
f
f
e
c
t

o
f

a
l
b
u
m
i
n

o
n

m
o
r
t
a
l
i
t
y

w
a
s

d
e
t
e
c
t
e
d
;

a
n
y

s
u
c
h

e
f
f
e
c
t

m
a
y

t
h
e
r
e
f
o
r
e

b
e

s
m
a
l
l
.

T
h
i
s

f
i
n
d
i
n
g

s
u
p
p
o
r
t
s

t
h
e

s
a
f
e
t
y

o
f

a
l
b
u
m
i
n
.
A
u
t
h
o
r
s

c
o
n
c
l
u
d
e

t
h
a
t

o
v
e
r
a
l
l

m
e
t
h
o
d
o
l
o
g
i
c
a
l

q
u
a
l
i
t
y

o
f

s
t
u
d
i
e
s

i
s

p
o
o
r

a
n
d

e
f
f
e
c
t
s

s
t
u
d
y

r
e
s
u
l
t
s
.

A

l
a
r
g
e

w
e
l
l
-
e
x
e
c
u
t
e
d

R
C
T

i
s

n
e
e
d
e
d
.
W
a
d
e
,

C
E
.
K
r
a
m
e
r
,

G
C
.
G
r
a
d
y
,

J
J
.
1
9
9
7
5
5
IT
r
a
u
m
a
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
e
c
t
s

o
f
H
y
p
e
r
t
o
n
i
c

S
a
l
i
n
e

a
n
d

H
y
p
e
r
t
o
n
i
c
S
a
l
i
n
e

/

D
e
x
t
r
a
n

o
n

s
u
r
v
i
v
a
l

u
n
t
i
l
d
i
s
c
h
a
r
g
e

o
r

f
o
r

3
0

d
a
y
s
.
H
S

w
a
s

n
o
t

e
f
f
e
c
t
i
v
e

i
n

i
m
p
r
o
v
i
n
g

s
u
r
v
i
v
a
l
.
H
S
D

r
e
s
u
l
t
e
d

i
n

a
n

i
n
c
r
e
a
s
e

i
n

s
u
r
v
i
v
a
l

i
n
7
/
8

t
r
i
a
l
s
.

O
R

1
.
2
0

(
9
5
%

C
I

0
.
9
4
-
1
.
5
7
)
B
2
H
y
p
e
r
t
o
n
i
c

S
a
l
i
n
e

a
l
o
n
e

d
o
e
s

n
o
t

o
f
f
e
r

a
n
y

b
e
n
e
f
i
t

i
n

t
e
r
m
s

o
f

3
0
-
d
a
y

s
u
r
v
i
v
a
l

o
v
e
r

i
s
o
t
o
n
i
c

c
r
y
s
t
a
l
l
o
i
d
s
.
H
y
p
e
r
t
o
n
i
c

S
a
l
i
n
e

w
i
t
h

D
e
x
t
r
a
n

m
a
y

i
m
p
r
o
v
e

m
o
r
t
a
l
i
t
y
.
T
h
e

m
e
t
a
-
a
n
a
l
y
s
i
s

o
f

t
h
e

a
v
a
i
l
a
b
l
e

d
a
t
a

s
h
o
w
s

t
h
a
t

H
S

i
s
n
o
t

d
i
f
f
e
r
e
n
t

f
r
o
m

t
h
e

s
t
a
n
d
a
r
d

o
f

c
a
r
e

a
n
d

t
h
a
t

H
S
D

m
a
y
b
e

s
u
p
e
r
i
o
r
.
W
a
d
e
,

C
E
.
G
r
a
d
y
,

J
J
.
K
r
a
m
e
r
,

G
C
.
Y
o
u
n
e
s
,

R
N
.
1
9
9
7
9
2
I
I
T
o

e
v
a
l
u
a
t
e

i
m
p
r
o
v
e
m
e
n
t
s

i
n

s
u
r
v
i
v
a
l

a
t

2
4

h
o
u
r
s

a
n
d
d
i
s
c
h
a
r
g
e

a
f
t
e
r

i
n
i
t
i
a
l

t
r
e
a
t
m
e
n
t

w
i
t
h

H
y
p
e
r
t
o
n
i
c

S
a
l
i
n
e

D
e
x
t
r
o
s
e

i
n

p
a
t
i
e
n
t
s

w
h
o

h
a
d

t
r
a
u
m
a
t
i
c

b
r
a
i
n

i
n
j
u
r
y
.
H
S
D

r
e
s
u
l
t
e
d

i
n

a

s
u
r
v
i
v
a
l

u
n
t
i
l

d
i
s
c
h
a
r
g
e

o
f

3
7
.
9
%

(
3
9

o
f

1
0
3
)

v
s
.

2
6
.
9
%

(
3
2

o
f

1
1
9
)
w
i
t
h

s
t
a
n
d
a
r
d

o
f

c
a
r
e

(
p

=

0
.
0
8
0
)
.

U
s
i
n
g

l
o
g
i
s
t
i
c
r
e
g
r
e
s
s
i
o
n
,

a
d
j
u
s
t
i
n
g

f
o
r

t
r
i
a
l

a
n
d

p
o
t
e
n
t
i
a
l
c
o
n
f
o
u
n
d
i
n
g

v
a
r
i
a
b
l
e
s
,

t
h
e

t
r
e
a
t
m
e
n
t

e
f
f
e
c
t

c
a
n

b
e

s
u
m
m
a
r
i
s
e
d

b
y

t
h
e

o
d
d
s

r
a
t
i
o

o
f

2
.
1
2

(
p

=

0
.
0
4
8
)

f
o
r

s
u
r
v
i
v
a
l

u
n
t
i
l

d
i
s
c
h
a
r
g
e
.
B
2
P
a
t
i
e
n
t
s

w
h
o

h
a
v
e

t
r
a
u
m
a
t
i
c

b
r
a
i
n

i
n
j
u
r
i
e
s

i
n

t
h
e

p
r
e
s
e
n
c
e
o
f

h
y
p
o
t
e
n
s
i
o
n

a
n
d

r
e
c
e
i
v
e

H
S
D

a
r
e

a
b
o
u
t

t
w
i
c
e

a
s

l
i
k
e
l
y

t
o
s
u
r
v
i
v
e

a
s

t
h
o
s
e

w
h
o

r
e
c
e
i
v
e

s
t
a
n
d
a
r
d

o
f

c
a
r
e
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 31
PAGE 32 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
M
a
t
t
o
x
,

K
L
.
M
a
n
i
n
g
a
s
,

P
A
.
M
o
o
r
e
,

E
E
.
1
9
9
1
9
3
I
I
A
T
o

c
o
m
p
a
r
e

2
5
0

m
L

o
f

H
S
D

v
e
r
s
u
s

2
5
0

m
L

o
f

n
o
r
m
a
l
c
r
y
s
t
a
l
l
o
i
d

s
o
l
u
t
i
o
n

a
d
m
i
n
i
s
t
e
r
e
d
b
e
f
o
r
e

r
o
u
t
i
n
e

p
r
e
h
o
s
p
i
t
a
l

a
n
d
e
m
e
r
g
e
n
c
y

c
e
n
t
r
e

r
e
s
u
s
c
i
t
a
t
i
o
n
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

s
u
r
v
i
v
a
l

b
e
t
w
e
e
n

t
h
e
t
w
o

g
r
o
u
p
s
.
T
h
e

H
S
D

g
r
o
u
p

h
a
d

a
n

i
m
p
r
o
v
e
d

b
l
o
o
d
p
r
e
s
s
u
r
e

(
p

=

0
.
0
2
4
)
.

H
a
e
m
a
t
o
c
r
i
t
,

s
o
d
i
u
m
c
h
l
o
r
i
d
e
,

a
n
d

o
s
m
o
l
a
l
i
t
y

l
e
v
e
l
s

w
e
r
e

s
i
g
n
i
f
i
c
a
n
t
l
y
e
l
e
v
a
t
e
d

i
n

t
h
e

e
m
e
r
g
e
n
c
y

c
e
n
t
r
e
.
T
h
i
s

s
t
u
d
y

s
h
o
w
e
d

t
h
e

s
a
f
e
t
y

o
f

H
S
D
,

b
u
t

f
a
i
l
e
d

t
o

s
h
o
w

a
n
y

b
e
n
e
f
i
t

o
f

t
h
i
s

s
o
l
u
t
i
o
n

i
n

r
e
d
u
c
i
n
g

m
o
r
t
a
l
i
t
y
.

I
n

l
i
g
h
t

o
f

t
h
e

c
o
s
t

o
f

t
h
i
s

s
o
l
u
t
i
o
n

i
n

c
o
m
p
a
r
i
s
o
n

t
o

s
t
a
n
d
a
r
d
t
h
e
r
a
p
y
,

u
n
t
i
l

p
r
o
v
e
n

e
f
f
i
c
a
c
i
o
u
s

i
s

n
o
t

r
e
c
o
m
m
e
n
d
e
d
.
M
a
n
i
n
g
a
s
,

P
A
.
M
a
t
t
o
x
,

K
L
.
P
e
p
e
,

P
E
.
J
o
n
e
s
,

R
L
.
1
9
8
9
9
4
I
I
B
1
P
i
l
o
t

s
t
u
d
y

t
o

a
s
s
e
s
s

t
h
e

s
a
f
e
t
y

o
f
s
a
l
i
n
e
-
d
e
x
t
r
a
n

s
o
l
u
t
i
o
n
s

i
n

t
r
a
u
m
a
p
a
t
i
e
n
t
s

w
i
t
h

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s
a
n
d

a

p
r
e
h
o
s
p
i
t
a
l

s
y
s
t
o
l
i
c

b
l
o
o
d
p
r
e
s
s
u
r
e

<

9
0

m
m

H
g
.
T
h
e
r
e

w
e
r
e

n
o

c
o
m
p
l
i
c
a
t
i
o
n
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h
t
h
e

i
n
f
u
s
i
o
n

o
f

t
h
e

h
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e
-
d
e
x
t
r
a
n
s
o
l
u
t
i
o
n
,

a
n
d

e
x
e
c
u
t
i
o
n

o
f

t
h
e

p
r
o
t
o
c
o
l

b
y
p
a
r
a
m
e
d
i
c

p
e
r
s
o
n
n
e
l

w
a
s

b
o
t
h

s
a
f
e

a
n
d
u
n
i
f
o
r
m
l
y

s
u
c
c
e
s
s
f
u
l
.
T
h
e

r
e
s
u
l
t
s

o
f

t
h
i
s

f
e
a
s
i
b
i
l
i
t
y

s
t
u
d
y

j
u
s
t
i
f
y

t
h
e

i
n
i
t
i
a
t
i
o
n

o
f

a

l
a
r
g
e
r

p
r
o
s
p
e
c
t
i
v
e
,

r
a
n
d
o
m
i
s
e
d

c
l
i
n
i
c
a
l

t
r
i
a
l

o
n

t
h
e

e
f
f
i
c
a
c
y

o
f

t
h
i
s

s
o
l
u
t
i
o
n

i
n

t
h
e

p
r
e
h
o
s
p
i
t
a
l

s
e
t
t
i
n
g
.
S
l
o
a
n
,

E
P
.
K
o
e
n
i
g
s
b
e
r
g
,
M
.

G
e
n
s
,

D
.
C
i
p
o
l
l
e
,

M
.
1
9
9
9
9
5
I
I
T
o

d
e
t
e
r
m
i
n
e

i
f

t
h
e

i
n
f
u
s
i
o
n

o
f

u
p

t
o

1
0
0
0

m
L

o
f

d
i
a
s
p
i
r
i
n

c
r
o
s
s
-
l
i
n
k
e
d

h
a
e
m
o
g
l
o
b
i
n

(
D
C
L
H
b
)

d
u
r
i
n
g

t
h
e

i
n
i
t
i
a
l

h
o
s
p
i
t
a
l
r
e
s
u
s
c
i
t
a
t
i
o
n

c
o
u
l
d

r
e
d
u
c
e

2
8
-
d
a
y

m
o
r
t
a
l
i
t
y

i
n

t
r
a
u
m
a
t
i
c
h
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k

p
a
t
i
e
n
t
s
.
A
t

2
8

d
a
y
s
,

2
4

(
4
6
%
)

o
f

t
h
e

5
2

p
a
t
i
e
n
t
s

i
n
f
u
s
e
d

w
i
t
h

D
C
L
H
b

d
i
e
d
,

a
n
d

8

(
1
7
%
)

o
f

t
h
e

4
6

p
a
t
i
e
n
t
s

i
n
f
u
s
e
d

w
i
t
h

t
h
e

s
a
l
i
n
e
s
o
l
u
t
i
o
n

d
i
e
d

(
p

=

.
0
0
3
)
.

A
t

4
8

h
o
u
r
s
,

2
0

(
3
8
%
)
o
f

t
h
e

5
2

p
a
t
i
e
n
t
s

i
n
f
u
s
e
d

w
i
t
h

D
C
L
H
b

d
i
e
d
a
n
d

7

(
1
5
%
)

o
f

t
h
e

4
6

p
a
t
i
e
n
t
s

i
n
f
u
s
e
d

w
i
t
h

t
h
e

s
a
l
i
n
e

s
o
l
u
t
i
o
n

d
i
e
d

(
p

=

.
0
1
)
.
B
2
M
o
r
t
a
l
i
t
y

w
a
s

h
i
g
h
e
r

f
o
r

p
a
t
i
e
n
t
s

t
r
e
a
t
e
d

w
i
t
h

D
C
L
H
b
.
D
C
L
H
b

d
o
e
s

n
o
t

a
p
p
e
a
r

t
o

b
e

a
n

e
f
f
e
c
t
i
v
e

r
e
s
u
s
c
i
t
a
t
i
o
n
f
l
u
i
d
.
B
o
u
w
m
a
n
,

D
L
.
W
e
a
v
e
r
,

D
W
.
V
e
g
a
,

J
.

e
t

a
l
.
1
9
7
8
9
6
I
I
T
o

s
t
u
d
y

t
h
e

e
f
f
e
c
t
s

o
f

a
l
b
u
m
i
n

o
n

s
e
r
u
m

p
r
o
t
e
i
n

h
o
m
e
o
s
t
a
s
i
s

i
n

5
2

s
e
r
i
o
u
s
l
y

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
A
l
t
e
r
e
d

h
a
e
m
o
s
t
a
s
i
s

a
n
d

d
e
p
r
e
s
s
e
d

i
m
m
u
n
e
r
e
s
p
o
n
s
e

a
r
e

t
w
o

p
o
s
s
i
b
l
e

e
f
f
e
c
t
s

w
i
t
h

c
l
i
n
i
c
a
l

s
i
g
n
i
f
i
c
a
n
c
e

e
x
p
e
r
i
e
n
c
e
d

i
n

t
h
e

a
l
b
u
m
i
n
-
r
e
c
e
i
v
i
n
g

g
r
o
u
p
.
B
1
A
d
d
i
t
i
o
n
a
l

i
n
v
e
s
t
i
g
a
t
i
o
n

o
f

s
e
c
o
n
d
a
r
y

h
o
m
e
o
s
t
a
t
i
c
r
e
s
p
o
n
s
e
s

a
r
e

n
e
c
e
s
s
a
r
y

t
o

m
o
r
e

c
o
m
p
l
e
t
e
l
y

e
v
a
l
u
a
t
e
t
h
e

e
f
f
e
c
t
s

o
f

a
l
b
u
m
i
n

i
n
f
u
s
i
o
n
.
W
u
,

J
J
.

H
u
a
n
g
,

M
S
.
T
a
n
g
,

G
J
.

K
a
o
,

W
F
.
2
0
0
1
9
7
I
I
T
o

c
o
m
p
a
r
e

t
h
e

c
a
r
d
i
a
c

a
n
d
h
a
e
m
o
d
y
n
a
m
i
c

r
e
s
p
o
n
s
e
s

t
o

a

r
a
p
i
d

i
n
f
u
s
i
o
n

o
f

1
0
0
0

m
l

o
f
m
o
d
i
f
i
e
d

f
l
u
i
d

g
e
l
a
t
i
n

(
g
r
o
u
p

A
)

o
r

1
0
0
0

m
l

o
f

l
a
c
t
a
t
e
d

R
i
n
g
e
r
'
s
s
o
l
u
t
i
o
n

(
g
r
o
u
p

B
)

i
n

e
m
e
r
g
e
n
c
y
r
o
o
m

p
a
t
i
e
n
t
s

s
u
f
f
e
r
i
n
g

f
r
o
m

s
h
o
c
k
.
I
n

b
o
t
h

g
r
o
u
p
s

t
h
e

m
e
a
n

a
r
t
e
r
i
a
l

b
l
o
o
d
p
r
e
s
s
u
r
e

(
M
A
P
)
,

s
y
s
t
o
l
i
c

a
n
d

d
i
a
s
t
o
l
i
c

p
r
e
s
s
u
r
e
,
c
e
n
t
r
a
l

v
e
n
o
u
s

p
r
e
s
s
u
r
e

(
C
V
P
)
,

a
n
d

p
u
l
m
o
n
a
r
y
a
r
t
e
r
y

o
c
c
l
u
s
i
o
n

p
r
e
s
s
u
r
e

(
P
A
O
P
)

i
n
c
r
e
a
s
e
d
s
i
g
n
i
f
i
c
a
n
t
l
y
.

T
h
e

C
V
P

a
n
d

P
A
O
P

i
n
c
r
e
a
s
e
d
s
i
g
n
i
f
i
c
a
n
t
l
y

m
o
r
e

i
n

t
h
e

m
o
d
i
f
i
e
d

f
l
u
i
d

g
e
l
a
t
i
n
r
e
s
u
s
c
i
t
a
t
i
o
n

g
r
o
u
p
.
B
1
M
o
d
i
f
i
e
d

F
l
u
i
d

G
e
l
a
t
i
n

w
a
s

m
o
r
e

e
f
f
e
c
t
i
v
e

t
h
a
n

L
R

i
n
i
n
c
r
e
a
s
i
n
g

B
P
,

M
A
P

a
n
d

C
O

i
m
m
e
d
i
a
t
e
l
y

a
f
t
e
r

i
n
f
u
s
i
o
n

(
<
1
5

m
i
n
u
t
e
s
)

(
p

<
0
.
0
5
)
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

s
u
r
v
i
v
a
l

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s
.
E
x
c
l
u
d
e
d

p
a
t
i
e
n
t
s

t
h
a
t

w
e
r
e

m
e
c
h
a
n
i
c
a
l
l
y

v
e
n
t
i
l
a
t
e
d
.
T
h
i
s

s
t
u
d
y

i
n
c
l
u
d
e
s

p
a
t
i
e
n
t
s

w
i
t
h

n
e
u
r
o
g
e
n
i
c

s
h
o
c
k
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 32
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 33
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
W
a
d
e
,

C
E
.
G
r
a
d
y
,

J
J
.
K
r
a
m
e
r
,

G
C
.
2
0
0
3
9
8
I
I
A
T
o

a
s
s
e
s
s

w
h
e
t
h
e
r

t
h
e
a
d
m
i
n
i
s
t
r
a
t
i
o
n

o
f

h
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e
d
e
x
t
r
a
n

(
H
S
D
)

w
a
s

d
e
t
r
i
m
e
n
t
a
l
w
h
e
n

a
d
m
i
n
i
s
t
e
r
e
d

t
o

p
a
t
i
e
n
t
s

w
h
o

w
e
r
e

h
y
p
o
t
e
n
s
i
v
e

b
e
c
a
u
s
e

o
f

p
e
n
e
t
r
a
t
i
n
g

i
n
j
u
r
i
e
s

t
o

t
h
e

t
o
r
s
o
.
8
2
.
5
%

t
r
e
a
t
e
d

w
i
t
h

H
S
D

s
u
r
v
i
v
e
d

v
s
.

7
5
.
5
%

p
a
t
i
e
n
t
s

w
h
o

r
e
c
e
i
v
e
d

n
o
r
m
a
l

s
a
l
i
n
e
.
T
h
e

d
i
f
f
e
r
e
n
c
e

i
n

s
u
r
v
i
v
a
l

r
a
t
e
s

b
e
t
w
e
e
n

g
r
o
u
p
s
w
a
s

n
o
t

s
t
a
t
i
s
t
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t

(
p

=

0
.
1
8
9
)
.
F
o
r

t
h
e

p
a
t
i
e
n
t
s

w
i
t
h

t
r
u
n
c
a
l

i
n
j
u
r
i
e
s

t
h
a
t

d
i
d
n
o
t

r
e
c
e
i
v
e

s
u
r
g
e
r
y
,

t
h
e
r
e

w
a
s

n
o

s
i
g
n
i
f
i
c
a
n
t
d
i
f
f
e
r
e
n
c
e

(
p

=

0
.
0
9
)

b
e
t
w
e
e
n

f
l
u
i
d

t
r
e
a
t
m
e
n
t
s
i
n

s
u
r
v
i
v
a
l

u
n
t
i
l

d
i
s
c
h
a
r
g
e
.

F
o
r

p
a
t
i
e
n
t
s

t
r
e
a
t
e
d
w
i
t
h

H
S
D
,

7
7
.
8
%

s
u
r
v
i
v
e
d

2
4

h
o
u
r
s

w
h
e
r
e
a
s
,
o
f

t
h
o
s
e

r
e
c
e
i
v
i
n
g

S
O
C
,

9
1
.
9
%

s
u
r
v
i
v
e
d

u
n
t
i
l
d
i
s
c
h
a
r
g
e
.
F
o
r

p
e
n
e
t
r
a
t
i
n
g

t
r
u
n
c
a
l

i
n
j
u
r
i
e
s

t
h
a
t

r
e
q
u
i
r
e
d
s
u
r
g
e
r
y
,

t
h
e
r
e

w
a
s

a

s
t
a
t
i
s
t
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t
e
f
f
e
c
t

(
p

=

0
.
0
1
)

o
f

t
r
e
a
t
m
e
n
t

o
n

o
v
e
r
a
l
l

s
u
r
v
i
v
a
l
u
n
t
i
l

d
i
s
c
h
a
r
g
e
.

O
f

t
h
e

8
4

p
a
t
i
e
n
t
s

t
r
e
a
t
e
d

w
i
t
h
H
S
D
,

8
4
.
5
%

s
u
r
v
i
v
e
d
,

w
h
e
r
e
a
s

s
u
r
v
i
v
a
l

w
a
s
6
7
.
1
%

i
n

t
h
e

7
3

p
a
t
i
e
n
t
s

r
e
c
e
i
v
i
n
g

S
O
C
.
T
h
e

i
n
c
r
e
a
s
e

i
n

b
l
e
e
d
i
n
g

a
n
d

m
o
r
t
a
l
i
t
y

a
s
s
o
c
i
a
t
e
d

w
i
t
h

t
h
e
i
n
f
u
s
i
o
n

o
f

H
S
D

r
e
s
u
l
t
e
d

i
n

a
n
i
m
a
l

s
t
u
d
i
e
s

w
a
s

n
o
t

f
o
u
n
d

i
n
t
h
i
s

s
t
u
d
y
.

A
u
t
h
o
r
s

h
y
p
o
t
h
e
s
i
s

t
h
a
t

t
h
i
s

i
s

b
e
c
a
u
s
e

t
h
e

r
a
t
e
o
f

i
n
f
u
s
i
o
n

a
n
d

t
i
m
i
n
g

o
f

i
n
f
u
s
i
o
n

a
f
t
e
r

i
n
j
u
r
y

w
a
s

d
i
f
f
e
r
e
n
t

i
n
t
h
i
s

s
t
u
d
y

p
e
r
h
a
p
s

h
i
g
h
l
i
g
h
t
i
n
g

t
h
e

t
i
m
i
n
g

o
f

t
h
e

i
n
i
t
i
a
t
i
o
n

o
f
f
l
u
i
d

i
n
f
u
s
i
o
n

a
n
d

t
h
e

r
a
t
e

m
a
y

i
n
f
l
u
e
n
c
e

o
u
t
c
o
m
e
.
T
h
e

r
e
s
u
l
t
s

o
f

t
h
i
s

s
t
u
d
y

s
u
g
g
e
s
t

t
h
a
t

t
h
e

a
d
m
i
n
i
s
t
r
a
t
i
o
n

o
f

h
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e

i
s

n
o
t

d
e
t
r
i
m
e
n
t
a
l

t
o

p
a
t
i
e
n
t
s

w
i
t
h
p
e
n
e
t
r
a
t
i
n
g

t
r
u
n
c
a
l

w
o
u
n
d
s

d
e
s
p
i
t
e

t
h
e

i
n
c
r
e
a
s
e

i
n

S
B
P
.

T
h
e
r
e

i
s

s
o
m
e

e
v
i
d
e
n
c
e

t
o

s
u
g
g
e
s
t

t
h
a
t

H
S
D

i
m
p
r
o
v
e
s
m
o
r
t
a
l
i
t
y

t
o

h
o
s
p
i
t
a
l

d
i
s
c
h
a
r
g
e
.
C
o
n
s
i
d
e
r

p
r
e
h
o
s
p
i
t
a
l

a
n
d

E
D

s
t
a
f
f

a
b
i
l
i
t
y

t
o

i
d
e
n
t
i
f
y

e
a
r
l
y

h
o
s
e

r
e
q
u
i
r
i
n
g

O
T
.
M
a
u
r
i
t
z
,

W
.
S
c
h
i
m
e
t
t
a
,

W
.
O
b
e
r
r
e
i
t
h
e
r
,

S
.
P
o
l
z
,

W
.
2
0
0
2
9
9
I
V
P
r
o
s
p
e
c
t
i
v
e
C
a
s
e

s
e
r
i
e
s
T
o

d
e
t
e
r
m
i
n
e

t
h
e

s
a
f
e
t
y

o
f
h
y
p
e
r
t
o
n
i
c

h
y
p
e
r

o
n
c
o
t
i
c

s
o
l
u
t
i
o
n
s
f
o
r

p
r
e
h
o
s
p
i
t
a
l

s
m
a
l
l
-
v
o
l
u
m
e
r
e
s
u
s
c
i
t
a
t
i
o
n
.
T
h
e
r
e

w
e
r
e

s
m
a
l
l

i
n
c
r
e
a
s
e
s

i
n

s
e
r
u
m

s
o
d
i
u
m
a
n
d

c
h
l
o
r
i
d
e

(
7

a
n
d

1
2

m
m
o
l
/
l
,

m
e
d
i
a
n
s
;
p

<
0
.
0
0
1
)
.

O
n

a
r
r
i
v
a
l

o
x
y
g
e
n

s
a
t
u
r
a
t
i
o
n

a
n
d
s
y
s
t
o
l
i
c

a
n
d

d
i
a
s
t
o
l
i
c

b
l
o
o
d

p
r
e
s
s
u
r
e

h
a
d
i
n
c
r
e
a
s
e
d

(
5
%
,

3
0

a
n
d

2
0

m
m
H
g
,

r
e
s
p
e
c
t
i
v
e
l
y
)
,
w
h
e
r
e
a
s

h
e
a
r
t

r
a
t
e

h
a
d

d
r
o
p
p
e
d

b
y

1
5

b
.
p
.
m
.
(
m
e
d
i
a
n
s
;

p

<
0
.
0
0
1
)
.
5
%

o
f

p
a
t
i
e
n
t
s

e
x
p
e
r
i
e
n
c
e
d

m
i
l
d

s
i
d
e

e
f
f
e
c
t
s
(
h
e
a
t

s
e
n
s
a
t
i
o
n
s
,

v
o
m
i
t
i
n
g
)
B
2
H
y
p
e
r
t
o
n
i
c

h
y
p
e
r

o
n
c
o
t
i
c

s
o
l
u
t
i
o
n
s

w
e
r
e

f
o
u
n
d

t
o

b
e

s
a
f
e

a
n
d

e
f
f
e
c
t
i
v
e

i
n

t
h
i
s

s
e
r
i
e
s

o
f

p
a
t
i
e
n
t
s
.

H
o
w
e
v
e
r

w
i
t
h

n
o

c
o
m
p
a
r
i
s
o
n

g
r
o
u
p

t
h
e

a
f
f
e
c
t
s

o
f

t
h
i
s

i
n
t
e
r
v
e
n
t
i
o
n

a
r
e

n
o
t

c
o
n
c
l
u
s
i
v
e
.
S
h
a
t
n
e
y
,

C
H
.
D
e
e
p
i
k
a
,

K
.
M
i
l
i
t
e
l
l
o
,

P
R
.
1
9
8
3
1
0
0
I
I
T
o

e
v
a
l
u
a
t
e

6
%

h
e
t
a
s
t
a
r
c
h

(
H
E
S
)

v

5
%

p
l
a
s
m
a

p
r
o
t
e
i
n

f
r
a
c
t
i
o
n

(
P
P
F
)
a
s

t
h
e

c
o
l
l
o
i
d

c
o
m
p
o
n
e
n
t

o
f
i
n
t
r
a
v
e
n
o
u
s

(
I
V
)

f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n
i
n

3
2

p
a
t
i
e
n
t
s

w
i
t
h

m
u
l
t
i
s
y
s
t
e
m
t
r
a
u
m
a

a
n
d
/
o
r

h
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k
.
N
o

i
n
t
e
r
g
r
o
u
p

d
i
f
f
e
r
e
n
c
e
s

w
e
r
e

n
o
t
e
d

i
n
i
n
d
e
x
e
s

o
f

h
e
p
a
t
i
c
,

p
u
l
m
o
n
a
r
y
,

o
r

r
e
n
a
l

f
u
n
c
t
i
o
n
o
r

i
n

t
h
e

i
n
c
i
d
e
n
c
e

o
f

i
n
f
e
c
t
i
o
n
.

T
h
e

f
r
e
q
u
e
n
c
y
o
f

o
t
h
e
r

c
o
m
p
l
i
c
a
t
i
o
n
s
,

i
n
c
l
u
d
i
n
g

b
l
e
e
d
i
n
g
d
i
a
t
h
e
s
e
s
,

a
n
d

m
o
r
t
a
l
i
t
y

w
e
r
e

i
d
e
n
t
i
c
a
l

i
n

t
h
e

t
w
o

g
r
o
u
p
s
.
B
1
R
e
s
u
l
t
s

o
f

t
h
i
s

p
i
l
o
t

s
t
u
d
y

s
u
g
g
e
s
t

t
h
a
t
,

c
o
m
p
a
r
e
d

w
i
t
h

P
P
F
,

H
E
S

i
n

l
a
r
g
e

v
o
l
u
m
e
s

i
s

a

s
a
f
e
,

e
f
f
e
c
t
i
v
e

c
o
l
l
o
i
d
s
o
l
u
t
i
o
n

i
n

t
h
e

r
e
s
u
s
c
i
t
a
t
i
o
n

o
f

p
a
t
i
e
n
t
s

w
i
t
h

m
u
l
t
i
s
y
s
t
e
m
t
r
a
u
m
a

a
n
d

/

o
r

h
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k
.
C
o
s
t

o
f

c
o
l
l
o
i
d
s

g
r
e
a
t
e
r

t
h
a
n

c
r
y
s
t
a
l
l
o
i
d
s
,

i
s

t
h
e
r
e

a
n
y
b
e
n
e
f
i
t
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 33
PAGE 34 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
V
a
s
s
a
r
,

M
J
.
P
e
r
r
y
,

C
A
.
G
a
n
n
a
w
a
y
,
W
L
.

1
9
9
1
1
0
1
I
I
B
1
7
.
5
%

N
a
C
l
/
D
e
x
t
r
a
n

(
H
T
S
)

v
s
.
L
a
c
t
a
t
e
d

R
i
n
g
e
r
s

(
L
R
)

s
o
l
u
t
i
o
n

f
o
r
f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

h
y
p
o
t
e
n
s
i
v
e
t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
S
u
r
v
i
v
a
l

a
t

h
o
s
p
i
t
a
l

d
i
s
c
h
a
r
g
e

w
a
s

6
4
%

v
s
.

5
9
%

f
o
r

H
T
S

a
n
d
L
R

r
e
s
p
e
c
t
i
v
e
l
y
.

T
h
e

r
a
t
e

o
f

s
u
r
v
i
v
a
l

t
o

h
o
s
p
i
t
a
l

d
i
s
c
h
a
r
g
e

f
o
r
t
h
e
p
a
t
i
e
n
t
s

w
i
t
h

s
e
v
e
r
e

h
e
a
d

i
n
j
u
r
i
e
s

w
a
s

3
2
%

f
o
r
t
h
e

H
T
S

g
r
o
u
p

v
s
.

1
6
%

f
o
r

t
h
e
L
R

s
o
l
u
t
i
o
n

g
r
o
u
p
.

(
t
h
i
s

d
i
d

n
o
t

r
e
a
c
h

s
t
a
t
i
s
t
i
c
a
l
s
i
g
n
i
f
i
c
a
n
c
e
)
.
H
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e
/
D
e
x
t
r
a
n

w
a
s

s
h
o
w
n

t
o

d
e
c
r
e
a
s
e

m
o
r
t
a
l
i
t
y

a
t

h
o
s
p
i
t
a
l

d
i
s
c
h
a
r
g
e

i
n

t
h
i
s

s
t
u
d
y
;

R
R
1
8
.
3
(
9
5
%

C
I

0
.
6
0
-
1
.
3
0
)
.
V
a
s
s
a
r
,

M
J
.
F
i
s
c
h
e
r
,

R
P
.
O
'
B
r
i
e
n
,

P
E
.
B
a
c
h
u
l
i
s
,

B
L
.
1
9
9
3
1
0
2
I
I
T
o

e
v
a
l
u
a
t
e

t
h
e

u
s
e

o
f

2
5
0

m
L

o
f

a

7
.
5
%

s
o
d
i
u
m

c
h
l
o
r
i
d
e

s
o
l
u
t
i
o
n
,
b
o
t
h

w
i
t
h

a
n
d

w
i
t
h
o
u
t

a
d
d
e
d
d
e
x
t
r
a
n

7
0
,

f
o
r

t
h
e

p
r
e
h
o
s
p
i
t
a
l
r
e
s
u
s
c
i
t
a
t
i
o
n

o
f

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
C
h
a
n
g
e

i
n

s
y
s
t
o
l
i
c

b
l
o
o
d

p
r
e
s
s
u
r
e

o
n

a
r
r
i
v
a
l

i
n
t
h
e

e
m
e
r
g
e
n
c
y

d
e
p
a
r
t
m
e
n
t

w
a
s

s
i
g
n
i
f
i
c
a
n
t
l
y
h
i
g
h
e
r

i
n

t
h
e

h
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e

s
o
l
u
t
i
o
n

g
r
o
u
p
t
h
a
n

t
h
a
t

i
n

t
h
e

l
a
c
t
a
t
e
d

R
i
n
g
e
r
'
s

s
o
l
u
t
i
o
n
g
r
o
u
p

(
3
4

p
l
u
s

o
r

m
i
n
u
s

4
6

v
s
.

1
1

p
l
u
s

o
r
m
i
n
u
s

4
9

m
m

H
g
,

p

<
.
0
3
)
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

s
u
r
v
i
v
a
l

b
e
t
w
e
e
n

t
h
e
g
r
o
u
p
s
.

R
R
0
9
7

(
0
.
6
8
-
1
.
3
7
)
.
B
1
P
r
e
h
o
s
p
i
t
a
l

i
n
f
u
s
i
o
n

o
f

2
5
0

m
L

o
f

7
.
5
%

s
o
d
i
u
m

c
h
l
o
r
i
d
e
i
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

a
n

i
n
c
r
e
a
s
e

i
n

b
l
o
o
d

p
r
e
s
s
u
r
e
.
H
o
w
e
v
e
r

n
o

s
t
a
t
i
s
t
i
c
a
l
l
y

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e

w
a
s

n
o
t
e
d
b
e
t
w
e
e
n

t
h
e

g
r
o
u
p
s
.
V
a
s
s
a
r
,

M
J
.
P
e
r
r
y
,

C
A
.
H
o
l
c
r
o
f
t
,

J
W
.
1
9
9
3
5
2
I
I
T
o

e
v
a
l
u
a
t
e

t
h
e

c
o
n
t
r
i
b
u
t
i
o
n

o
f

t
h
e
d
e
x
t
r
a
n

c
o
m
p
o
n
e
n
t

i
n

r
e
s
u
s
c
i
t
a
t
i
o
n
o
f

h
y
p
o
t
e
n
s
i
v
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

m
o
r
t
a
l
i
t
y

b
e
t
w
e
e
n
t
h
e

g
r
o
u
p
s
.
R
R
1
.
4
2

(
0
.
7
7
-
2
.
6
)
B
1
T
h
e

a
d
d
i
t
i
o
n

o
f

a

c
o
l
l
o
i
d
,

i
n

t
h
e

f
o
r
m

o
f

6
%

d
e
x
t
r
a
n

7
0
,

d
i
d

n
o
t

o
f
f
e
r

a
n
y

a
d
d
i
t
i
o
n
a
l

b
e
n
e
f
i
t
,

a
t

l
e
a
s
t

i
n

t
h
i
s

s
e
t
t
i
n
g

o
f

r
a
p
i
d

u
r
b
a
n

t
r
a
n
s
p
o
r
t
.
T
r
a
n
b
a
u
g
h
,

R
F
.
L
e
w
i
s
,

F
R
.
1
9
8
3
1
0
3
I
I
I
-
2
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
e
c
t
s

o
f

c
r
y
s
t
a
l
l
o
i
d
f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

o
n

l
u
n
g

w
a
t
e
r
(
p
u
l
m
o
n
a
r
y

o
e
d
e
m
a
)
.
E
x
t
r
a
-
v
a
s
c
u
l
a
r

l
u
n
g

w
a
t
e
r

r
e
m
a
i
n
e
d

i
n

t
h
e
n
o
r
m
a
l

r
a
n
g
e

o
f

7
.
0

+
/
-

1
.
0

m
l
/
k
g

d
u
r
i
n
g

t
h
e
f
i
r
s
t

f
i
v
e

h
o
s
p
i
t
a
l

d
a
y
s

f
o
r

a
l
l

p
a
t
i
e
n
t
s

d
e
s
p
i
t
e
p
r
o
f
o
u
n
d

d
e
c
r
e
a
s
e

i
n

P
C
O
P

(
l
e
s
s

t
h
a
n

1
5
m
m

H
g
)
.
S
c
i
e
n
t
i
f
i
c
C
r
y
s
t
a
l
l
o
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

c
l
e
a
r
l
y

i
s

n
o
t

h
a
r
m
f
u
l

t
o

t
h
e

l
u
n
g

a
n
d

i
t

i
s

e
q
u
a
l
l
y

a
s

e
f
f
e
c
t
i
v
e

a
s

c
o
l
l
o
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n
.
C
r
y
s
t
a
l
l
o
i
d

i
s

m
a
r
k
e
d
l
y

l
e
s
s

e
x
p
e
n
s
i
v
e

t
h
a
n

c
o
l
l
o
i
d

a
n
d
,
g
i
v
e
n

t
h
e

g
r
e
a
t
e
r

c
o
s
t

o
f

c
o
l
l
o
i
d

w
i
t
h
o
u
t

e
v
i
d
e
n
t

b
e
n
e
f
i
t
.
H
o
l
c
r
o
f
t
,

J
W
.
V
a
s
s
a
r
,

M
J
.
P
e
r
r
y
,

C
A
.
1
9
8
9
1
0
4
I
I
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
e
c
t
s

o
f

a
h
y
p
e
r
t
o
n
i
c

7
.
5
%

N
a
C
l

/

6
%

D
e
x
t
r
a
n

7
0

(
H
S
D
)

s
o
l
u
t
i
o
n

i
n

t
h
e
r
e
s
u
s
c
i
t
a
t
i
o
n

o
f

p
a
t
i
e
n
t
s

i
n

t
h
e
e
m
e
r
g
e
n
c
y

r
o
o
m
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

m
o
r
t
a
l
i
t
y

b
e
t
w
e
e
n
t
h
e

t
w
o

g
r
o
u
p
s
,

o
r

i
n

t
h
e

p
h
y
s
i
o
l
o
g
i
c
a
l

v
a
r
i
a
b
l
e
t
h
a
t

w
e
r
e

m
e
a
s
u
r
e
d
.
A
H
y
p
e
r
t
o
n
i
c

s
o
l
u
t
i
o
n

w
a
s

s
a
f
e

t
o

u
s
e
,

b
u
t

t
h
e

d
a
t
a

p
r
e
s
e
n
t
e
d

i
n

t
h
i
s

s
t
u
d
y

s
h
o
w

n
o

a
f
f
e
c
t

o
n

m
o
r
t
a
l
i
t
y

o
n

b
l
e
e
d
i
n
g

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 34
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 35
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: EVIDENCE TABLES
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
J
o
h
n
s
o
n
,

J
L
.
M
o
o
r
e
,

E
E
.
O
f
f
n
e
r
,

P
J
.
H
a
e
n
e
l
,

J
B
.
1
9
9
8
1
0
5
I
I
B
2
T
o

t
e
s
t

t
h
e

v
a
s
o
c
o
n
s
t
r
i
c
t
i
o
n
f
o
l
l
o
w
i
n
g

a
d
m
i
n
i
s
t
r
a
t
i
o
n

o
f
t
e
t
r
a
m
e
r
i
c

h
a
e
m
o
g
l
o
b
i
n
s

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

a
n
y

o
f

t
h
e

m
e
a
s
u
r
e
d
h
a
e
m
o
d
y
n
a
m
i
c

p
a
r
a
m
e
t
e
r
s

b
e
t
w
e
e
n

p
a
t
i
e
n
t
s
r
e
s
u
s
c
i
t
a
t
e
d

w
i
t
h

p
o
l
y
m
e
r
i
z
e
d

h
a
e
m
o
g
l
o
b
i
n
v
e
r
s
u
s

b
l
o
o
d
.
P
o
l
y
m
e
r
i
s
e
d

h
a
e
m
o
g
l
o
b
i
n

g
i
v
e
n

i
n

l
a
r
g
e

d
o
s
e
s

t
o

i
n
j
u
r
e
d
p
a
t
i
e
n
t
s

l
a
c
k
s

t
h
e

v
a
s
o
c
o
n
s
t
r
i
c
t
i
v
e

e
f
f
e
c
t
s

r
e
p
o
r
t
e
d

i
n

t
h
e

u
s
e

o
f

o
t
h
e
r

h
a
e
m
o
g
l
o
b
i
n
-
b
a
s
e
d

b
l
o
o
d

s
u
b
s
t
i
t
u
t
e
s
.

T
h
i
s

s
u
p
p
o
r
t
s

t
h
e

c
o
n
t
i
n
u
e
d

i
n
v
e
s
t
i
g
a
t
i
o
n

o
f

p
o
l
y
m
e
r
i
s
e
d
h
a
e
m
o
g
l
o
b
i
n

i
n

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s

r
e
q
u
i
r
i
n
g

u
r
g
e
n
t

t
r
a
n
s
f
u
s
i
o
n
.
K
e
r
n
e
r
,

T
.
A
h
l
e
r
s
,

O
.

V
e
i
t
,

S
.

R
i
o
u
,

B
.
2
0
0
3
1
0
6
I
I
(
E
u
r
o
p
e
a
n

O
n
-
S
c
e
n
e

m
u
l
t
i
c
e
n
t
r
e
s
t
u
d
y
)
T
o

t
e
s
t

t
h
e

h
y
p
o
t
h
e
s
i
s

t
h
a
t

t
h
e
e
a
r
l
y

a
d
m
i
n
i
s
t
r
a
t
i
o
n

o
f

a
n

o
x
y
g
e
n
c
a
r
r
i
e
r

m
a
y

r
e
d
u
c
e

t
h
e

o
c
c
u
r
r
e
n
c
e
o
f

o
r
g
a
n

f
a
i
l
u
r
e
s

a
n
d

i
m
p
r
o
v
e
s
u
r
v
i
v
a
l
.
(
1
0
%

d
i
a
s
p
i
r
i
n

c
r
o
s
s
-
l
i
n
k
e
d
h
a
e
m
o
g
l
o
b
i
n

(
D
C
L
H
b
)

v
s
.

s
t
a
n
d
a
r
d

I
V
F
.
)
O
r
g
a
n

f
a
i
l
u
r
e
s

a
n
d

s
u
r
v
i
v
a
l

r
a
t
e
s

u
n
t
i
l

d
a
y

f
i
v
e
a
n
d

d
a
y

2
8

s
h
o
w
e
d

n
o

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e
s
.
B
2
T
h
e

e
a
r
l
y

a
p
p
l
i
c
a
t
i
o
n

o
f

a
n

o
x
y
g
e
n

c
a
r
r
i
e
r

(
D
C
L
H
b
)

t
o
p
a
t
i
e
n
t
s

w
i
t
h

s
e
v
e
r
e

h
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k

f
o
l
l
o
w
i
n
g
t
r
a
u
m
a

h
a
d

n
o

s
i
g
n
i
f
i
c
a
n
t

e
f
f
e
c
t

o
n

t
h
e

o
c
c
u
r
r
e
n
c
e

o
f
o
r
g
a
n

f
a
i
l
u
r
e

o
r

o
n

5
-

a
n
d

2
8
-
d
a
y

s
u
r
v
i
v
a
l

i
n

t
h
i
s
a
b
b
r
e
v
i
a
t
e
d

t
r
i
a
l
.
(
T
h
i
s

s
t
u
d
y

w
a
s

s
t
o
p
p
e
d

a
f
t
e
r

i
n
t
e
r
i
m

a
n
a
l
y
s
i
s
,

s
p
o
n
s
o
r
s

e
x
p
r
e
s
s
e
d

s
o
m
e

c
o
n
c
e
r
n

o
n

t
h
e

l
o
n
g
-
t
e
r
m

e
f
f
e
c
t
s

o
f

t
h
i
s

d
r
u
g
.
)
J
o
h
n
s
o
n
,

J
L
.
M
o
o
r
e
,

E
E
.
O
f
f
n
e
r
,

P
J
.
2
0
0
1
1
0
7
I
I
T
o

c
o
m
p
a
r
e

t
h
e

i
m
p
a
c
t

o
f

R
B
C

o
r

B
l
o
o
d

s
u
b
s
t
i
t
u
t
e
s

o
n

n
e
u
t
r
o
p
h
i
l
a
c
t
i
v
i
t
y
.
(
P
a
c
k
e
d

r
e
d

b
l
o
o
d

c
e
l
l
s

h
a
v
e

t
h
e

p
o
t
e
n
t
i
a
l

t
o

e
x
a
c
e
r
b
a
t
e

e
a
r
l
y
p
o
s
t

i
n
j
u
r
y

h
y
p
e
r

i
n
f
l
a
m
m
a
t
i
o
n
a
n
d

m
u
l
t
i
p
l
e

o
r
g
a
n

f
a
i
l
u
r
e

t
h
r
o
u
g
h
p
r
i
m
i
n
g

o
f

c
i
r
c
u
l
a
t
i
n
g

n
e
u
t
r
o
p
h
i
l
s
[
P
M
N
s
]
)
.
P
o
l
y
h
e
m
e

d
i
d

n
o
t

r
e
s
u
l
t

i
n

t
h
e

a
g
g
r
a
v
a
t
i
o
n

o
f
c
i
r
c
u
l
a
t
i
n
g

n
e
u
t
r
o
p
h
i
l
s

i
n

c
o
n
t
r
a
s
t

t
o

P
R
B
C
.
B
1
T
h
e

u
s
e

o
f

a

b
l
o
o
d

s
u
b
s
t
i
t
u
t
e

i
n

t
h
e

e
a
r
l
y

p
o
s
t

i
n
j
u
r
y

p
e
r
i
o
d

a
v
o
i
d
s

P
M
N

p
r
i
m
i
n
g

a
n
d

m
a
y

t
h
e
r
e
b
y

p
r
o
v
i
d
e

a
n

a
v
e
n
u
e

t
o

d
e
c
r
e
a
s
e

t
h
e

i
n
c
i
d
e
n
c
e

o
r

s
e
v
e
r
i
t
y

o
f

p
o
s
t

i
n
j
u
r
y

m
u
l
t
i
p
l
e

o
r
g
a
n

f
a
i
l
u
r
e
.
H
i
r
s
h
b
e
r
g
,

A
.
D
u
g
a
s
,

M
.
B
a
n
e
z
,

E
I
.
2
0
0
3
1
0
8
S
c
i
e
n
t
i
f
i
c
/
C
o
m
p
u
t
e
r
s
i
m
u
l
a
t
i
o
n
T
o

c
a
l
c
u
l
a
t
e

t
h
e

c
h
a
n
g
e
s

i
n
p
r
o
t
h
r
o
m
b
i
n

t
i
m
e

(
P
T
)
,

f
i
b
r
i
n
o
g
e
n
,
a
n
d

p
l
a
t
e
l
e
t
s

w
i
t
h

b
l
e
e
d
i
n
g
.
P
r
o
l
o
n
g
a
t
i
o
n

o
f

P
T

i
s

t
h
e

s
e
n
t
i
n
e
l

e
v
e
n
t

o
f
d
i
l
u
t
i
o
n
a
l

c
o
a
g
u
l
o
p
a
t
h
y

a
n
d

o
c
c
u
r
s

e
a
r
l
y

i
n

t
h
e
o
p
e
r
a
t
i
o
n
.

T
h
e

k
e
y

t
o

p
r
e
v
e
n
t
i
n
g

c
o
a
g
u
l
o
p
a
t
h
y
i
s

p
l
a
s
m
a

i
n
f
u
s
i
o
n

b
e
f
o
r
e

P
T

b
e
c
o
m
e
s
s
u
b
h
e
m
o
s
t
a
t
i
c
.

T
h
e

o
p
t
i
m
a
l

r
e
p
l
a
c
e
m
e
n
t

r
a
t
i
o
s
w
e
r
e

2
:
3

f
o
r

p
l
a
s
m
a

a
n
d

8
:
1
0

f
o
r

p
l
a
t
e
l
e
t
s
.
C
E
x
i
s
t
i
n
g

p
r
o
t
o
c
o
l
s

u
n
d
e
r
e
s
t
i
m
a
t
e

t
h
e

d
i
l
u
t
i
o
n

o
f

c
l
o
t
t
i
n
g
f
a
c
t
o
r
s

i
n

s
e
v
e
r
e
l
y

b
l
e
e
d
i
n
g

p
a
t
i
e
n
t
s
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 35
PAGE 36 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
G
o
u
l
d
,

S
A
.
M
o
o
r
e
,

E
E
.
H
o
y
t
,

D
B
.
1
9
9
8
1
0
9
I
I
B
1
T
o

c
o
m
p
a
r
e

d
i
r
e
c
t
l
y

t
h
e

t
h
e
r
a
p
e
u
t
i
c
b
e
n
e
f
i
t

o
f

P
o
l
y
H
e
m
e

w
i
t
h

t
h
a
t

o
f
a
l
l
o
g
e
n
e
i
c

r
e
d

b
l
o
o
d

c
e
l
l
s

(
R
B
C
s
)

i
n
t
h
e

t
r
e
a
t
m
e
n
t

o
f

a
c
u
t
e

b
l
o
o
d

l
o
s
s
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

t
o
t
a
l

[
H
b
]

b
e
t
w
e
e
n
t
h
e

g
r
o
u
p
s

b
e
f
o
r
e

i
n
f
u
s
i
o
n

(
1
0
.
4

+
/
-

2
.
3

g
/
d
L
c
o
n
t
r
o
l

v
s
.

9
.
4

+
/
-

1
.
9

g
/
d
L

e
x
p
e
r
i
m
e
n
t
a
l
)
.
A
t

e
n
d
-
i
n
f
u
s
i
o
n

t
h
e

e
x
p
e
r
i
m
e
n
t
a
l

R
B
C

[
H
b
]
f
e
l
l

t
o

5
.
8

+
/
-

2
.
8

g
/
d
L

v
s
.

1
0
.
6

+
/
-

1
.
8

g
/
d
L
(
p

<
0
.
0
5
)

i
n

t
h
e

c
o
n
t
r
o
l
.
P
o
l
y
H
e
m
e

i
s

s
a
f
e

i
n

a
c
u
t
e

b
l
o
o
d

l
o
s
s
,

m
a
i
n
t
a
i
n
s

t
o
t
a
l

[
H
b
]
i
n

l
i
e
u

o
f

r
e
d

c
e
l
l
s

d
e
s
p
i
t
e

t
h
e

m
a
r
k
e
d

f
a
l
l

i
n

R
B
C

[
H
b
]
,

a
n
d

r
e
d
u
c
e
s

t
h
e

u
s
e

o
f

a
l
l
o
g
e
n
e
i
c

b
l
o
o
d
.

P
o
l
y
H
e
m
e

a
p
p
e
a
r
s

t
o

b
e

a

c
l
i
n
i
c
a
l
l
y

u
s
e
f
u
l

b
l
o
o
d

s
u
b
s
t
i
t
u
t
e
.
G
o
u
l
d
,

S
A
.
M
o
o
r
e
,

E
E
.
M
o
o
r
e
,

F
A
.
1
9
9
7
1
1
0
I
I
T
o

a
s
s
e
s
s

t
h
e

t
h
e
r
a
p
e
u
t
i
c

b
e
n
e
f
i
t

o
f

P
o
l
y

S
F
H
-
P

i
n

a
c
u
t
e

b
l
o
o
d

l
o
s
s
i
n

3
9

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
P
o
l
y

S
F
H
-
P

m
a
i
n
t
a
i
n
e
d

t
o
t
a
l

[
H
b
]
,

d
e
s
p
i
t
e

t
h
e
m
a
r
k
e
d

f
a
l
l

i
n

r
e
d

c
e
l
l

[
H
b
]

d
u
e

t
o

b
l
o
o
d

l
o
s
s
.
T
h
e

u
t
i
l
i
s
a
t
i
o
n

o
f

O
2

(
e
x
t
r
a
c
t
i
o
n

r
a
t
i
o
)

w
a
s

2
7

+
/
-

1
6
%

f
r
o
m

t
h
e

r
e
d

c
e
l
l
s

a
n
d

3
7

+
/
-

1
3
%
f
r
o
m

t
h
e

P
o
l
y

S
F
H
-
P
.

T
w
e
n
t
y
-
t
h
r
e
e

p
a
t
i
e
n
t
s
(
5
9
%
)

a
v
o
i
d
e
d

a
l
l
o
g
e
n
e
i
c

t
r
a
n
s
f
u
s
i
o
n
s

d
u
r
i
n
g

t
h
e

f
i
r
s
t

2
4

h
o
u
r
s

a
f
t
e
r

b
l
o
o
d

l
o
s
s
.
B
1
H
u
m
a
n

p
o
l
y
m
e
r
i
s
e
d

h
a
e
m
o
g
l
o
b
i
n

e
f
f
e
c
t
i
v
e
l
y

l
o
a
d
s

a
n
d
u
n
l
o
a
d
s

O
2
a
n
d

m
a
i
n
t
a
i
n
s

t
o
t
a
l

h
a
e
m
o
g
l
o
b
i
n

i
n

l
i
e
u

o
f

r
e
d

c
e
l
l
s

a
f
t
e
r

a
c
u
t
e

b
l
o
o
d

l
o
s
s
,

t
h
e
r
e
b
y

r
e
d
u
c
i
n
g

a
l
l
o
g
e
n
e
i
c

t
r
a
n
s
f
u
s
i
o
n
s
.
Y
o
u
n
e
s
,

R
N
.
A
u
n
,

F
.

A
c
c
i
o
l
y
,

C
Q
.
1
9
9
2
5
4
I
I
T
o

c
o
m
p
a
r
e

t
h
e

i
m
m
e
d
i
a
t
e
h
a
e
m
o
d
y
n
a
m
i
c

e
f
f
e
c
t
s

o
f

a

b
o
l
u
s

i
n
f
u
s
i
o
n

o
f

7
.
5
%

N
a
C
l

o
r
7
.
5
%

N
a
C
l

p
l
u
s

6
%

d
e
x
t
r
a
n

7
0
(
b
o
t
h

2
4
0
0

m
O
s
m
/
L
)

i
n

s
e
v
e
r
e
h
y
p
o
v
o
l
a
e
m
i
a
.
M
o
r
t
a
l
i
t
y

w
a
s

s
i
m
i
l
a
r

b
e
t
w
e
e
n

t
h
e

g
r
o
u
p
s
.
H
y
p
e
r
t
o
n
i
c

s
o
l
u
t
i
o
n
s

a
c
t
e
d

f
a
s
t
e
r

i
n

r
e
s
t
o
r
i
n
g
b
l
o
o
d

p
r
e
s
s
u
r
e

t
h
a
n

i
s
o
t
o
n
i
c

s
o
l
u
t
i
o
n
s
.

G
r
e
a
t
e
r
v
o
l
u
m
e

w
a
s

r
e
q
u
i
r
e
d

f
o
r

i
s
o
t
o
n
i
c

s
o
l
u
t
i
o
n
s

t
o
a
c
h
i
e
v
e

t
h
e

s
a
m
e

B
P
.
A
W
h
i
l
s
t

t
h
e

s
a
f
e
t
y

o
f

h
y
p
e
r
t
o
n
i
c

s
o
l
u
t
i
o
n
s

i
s

s
u
p
p
o
r
t
e
d
b
y

t
h
i
s

s
t
u
d
y
,

h
y
p
e
r
t
o
n
i
c

s
o
l
u
t
i
o
n
s

d
i
d

n
o
t

p
r
o
v
e

t
o

b
e

o
f

a
n
y

b
e
n
e
f
i
t

i
n

r
e
d
u
c
i
n
g

m
o
r
t
a
l
i
t
y
.
K
n
u
d
s
o
n
,

M
M
.
L
e
e
,

S
.
E
r
i
c
k
s
o
n
,

V
.
2
0
0
3
1
1
1
I
I
A
n
i
m
a
l
S
t
u
d
y
S
m
a
l
l
-
v
o
l
u
m
e

r
e
s
u
s
c
i
t
a
t
i
o
n

w
i
t
h

H
B
O
C
-
2
0
1

(
B
i
o
p
u
r
e
)

v
s
.
l
a
c
t
a
t
e
d

R
i
n
g
e
r
'
s

(
L
R
)

s
o
l
u
t
i
o
n

v
s


h
y
p
e
r
t
o
n
i
c

s
a
l
i
n
e

d
e
x
t
r
a
n

(
H
S
D
)
i
n

h
a
e
m
o
r
r
h
a
g
i
c

s
h
o
c
k
.
T
h
e
r
e

w
e
r
e

n
o

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e
s

i
n
m
e
a
s
u
r
e
d

l
i
v
e
r

o
r

m
u
s
c
l
e

P
O
2
v
a
l
u
e
s

a
f
t
e
r
r
e
s
u
s
c
i
t
a
t
i
o
n

w
i
t
h

a
n
y

o
f

t
h
e

t
h
r
e
e

s
o
l
u
t
i
o
n
s
.

T
h
e

c
a
r
d
i
a
c

o
u
t
p
u
t

w
a
s

i
n
c
r
e
a
s
e
d

f
r
o
m

s
h
o
c
k

v
a
l
u
e
s

i
n

a
l
l

t
h
r
e
e

a
n
i
m
a
l

g
r
o
u
p
s

w
i
t
h
r
e
s
u
s
c
i
t
a
t
i
o
n
,

b
u
t

w
a
s

s
i
g
n
i
f
i
c
a
n
t
l
y

h
i
g
h
e
r

i
n
t
h
e
,

a
n
i
m
a
l
s

r
e
s
u
s
c
i
t
a
t
e
d

w
i
t
h

H
S
D
.

S
i
m
i
l
a
r
l
y
,
M
A
P

w
a
s

i
n
c
r
e
a
s
e
d

b
y

a
l
l

s
o
l
u
t
i
o
n
s

d
u
r
i
n
g
r
e
s
u
s
c
i
t
a
t
i
o
n
,

b
u
t

r
e
m
a
i
n
e
d

s
i
g
n
i
f
i
c
a
n
t
l
y

b
e
l
o
w
b
a
s
e
l
i
n
e

e
x
c
e
p
t

i
n

t
h
e

g
r
o
u
p

o
f

a
n
i
m
a
l
s
r
e
c
e
i
v
i
n
g

H
B
O
C
-
2
0
1

(
p

<

0
.
0
1
)
.
N
/
A
H
B
O
C
-
2
0
1

i
s

s
i
g
n
i
f
i
c
a
n
t
l
y

m
o
r
e

e
f
f
e
c
t
i
v
e

t
h
a
n

H
S
D

a
n
d
L
R

s
o
l
u
t
i
o
n

i
n

r
e
s
t
o
r
i
n
g

M
A
P

a
n
d

s
y
s
t
o
l
i
c

b
l
o
o
d

p
r
e
s
s
u
r
e

t
o

n
o
r
m
a
l

v
a
l
u
e
s

a
l
t
h
o
u
g
h

i
t
s

a
b
i
l
i
t
y

t
o

r
e
s
t
o
r
e

t
i
s
s
u
e
o
x
y
g
e
n
a
t
i
o
n

i
s

n
o

d
i
f
f
e
r
e
n
t

f
r
o
m

c
o
n
v
e
n
t
i
o
n
a
l

f
l
u
i
d

t
h
e
r
a
p
i
e
s
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 36
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 37
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
Evidence Table 5. What are the endpoints of fluid resuscitation in the trauma patient?
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
B
i
s
h
o
p
,

M
H
.
S
h
o
e
m
a
k
e
r
,
W
C
.

A
p
p
e
l
,

P
L
.
1
9
9
5
7
6
I
I
I
-
I
B
1
T
o

t
e
s
t

p
r
o
s
p
e
c
t
i
v
e
l
y

s
u
p
r
a
n
o
r
m
a
l
v
a
l
u
e
s

o
f

c
a
r
d
i
a
c

i
n
d
e
x

(
C
I
)
,

o
x
y
g
e
n
d
e
l
i
v
e
r
y

i
n
d
e
x

(
D
O
2
I
)
,

a
n
d

o
x
y
g
e
n
c
o
n
s
u
m
p
t
i
o
n

i
n
d
e
x

(
V
O
2
I
)

a
s
r
e
s
u
s
c
i
t
a
t
i
o
n

g
o
a
l
s

t
o

i
m
p
r
o
v
e
o
u
t
c
o
m
e

i
n

s
e
v
e
r
e
l
y

t
r
a
u
m
a
t
i
s
e
d
p
a
t
i
e
n
t
s
.
S
u
p
r
a
n
o
r
m
a
l

v
a
l
u
e
s

t
o

a
c
h
i
e
v
e
d
u
s
i
n
g

v
o
l
u
m
e

l
o
a
d
i
n
g

t
o

P
C
W
P
1
8
m
m
H
g

a
n
d

t
h
e
n

d
o
b
u
t
a
m
i
n
e
i
n
f
u
s
i
o
n
.
M
o
r
t
a
l
i
t
y

i
n

s
u
p
r
a
n
o
r
m
a
l

v
a
l
u
e
s

g
r
o
u
p

1
8
%

v
s
.
3
7
%

i
n

n
o
r
m
a
l

c
i
r
c
u
l
a
t
o
r
y

v
a
l
u
e
s

(
p

<
0
.
0
2
7
)
.
O
r
g
a
n

f
a
i
l
u
r
e

0
7
4
+
/
-
0
.
2
8

v
s
.

1
.
6
2

+
/
-

0
.
2
8

(
p

<
0
.
0
0
2
)

i
n

s
u
p
r
a
n
o
r
m
a
l

a
n
d

n
o
r
m
a
l
c
i
r
c
u
l
a
t
o
r
y

g
r
o
u
p
s

r
e
s
p
e
c
t
i
v
e
l
y
.
R
e
s
u
s
c
i
t
a
t
i
o
n

t
o

s
u
p
r
a
n
o
r
m
a
l

c
i
r
c
u
l
a
t
o
r
y

v
a
l
u
e
s

d
e
c
r
e
a
s
e
d

m
o
r
t
a
l
i
t
y

a
n
d

o
r
g
a
n

f
a
i
l
u
r
e

i
n

t
h
i
s

s
t
u
d
y
.

D
u
r
h
a
m
,

R
M
.
N
e
u
n
a
b
e
r
,

K
.
M
a
z
u
s
k
i
,

J
E
.
1
9
9
6
1
1
2
I
I
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
i
c
a
c
y

o
f

O
x
y
g
e
n

c
o
n
s
u
m
p
t
i
o
n

(
V
O
2
I
)

a
n
d

d
e
l
i
v
e
r
y

(
D
O
2
I
)

i
n
d
i
c
e
s

a
s
e
n
d
p
o
i
n
t
s

o
f

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

5
8

c
r
i
t
i
c
a
l
l
y

i
l
l

p
a
t
i
e
n
t
s
.
M
o
r
t
a
l
i
t
y

w
a
s

n
o
t

d
i
f
f
e
r
e
n
t

b
e
t
w
e
e
n

t
h
e

g
r
o
u
p
s

e
v
e
n

w
i
t
h

e
x
c
l
u
s
i
o
n

o
f

t
h
e

g
r
o
u
p

1
p
a
t
i
e
n
t
s

w
h
o

f
a
i
l
e
d

t
o

m
e
e
t

V
O
2
I
/
D
O
2
I

g
o
a
l
s

(
p

=

0
.
6
6
)
.

O
F

o
c
c
u
r
r
e
d

i
n

1
8

o
f

2
7

(
6
7
%
)

i
n
g
r
o
u
p

1

a
n
d

i
n

2
2

o
f

3
0

(
7
3
%
)

i
n

g
r
o
u
p

2

(
p

=

0
.
5
8
)
.

L
e
n
g
t
h

o
f

v
e
n
t
i
l
a
t
o
r

s
u
p
p
o
r
t
,
i
n
t
e
n
s
i
v
e

c
a
r
e

u
n
i
t

s
t
a
y
,

a
n
d

h
o
s
p
i
t
a
l

s
t
a
y

w
e
r
e

n
o
t

d
i
f
f
e
r
e
n
t

b
e
t
w
e
e
n

g
r
o
u
p
s
.
B
1
N
o

d
i
f
f
e
r
e
n
c
e

w
a
s

f
o
u
n
d

i
n

t
h
e

i
n
c
i
d
e
n
c
e

o
f

o
r

d
e
a
t
h

i
n

p
a
t
i
e
n
t
s

r
e
s
u
s
c
i
t
a
t
e
d

b
a
s
e
d

o
n

o
x
y
g
e
n

t
r
a
n
s
p
o
r
t
p
a
r
a
m
e
t
e
r
s

c
o
m
p
a
r
e
d

t
o

c
o
n
v
e
n
t
i
o
n
a
l

p
a
r
a
m
e
t
e
r
s
.

A
u
t
h
o
r
s

s
u
g
g
e
s
t

t
h
a
t

o
x
y
g
e
n
-
b
a
s
e
d

p
a
r
a
m
e
t
e
r
s

a
r
e

m
o
r
e

u
s
e
f
u
l

a
s

p
r
e
d
i
c
t
o
r
s

o
f

o
u
t
c
o
m
e

t
h
a
n

a
s

e
n
d
p
o
i
n
t
s

f
o
r

r
e
s
u
s
c
i
t
a
t
i
o
n
.
D
u
t
t
o
n
,

R
P
.
M
a
c
k
e
n
z
i
e
,

C
F
.
S
c
a
l
e
a
,

T
M
.
2
0
0
2
4
2
I
I
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
i
c
a
c
y

o
f

f
l
u
i
d
r
e
s
u
s
c
i
t
a
t
i
o
n

t
i
t
r
a
t
e
d

t
o

a

l
o
w
e
r
t
h
a
n

n
o
r
m
a
l

S
B
P

d
u
r
i
n
g

t
h
e

p
e
r
i
o
d
o
f

a
c
t
i
v
e

h
a
e
m
o
r
r
h
a
g
e

o
n

s
u
r
v
i
v
a
l
i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
D
u
r
a
t
i
o
n

o
f

a
c
t
i
v
e

h
a
e
m
o
r
r
h
a
g
e

(
2
.
9
7

+
/
-

1
.
7
5
h
o
u
r
s

v
s
.

2
.
5
7

+
/
-

1
.
4
6

h
o
u
r
s
,

p

=

0
.
2
0
)

w
a
s
n
o
t

d
i
f
f
e
r
e
n
t

b
e
t
w
e
e
n

g
r
o
u
p
s
.
M
o
r
t
a
l
i
t
y

b
e
t
w
e
e
n

t
h
e

g
r
o
u
p
s

w
a
s

t
h
e

s
a
m
e
.
(
7
.
3
%

v
s
.

7
.
3
%
)
.
B
2
T
i
t
r
a
t
i
o
n

o
f

i
n
i
t
i
a
l

f
l
u
i
d

t
h
e
r
a
p
y

t
o

a

l
o
w
e
r

t
h
a
n

n
o
r
m
a
l

S
B
P

(
<
7
0
m
m
H
g
)

d
u
r
i
n
g

a
c
t
i
v
e

h
a
e
m
o
r
r
h
a
g
e

d
i
d

n
o
t

a
f
f
e
c
t

m
o
r
t
a
l
i
t
y

i
n

t
h
i
s

s
t
u
d
y
.
I
v
a
t
u
r
y
,

R
R
.
S
i
m
o
n
,

R
J
.
I
s
l
a
m
,

S
.
1
9
9
6
1
1
3
I
I
G
l
o
b
a
l

o
x
y
g
e
n

t
r
a
n
s
p
o
r
t

i
n
d
i
c
e
s
v
e
r
s
u
s

o
r
g
a
n
-
s
p
e
c
i
f
i
c

g
a
s
t
r
i
c
m
u
c
o
s
a
l

p
H

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
a
s

n
o

s
i
g
n
i
f
i
c
a
n
t

d
i
f
f
e
r
e
n
c
e

i
n

m
o
r
t
a
l
i
t
y
b
e
t
w
e
e
n

t
h
o
s
e

w
h
o

r
e
s
u
s
c
i
t
a
t
i
o
n

g
o
a
l

w
a
s
o
p
t
i
m
i
s
i
n
g

o
x
y
g
e
n

d
e
l
i
v
e
r
y

v
s

o
p
t
i
m
i
s
a
t
i
o
n

o
f

g
a
s
t
r
i
c

p
H

(
7
4
.
1
%

v
s

9
0
%
,

p

=

0
.
1
6
)
.
B
2
S
u
r
v
i
v
a
l

w
a
s

s
i
m
i
l
a
r

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 37
PAGE 38 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
F
l
e
m
i
n
g
,

A
.
B
i
s
h
o
p
,

M
.
S
h
o
e
m
a
k
e
r
,

W
.
A
p
p
e
l
,

P
.

1
9
9
2
1
1
4
I
I
I
-
2
B
1
T
o

e
v
a
l
u
a
t
e

t
h
e

e
a
r
l
y

p
o
s
t

i
n
j
u
r
y
a
t
t
a
i
n
m
e
n
t

o
f

s
u
p
r
a
n
o
r
m
a
l

v
a
l
u
e
s
o
f

c
a
r
d
i
a
c

i
n
d
e
x

(
>

=

4
.
5
2

L
/
m
i
n
)
,
o
x
y
g
e
n

d
e
l
i
v
e
r
y

(
>

=

6
7
0

m
L
/
m
i
n
)
,
a
n
d

o
x
y
g
e
n

c
o
n
s
u
m
p
t
i
o
n

(
>

=

1
6
6

m
L
/
m
i
n
)

o
n

o
u
t
c
o
m
e

i
n

t
r
a
u
m
a
t
i
s
e
d

p
a
t
i
e
n
t
s

w
i
t
h

a
n

e
s
t
i
m
a
t
e
d

b
l
o
o
d

l
o
s
s

o
f

2
0
0
0

m
L

o
r

m
o
r
e
.
M
o
r
t
a
l
i
t
y

w
a
s

2
4
%

v
s
.

4
4
%

i
n

p
r
o
t
o
c
o
l

a
n
d

c
o
n
t
r
o
l

r
e
s
p
e
c
t
i
v
e
l
y
.
T
h
e

p
r
o
t
o
c
o
l

p
a
t
i
e
n
t
s

h
a
d

f
e
w
e
r

m
e
a
n

o
r
g
a
n
f
a
i
l
u
r
e
s

p
e
r

p
a
t
i
e
n
t

(
0
.
7
6

+
/
-

1
.
2
1

v
s
.

1
.
5
9

+
/
-
1
.
6
0
)
,

s
h
o
r
t
e
r

s
t
a
y
s

i
n

t
h
e

i
n
t
e
n
s
i
v
e

c
a
r
e

u
n
i
t

(
5

+
/

-
3

v
s

1
2

+
/
-

1
2
)
,

a
n
d

f
e
w
e
r

m
e
a
n

d
a
y
s
r
e
q
u
i
r
i
n
g

v
e
n
t
i
l
a
t
i
o
n

(
4

+
/
-

3

v
s

1
1

+
/
-

1
0
)

t
h
a
n
d
i
d

t
h
e

c
o
n
t
r
o
l

p
a
t
i
e
n
t
s

(
P
<
.
0
5

f
o
r

e
a
c
h
)
.
T
h
i
s

n
o
n
-
r
a
n
d
o
m
i
s
e
d

s
t
u
d
y

d
i
s
p
l
a
y
e
d

a
t
t
a
i
n
i
n
g

s
u
p
r
a
n
o
r
m
a
l

c
i
r
c
u
l
a
t
o
r
y

v
a
l
u
e
s

i
m
p
r
o
v
e
s

s
u
r
v
i
v
a
l

a
n
d
d
e
c
r
e
a
s
e
s

m
o
r
b
i
d
i
t
y

i
n

t
h
e

s
e
v
e
r
e
l
y

t
r
a
u
m
a
t
i
s
e
d

p
a
t
i
e
n
t
.
V
e
l
m
a
h
o
s
,

G
C
.
D
e
m
e
t
r
i
a
d
e
s
,
D
.
2
0
0
0
7
7
I
I
T
r
a
u
m
a
T
o

e
v
a
l
u
a
t
e

t
h
e

e
f
f
e
c
t

o
f

e
a
r
l
y
o
p
t
i
m
i
s
a
t
i
o
n

i
n

t
h
e

s
u
r
v
i
v
a
l

o
f

s
e
v
e
r
e
l
y

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
T
h
e
r
e

w
a
s

n
o

d
i
f
f
e
r
e
n
c
e

i
n

r
a
t
e
s

o
f

d
e
a
t
h

(
1
5
%

o
p
t
i
m
a
l

v
s

1
1
%

c
o
n
t
r
o
l
)
,

o
r
g
a
n

f
a
i
l
u
r
e
,
s
e
p
s
i
s
,

o
r

t
h
e

l
e
n
g
t
h

o
f

i
n
t
e
n
s
i
v
e

c
a
r
e

u
n
i
t

o
r

h
o
s
p
i
t
a
l

s
t
a
y

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s
.
B
2
S
e
v
e
r
e
l
y

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s

w
h
o

c
a
n

a
c
h
i
e
v
e

o
p
t
i
m
a
l
h
a
e
m
o
d
y
n
a
m
i
c

v
a
l
u
e
s

a
r
e

m
o
r
e

l
i
k
e
l
y

t
o

s
u
r
v
i
v
e

t
h
a
n

t
h
o
s
e

w
h
o

c
a
n
n
o
t
,

r
e
g
a
r
d
l
e
s
s

o
f

t
h
e

r
e
s
u
s
c
i
t
a
t
i
o
n
t
e
c
h
n
i
q
u
e
.

I
n

t
h
i
s

s
t
u
d
y
,

a
t
t
e
m
p
t
s

a
t

e
a
r
l
y

o
p
t
i
m
i
s
a
t
i
o
n

d
i
d

n
o
t

i
m
p
r
o
v
e

t
h
e

o
u
t
c
o
m
e

o
f

t
h
e

e
x
a
m
i
n
e
d

s
u
b
g
r
o
u
p

o
f

s
e
v
e
r
e
l
y

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
S
h
o
e
m
a
k
e
r
,
W
C
.

F
l
e
m
i
n
g
,

A
W
.
1
9
8
6
7
9
I
I
I
-
2
T
r
a
u
m
a
T
o

c
o
m
p
a
r
e

o
u
t
c
o
m
e
s

i
n

t
r
a
u
m
a
p
a
t
i
e
n
t
s

w
h
o

h
a
d

r
e
s
u
s
c
i
t
a
t
i
o
n
a
i
m
e
d

a
t

i
m
p
r
o
v
i
n
g

c
i
r
c
u
l
a
t
o
r
y
v
a
l
u
e
s

a
n
d

c
h
e
m
i
s
t
r
y

v
s
.

t
h
o
s
e
a
i
m
e
d

a
t

o
p
t
i
m
i
s
i
n
g


p
h
y
s
i
o
l
o
g
i
c
p
a
t
t
e
r
n
s

.
C
o
u
l
d

n
o
t

d
e
t
e
r
m
i
n
e

r
e
s
u
l
t
s
.
D
a
t
a

w
a
s

n
o
t

p
r
e
s
e
n
t
e
d

c
l
e
a
r
l
y
.
B
2

B
i
s
h
o
p
,

M
H
.
S
h
o
e
m
a
k
e
r
,
W
C
.

A
p
p
e
l
,

P
L
.
1
9
9
3
8
0
I
I
I
-
2
T
o

d
e
s
c
r
i
b
e

t
h
e

t
e
m
p
o
r
a
l

p
a
t
t
e
r
n
s
o
f

h
a
e
m
o
d
y
n
a
m
i
c
s

a
n
d

o
x
y
g
e
n
t
r
a
n
s
p
o
r
t

i
n

s
u
r
v
i
v
o
r
s

a
n
d
n
o
n
s
u
r
v
i
v
o
r
s

o
f

s
e
v
e
r
e

t
r
a
u
m
a
i
n

r
e
l
a
t
i
o
n

t
o

t
i
m
e

d
e
l
a
y
s
,

m
o
r
t
a
l
i
t
y
,

a
n
d

m
o
r
b
i
d
i
t
y
.
D
u
r
i
n
g

t
h
e

f
i
r
s
t

2
4

h
o
u
r
s
,

t
h
e

m
e
a
n

v
a
l
u
e
s

o
f

C
I

(
4
.
5
2

+
/
-

1
.
4
5

v
s

3
.
8

+
/
-

1
.
2
0
l
/
m
i
n
/
m
2
;
p
<
0
.
0
5
)
,

D
O
2
(
6
7
0

+
/
-

2
3
0

v
s

5
4
0
+
/
-
2
0
0
m
l
/
m
i
n
/
m
2
;

p
<
0
.
0
1
)

a
n
d

V
O
2
(
1
6
6

+
/
-

4
8

v
s

1
3
4

+
/
-

4
7
m
l
/
m
i
n
/
m
2
;

p
<
0
.
0
1
)

o
f

t
h
e

6
0

s
u
r
v
i
v
o
r
s

w
e
r
e

s
i
g
n
i
f
i
c
a
n
t
l
y

h
i
g
h
e
r

t
h
a
n

t
h
e

3
0

n
o
n
-
s
u
r
v
i
v
o
r
s
.
P
a
t
i
e
n
t
s

w
h
o

a
c
h
i
e
v
e
d

s
u
r
v
i
v
o
r

v
a
l
u
e
s

i
n

l
e
s
s
t
h
a
n

2
4

h
o
u
r
s

h
a
d

a

m
o
r
t
a
l
i
t
y

o
f
1
2
%

v
s

5
4
%
f
o
r

t
h
o
s
e

w
h
o

d
i
d

n
o
t

r
e
a
c
h

s
u
r
v
i
v
o
r

v
a
l
u
e
s

a
t
a
l
l

o
r

t
o
o
k

l
o
n
g
e
r

t
h
a
n

2
4

h
o
u
r
s
.
B
2
R
e
a
c
h
i
n
g

s
u
r
v
i
v
o
r

v
a
l
u
e
s

(
o
r

s
u
p
r
a
n
o
r
m
a
l

c
i
r
c
u
l
a
t
o
r
y

v
a
l
u
e
s
)
w
i
t
h
i
n

2
4

h
o
u
r
s

o
f

i
n
j
u
r
y

m
a
y

g
r
e
a
t
l
y

i
m
p
r
o
v
e

s
u
r
v
i
v
a
l

a
s
d
e
m
o
n
s
t
r
a
t
e
d

i
n

t
h
i
s

o
b
s
e
r
v
a
t
i
o
n
a
l

s
t
u
d
y
.
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 38
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 39
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
W
a
x
m
a
n
,

K
.
A
n
n
a
s
,

C
.
D
a
u
g
h
t
e
r
s
,

K
.
T
o
m
i
n
a
g
a
,

G
T
.
1
9
9
4
1
1
5
I
I
I
-
2
D
i
a
g
n
o
s
t
i
c
t
e
s
t
B
1
T
o

t
e
s
t

t
h
e

h
y
p
o
t
h
e
s
i
s

t
h
a
t

c
h
a
n
g
e
i
n

t
i
s
s
u
e

P
O
2
i
n

r
e
s
p
o
n
s
e

t
o

a
n
i
n
c
r
e
a
s
e
d

i
n
s
p
i
r
e
d

O
2
c
h
a
l
l
e
n
g
e
m
a
y

b
e

r
e
l
a
t
e
d

t
o

t
h
e

s
t
a
t
e

o
f
c
e
l
l
u
l
a
r

o
x
y
g
e
n
a
t
i
o
n
,

a
n
d

h
e
n
c
e
t
h
e

a
d
e
q
u
a
c
y

o
f

r
e
s
u
s
c
i
t
a
t
i
o
n
.
(
T
i
s
s
u
e

P
O
2
i
s

m
e
a
s
u
r
e
d

t
h
r
o
u
g
h

a

p
r
o
b
e

i
n
s
e
r
t
e
d

i
n

t
h
e

d
e
l
t
o
i
d
m
u
s
c
l
e
)
.
P
a
t
i
e
n
t
s

w
e
r
e

d
e
t
e
r
m
i
n
e
d

t
o

h
a
v
e

i
n
a
d
e
q
u
a
t
e
r
e
s
u
s
c
i
t
a
t
i
o
n

i
f

a

r
i
s
e

i
n

t
i
s
s
u
e

P
O
2
d
i
d

n
o
t
o
c
c
u
r

w
i
t
h

a
n

i
n
c
r
e
a
s
e

i
n

i
n
s
p
i
r
e
d

o
x
y
g
e
n
.
N
i
n
e

t
r
a
u
m
a

p
a
t
i
e
n
t
s

d
i
d

n
o
t

e
x
h
i
b
i
t

a
n
i
n
c
r
e
a
s
e

i
n

t
i
s
s
u
e

P
O
2
.

F
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n
c
o
r
r
e
c
t
e
d

t
h
e
s
e

f
i
n
d
i
n
g
s

i
n

5
/
9
.

F
o
u
r

p
a
t
i
e
n
t
s
d
i
d

n
o
t

r
e
s
p
o
n
d

a
f
t
e
r

r
e
p
e
a
t
e
d

f
l
u
i
d
a
d
m
i
n
i
s
t
r
a
t
i
o
n
.
T
h
e

u
s
e
f
u
l
n
e
s
s

o
f

t
h
i
s

t
e
s
t

i
s

n
o
t

d
e
m
o
n
s
t
r
a
t
e
d

c
o
n
c
l
u
s
i
v
e
l
y
i
n

t
h
i
s

a
r
t
i
c
l
e
.

T
h
e
r
e

i
s

i
n
s
u
f
f
i
c
i
e
n
t

d
a
t
a

s
u
p
p
l
i
e
d

t
o

d
e
t
e
r
m
i
n
e
i
f

t
h
e
r
e

i
s

a
n

a
b
s
o
l
u
t
e

t
i
s
s
u
e

o
x
y
g
e
n

c
u
t

o
f
f
.

F
u
r
t
h
e
r

w
o
r
k

i
s
n
e
e
d
e
d

b
e
f
o
r
e

t
h
i
s

t
o
o
l

c
a
n

b
e

r
o
u
t
i
n
e
l
y

i
n
c
o
r
p
o
r
a
t
e
d

i
n
c
l
i
n
i
c
a
l

p
r
a
c
t
i
c
e
.
D
a
v
i
s
,

J
W
.
S
h
a
c
k
f
o
r
d
,

S
R
.
M
a
c
k
e
r
s
i
e
,

R
C
.

1
9
8
8
6
2
I
V
T
o

e
v
a
l
u
a
t
e

B
a
s
e

D
e
f
i
c
i
t

(
B
D
)
a
s

a
n

i
n
d
e
x

f
o
r

f
l
u
i
d

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

t
h
e

i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
A

r
e
t
r
o
s
p
e
c
t
i
v
e

r
e
v
i
e
w

o
f

2
0
9

c
h
a
r
t
s

r
e
v
e
a
l
e
d
a
s

B
a
s
e

D
e
f
i
c
i
t

b
e
c
a
m
e

m
o
r
e

n
e
g
a
t
i
v
e

M
A
P
d
e
c
r
e
a
s
e
d

s
i
g
n
i
f
i
c
a
n
t
l
y

a
n
d

t
h
e

v
o
l
u
m
e

o
f

f
l
u
i
d

r
e
q
u
i
r
e
d

f
o
r

r
e
s
u
s
c
i
t
a
t
i
o
n

i
n
c
r
e
a
s
e
d

w
i
t
h
i
n
c
r
e
a
s
i
n
g

s
e
v
e
r
i
t
y

o
f

B
D

g
r
o
u
p
.

(
p

<
0
.
0
0
1
)

A

B
D

t
h
a
t

b
e
c
a
m
e

m
o
r
e

n
e
g
a
t
i
v
e

w
i
t
h
r
e
s
u
s
c
i
t
a
t
i
o
n

w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

o
n
g
o
i
n
g
h
a
e
m
o
r
r
h
a
g
e

i
n

6
5
%
.

(
p

<
0
.
0
0
2
)
.
I
n
c
r
e
a
s
i
n
g

B
a
s
e

D
e
f
i
c
i
t

w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

d
e
c
r
e
a
s
i
n
g

M
A
P
,

a
n
d

d
e
c
r
e
a
s
i
n
g

T
r
a
u
m
a

S
c
o
r
e

(
p

<
0
.
0
0
1

f
o
r

b
o
t
h
)
.
B
2
T
h
i
s

s
t
u
d
y

i
n
d
i
c
a
t
e
s

t
h
a
t

b
a
s
e

d
e
f
i
c
i
t

m
a
y

b
e

a

r
e
l
i
a
b
l
e
i
n
d
i
c
a
t
o
r

o
f

t
h
e

r
e
l
a
t
i
v
e

m
a
g
n
i
t
u
d
e

o
f

v
o
l
u
m
e

d
e
f
i
c
i
t
.
B
D

m
a
y

b
e

a

u
s
e
f
u
l

g
u
i
d
e

t
o

v
o
l
u
m
e

r
e
p
l
a
c
e
m
e
n
t

i
n

t
h
e

r
e
s
u
s
c
i
t
a
t
i
o
n

o
f

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
H
u
s
a
i
n
,

F
A
.
M
a
r
t
i
n
,

M
J
.
M
u
l
l
e
n
i
x
,

P
S
.
2
0
0
3
1
1
6
I
I
I
-
2
T
o

d
e
t
e
r
m
i
n
e

w
h
e
t
h
e
r

l
a
c
t
a
t
e

l
e
v
e
l
s

a
n
d

b
a
s
e

d
e
f
i
c
i
t
s

i
n

c
r
i
t
i
c
a
l
l
y
i
l
l

s
u
r
g
i
c
a
l

i
n
t
e
n
s
i
v
e

c
a
r
e

u
n
i
t

(
S
I
C
U
)
p
a
t
i
e
n
t
s

c
o
r
r
e
l
a
t
e

a
n
d

w
h
e
t
h
e
r
e
i
t
h
e
r

m
e
a
s
u
r
e

i
s

a

s
i
g
n
i
f
i
c
a
n
t
i
n
d
i
c
a
t
o
r

o
f

m
o
r
t
a
l
i
t
y

a
n
d

m
o
r
b
i
d
i
t
y
.
I
n
i
t
i
a
l

a
n
d

2
4
-
h
o
u
r

l
a
c
t
a
t
e

l
e
v
e
l

w
a
s

s
i
g
n
i
f
i
c
a
n
t
l
y
e
l
e
v
a
t
e
d

i
n

n
o
n
s
u
r
v
i
v
o
r
s

v
e
r
s
u
s

s
u
r
v
i
v
o
r
s
(
p

=

0
.
0
0
2
)
.

I
n
i
t
i
a
l

b
a
s
e

d
e
f
i
c
i
t

w
a
s

n
o
t
s
i
g
n
i
f
i
c
a
n
t
l
y

d
i
f
f
e
r
e
n
t
;

2
4
-
h
o
u
r

b
a
s
e

d
e
f
i
c
i
t

d
i
d

a
c
h
i
e
v
e

s
t
a
t
i
s
t
i
c
a
l

s
i
g
n
i
f
i
c
a
n
c
e

(
p

=

0
.
0
2
)
.
M
o
r
t
a
l
i
t
y

i
f

l
a
c
t
a
t
e

n
o
r
m
a
l
i
s
e
d

w
i
t
h
i
n

2
4

h
o
u
r
s
w
a
s

1
0
%
,

c
o
m
p
a
r
e
d

w
i
t
h

2
4
%

f
o
r

>
4
8

h
o
u
r
s
a
n
d

6
7
%

i
f

l
a
c
t
a
t
e

f
a
i
l
e
d

t
o

n
o
r
m
a
l
i
s
e
.
B
1
E
l
e
v
a
t
e
d

i
n
i
t
i
a
l

a
n
d

2
4
-
h
o
u
r

l
a
c
t
a
t
e

l
e
v
e
l
s

a
r
e

s
i
g
n
i
f
i
c
a
n
t
l
y
c
o
r
r
e
l
a
t
e
d

w
i
t
h

m
o
r
t
a
l
i
t
y

a
n
d

a
p
p
e
a
r

t
o

b
e

s
u
p
e
r
i
o
r

t
o
c
o
r
r
e
s
p
o
n
d
i
n
g

b
a
s
e

d
e
f
i
c
i
t

l
e
v
e
l
s
.

L
a
c
t
a
t
e

c
l
e
a
r
a
n
c
e

t
i
m
e
m
a
y

b
e

u
s
e
d

t
o

p
r
e
d
i
c
t

m
o
r
t
a
l
i
t
y

a
n
d

i
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h
o
u
t
c
o
m
e

a
t

d
i
s
c
h
a
r
g
e
.

I
n
i
t
i
a
l

b
a
s
e

d
e
f
i
c
i
t

w
a
s

a

p
o
o
r
p
r
e
d
i
c
t
o
r

o
f

m
o
r
t
a
l
i
t
y

b
u
t

d
i
d

c
o
r
r
e
l
a
t
e

w
i
t
h

l
a
c
t
a
t
e

l
e
v
e
l
s
i
n

t
r
a
u
m
a

n
o
n
s
u
r
v
i
v
o
r
s
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 39
PAGE 40 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
W
e
i
l
,

M
H
.
N
a
k
a
g
a
w
a
,

Y
.
W
a
n
c
h
u
n
,

T
.
S
a
t
o
,

Y
.

1
9
9
9
1
1
7
I
I
I
-
2
B
2
T
o

c
l
i
n
i
c
a
l
l
y

v
a
l
i
d
a
t
e

s
u
b
l
i
n
g
u
a
l
P
C
O
2
f
o
r

d
i
a
g
n
o
s
i
n
g

s
h
o
c
k

i
n
p
a
t
i
e
n
t
s

w
i
t
h

c
i
r
c
u
l
a
t
o
r
y
d
i
s
a
r
r
a
n
g
e
m
e
n
t
.
S
u
b
l
i
n
g
u
a
l

C
O
2
c
o
r
r
e
l
a
t
e
d

s
t
r
o
n
g
l
y

w
i
t
h

a
r
t
e
r
i
a
l
b
l
o
o
d

l
a
c
t
a
t
e

a
n
d

m
e
a
n

a
r
t
e
r
i
a
l

p
r
e
s
s
u
r
e
.
I
n
c
r
e
a
s
e
s

i
n

P
s
l
C
O
2
c
o
r
r
e
l
a
t
e
d

w
i
t
h

i
n
c
r
e
a
s
e
s

i
n
a
r
t
e
r
i
a
l

b
l
o
o
d

l
a
c
t
a
t
e

(
r

=

0
8
4
,

p
<
0
.
0
0
1
)
.

W
h
e
n
P
s
l
C
O
2
e
x
c
e
e
d
e
d

a

t
h
r
e
s
h
o
l
d

7
0
m
m
H
g

i
t
s
p
o
s
i
t
i
v
e

p
r
e
d
i
c
t
i
v
e

v
a
l
u
e

o
f

c
i
r
c
u
l
a
t
o
r
y

s
h
o
c
k
w
a
s

1
.
0
.

W
h
e
n

i
t

w
a
s

<
7
0
m
m
H
g

i
t
s

p
r
e
d
i
c
t
e
d
s
u
r
v
i
v
a
l

w
a
s

0
.
9
3
.
T
h
e

v
a
l
i
d
i
t
y

o
f

e
l
e
v
a
t
e
d

S
u
b
l
i
n
g
u
a
l

P
C
O
2
a
s

a

m
a
r
k
e
r

o
f
s
h
o
c
k

i
s

s
h
o
w
n

i
n

t
h
i
s

s
t
u
d
y
.

H
o
w
e
v
e
r

a
b
s
o
l
u
t
e

v
a
l
u
e
s

o
f
P
s
l
C
O
2
a
r
e

n
o
t

d
e
t
e
r
m
i
n
e
d
.

T
h
e
r
e

s
t
i
l
l

r
e
m
a
i
n
s

a
n

o
v
e
r
l
a
p

o
f
r
e
a
d
i
n
g
s

i
n

p
a
t
i
e
n
t
s

w
h
o

d
i
d

a
n
d

d
i
d

n
o
t

h
a
v
e

c
l
i
n
i
c
a
l

s
h
o
c
k
.
L
a
r
g
e
r

t
r
i
a
l
s

a
r
e

w
a
r
r
a
n
t
e
d

a
s

t
h
i
s

t
e
c
h
n
i
q
u
e

m
a
y

p
r
o
v
e

t
o

b
e
a

u
s
e
f
u
l
,

s
i
m
p
l
e

a
n
d

n
o
n
-
i
n
v
a
s
i
v
e

t
e
c
h
n
i
q
u
e

f
o
r

q
u
a
n
t
i
f
y
i
n
g
p
e
r
f
u
s
i
o
n

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.

T
h
e

s
t
u
d
y

n
e
e
d
s

t
o

i
n
c
o
r
p
o
r
a
t
e
p
a
t
i
e
n
t
s

w
i
t
h

a
n
d

w
i
t
h
o
u
t

c
l
i
n
i
c
a
l

s
i
g
n
s

o
f

s
h
o
c
k

t
o

d
e
t
e
r
m
i
n
e

i
f

s
u
b
l
i
n
g
u
a
l

C
O
2
i
s

a

m
o
r
e

a
c
c
u
r
a
t
e

m
a
r
k
e
r

o
f

s
h
o
c
k

t
h
a
t
r
e
a
d
i
l
y

m
e
a
s
u
r
e
d

v
a
r
i
a
b
l
e
s

s
u
c
h

a
s

H
R
,

B
P

a
n
d

u
r
i
n
e

o
u
t
p
u
t
.

O
n
e

o
f

t
h
e

p
r
o
b
l
e
m
s

w
i
t
h

d
e
t
e
r
m
i
n
i
n
g

t
h
e

c
l
i
n
i
c
a
l

u
t
i
l
i
t
y

o
f

s
u
b
l
i
n
g
u
a
l

C
O
2
i
s

t
h
a
t

t
h
e
r
e

i
s

n
o


g
o
l
d

s
t
a
n
d
a
r
d


w
i
t
h
w
h
i
c
h

t
o

c
o
m
p
a
r
e
.
K
i
r
t
o
n
,

O
C
.
W
i
n
d
s
o
r
,

J
.
1
9
9
8
1
1
8
I
I
I
-
2
T
o

c
o
m
p
a
r
e

g
a
s
t
r
i
c

p
H

a
n
d

o
x
y
g
e
n

v
a
r
i
a
b
l
e
s

i
n

s
u
r
v
i
v
o
r
s

a
n
d
n
o
n
-
s
u
r
v
i
v
o
r
s

o
f

t
r
a
u
m
a

i
n

a

I
C
U
.
S
e
n
s
i
t
i
v
i
t
y

o
f

g
a
s
t
r
i
c

p
H

<
7
.
3
2

i
n

p
r
e
d
i
c
t
i
n
g
m
o
r
t
a
l
i
t
y

w
a
s

8
3
%

a
n
d

s
p
e
c
i
f
i
c
i
t
y

6
1
%
.
I
n

p
r
e
d
i
c
t
i
n
g

m
u
l
t
i
-
o
r
g
a
n

f
a
i
l
u
r
e

8
6
%

s
e
n
s
i
t
i
v
i
t
y

a
n
d

s
p
e
c
i
f
i
c
i
t
y

6
6
%
.
T
h
e

r
i
s
k

o
f

d
e
a
t
h

w
i
t
h

a

p
H
i

<
7
.
3
2

4
.
5
(
p
<
0
.
0
1
)

a
n
d

r
i
s
k

o
f

M
O
F

5
.
4

(
p
<
0
.
0
1
)
.
T
h
e

r
i
s
k

o
f

d
e
a
t
h

a
s
s
o
c
i
a
t
e
d

w
i
t
h

a
n

a
b
n
o
r
m
a
l

l
a
c
t
a
t
e

a
t

2
4

h
o
u
r
s

w
a
s

3
.
0
.
T
h
e

r
i
s
k

o
f

M
O
F

w
a
s

3
.
6
.
B
1
A

g
a
s
t
r
i
c

p
H
<
7
.
3
2

a
n
d

l
a
c
t
a
t
e

>
2
.
3
m
m
o
l

a
t

2
4

h
o
u
r
s
i
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

h
i
g
h

m
o
r
t
a
l
i
t
y

r
a
t
e
s

a
n
d

i
n
c
i
d
e
n
c
e

o
f

m
u
l
t
i
-
o
r
g
a
n

f
a
i
l
u
r
e
.
R
o
u
m
e
n
,

R
M
.
V
r
e
u
g
d
e
,

J
P
.
1
9
9
4
1
1
9
I
V
T
o

e
x
a
m
i
n
e

t
h
e

p
o
s
t
t
r
a
u
m
a
t
i
c
g
a
s
t
r
i
c

p
H

i
n

1
5

m
u
l
t
i
p
l
y

i
n
j
u
r
e
d
t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
N
o

c
o
r
r
e
l
a
t
i
o
n

b
e
t
w
e
e
n

g
a
s
t
r
i
c

p
H

a
n
d

s
h
o
c
k
,
I
S
S
,

l
a
c
t
i
c

a
c
i
d
o
s
i
s
,

o
r

A
P
A
C
H
E

I
I

s
c
o
r
e
s

o
n
a
d
m
i
s
s
i
o
n

w
e
r
e

f
o
u
n
d
.
2
5
%

o
f

p
a
t
i
e
n
t
s

w
i
t
h

a

p
H
i

<
7
.
3
2

d
i
e
d
.

A
l
l

p
a
t
i
e
n
t
s

w
i
t
h

n
o
r
m
a
l

p
H
i

s
u
r
v
i
v
e
d
.
B
1
G
a
s
t
r
i
c

p
H

m
a
y

b
e

u
s
e
f
u
l

i
n

i
d
e
n
t
i
f
y
i
n
g

p
a
t
i
e
n
t
s

w
i
t
h

s
p
l
a
n
c
h
i
c

m
a
l
p
e
r
f
u
s
i
o
n

t
h
a
t

i
s

n
o
t

i
d
e
n
t
i
f
i
e
d

b
y

r
o
u
t
i
n
e

m
o
n
i
t
o
r
i
n
g
.

HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 40
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 41
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
A
u
t
h
o
r
L
e
v
e
l

o
f
S
t
u
d
y

&

y
e
a
r
e
v
i
d
e
n
c
e
Q
u
a
l
i
t
y
q
u
e
s
t
i
o
n

/

p
o
p
u
l
a
t
i
o
n
R
e
s
u
l
t
s
C
o
n
c
l
u
s
i
o
n
I
v
a
t
u
r
y
,

R
R
.
S
i
m
o
n
,

R
J
.
1
9
9
5
7
0
I
I
B
2
T
o

c
o
m
p
a
r
e

g
a
s
t
r
i
c

m
u
c
o
s
a
l

p
H
a
n
d

g
l
o
b
a
l

o
x
y
g
e
n

v
a
r
i
a
b
l
e
s

(
D
O
2
l

/

V
O
2
l
)

a
s

i
n
d
i
c
a
t
o
r
s

o
f

a
d
e
q
u
a
t
e
r
e
s
u
s
c
i
t
a
t
i
o
n

i
n

t
r
a
u
m
a

p
a
t
i
e
n
t
s
.
M
o
r
t
a
l
i
t
y

w
a
s

9
.
1
%

f
o
r

p
a
t
i
e
n
t
s

i
n

n
o
r
m
a
l
i
z
a
t
i
o
n
o
f

g
a
s
t
r
i
c

p
H

(
`
7
.
3
0
)

c
o
m
p
a
r
e
d

t
o

3
1
.
3
%

(
p

=

0
.
2
7
)
.
T
h
e

c
o
n
t
r
o
l

g
r
o
u
p

i
n

t
h
i
s

s
t
u
d
y

w
a
s

s
i
c
k
e
r

t
h
a
n

t
h
e

i
n
t
e
r
v
e
n
t
i
o
n

g
r
o
u
p

a
s

i
n
d
i
c
a
t
e
d

b
y

i
n
i
t
i
a
l

l
a
c
t
a
t
e

(
5
.
2
+
/
-

3
.
4

v
s

8
.
3
+
/
-
5
.
7
)

a
n
d

b
a
s
e

d
e
f
i
c
i
t

(
7
.
0

+
/
-
3
.
9

v
s

1
1
.
7

+
/
-

8
.
3
)
,

a
l
t
h
o
u
g
h

I
S
S

w
a
s

s
i
m
i
l
a
r

b
e
t
w
e
e
n

t
h
e

t
w
o

g
r
o
u
p
s

(
2
4
.
4

v
s

2
4
.
3
)
.

G
a
s
t
r
i
c

p
H

m
a
y

b
e

a
n

i
m
p
o
r
t
a
n
t

m
a
r
k
e
r

t
o

a
s
s
e
s
s

t
h
e
a
d
e
q
u
a
c
y

o
f

r
e
s
u
s
c
i
t
a
t
i
o
n
.

F
a
i
l
u
r
e

t
o

n
o
r
m
a
l
i
s
e

p
h

i
n

t
h
i
s
s
t
u
d
y

w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

h
i
g
h

o
r
g
a
n

f
a
i
l
u
r
e

a
n
d

d
e
a
t
h
.
H
o
w
e
v
e
r
,

t
h
e

a
b
i
l
i
t
y

t
o

m
a
n
i
p
u
l
a
t
e

p
H
i

t
h
r
o
u
g
h

o
x
y
g
e
n
i
n
d
i
c
e
s

a
n
d

i
n
o
t
r
o
p
e
s

h
a
s

y
e
t

t
o

b
e

d
e
m
o
n
s
t
r
a
t
e
d
.
T
h
e

r
e
s
u
l
t
s

d
o

n
o
t

r
e
a
c
h

s
t
a
t
i
s
t
i
c
a
l

s
i
g
n
i
f
i
c
a
n
c
e

b
u
t

t
h
i
s

m
a
y
b
e

d
u
e

t
o

s
m
a
l
l

s
t
u
d
y

n
u
m
b
e
r
s
.

A

l
a
r
g
e
r

s
t
u
d
y

i
s

w
a
r
r
a
n
t
e
d
t
o

v
a
l
i
d
a
t
e

t
h
e

r
e
s
u
l
t
s

o
f

t
h
i
s

s
t
u
d
y
.

C
h
a
n
g
,

M
C
.
C
h
e
a
t
h
a
m
,
M
L
.

1
9
9
4
1
2
0
I
I
I
-
2
T
o

a
s
s
e
s
s

t
h
e

c
o
r
r
e
l
a
t
i
o
n

b
e
t
w
e
e
n
g
a
s
t
r
i
c

p
H

a
n
d

o
t
h
e
r

m
a
r
k
e
r
s

o
f
h
a
e
m
o
d
y
n
a
m
i
c

s
t
a
t
u
s

a
n
d
m
o
r
t
a
l
i
t
y

i
n

c
r
i
t
i
c
a
l
l
y
.

T
h
e
r
e

w
a
s

p
o
o
r

c
o
r
r
e
l
a
t
i
o
n

b
e
t
w
e
e
n

g
a
s
t
r
i
c

p
H

a
n
d

g
l
o
b
a
l

m
a
r
k
e
r
s

o
f

h
a
e
m
o
d
y
n
a
m
i
c
f
u
n
c
t
i
o
n

a
n
d

o
x
y
g
e
n

t
r
a
n
s
p
o
r
t

v
a
r
i
a
b
l
e
s
.

P
H

t
h
a
t

d
i
d

n
o
t

c
o
r
r
e
c
t

i
t
s
e
l
f

w
i
t
h
i
n

2
4

h
o
u
r
s
w
a
s

a
s
s
o
c
i
a
t
e
d

w
i
t
h

a

h
i
g
h
e
r

m
o
r
t
a
l
i
t
y

(
5
0
%

v
s

0
%
,

p

=

0
.
0
3
)

a
n
d

o
r
g
a
n

f
a
i
l
u
r
e

(
2
.
6

o
r
g
a
n
s

/

p
a
t
i
e
n
t

v
s

0
.
6
2

o
r
g
a
n
s

/

p
a
t
i
e
n
t
)
.
B
1
G
a
s
t
r
i
c

p
H

s
u
p
p
l
e
m
e
n
t
s

i
n
f
o
r
m
a
t
i
o
n

p
r
o
v
i
d
e
d

b
y

s
t
a
n
d
a
r
d
h
a
e
m
o
d
y
n
a
m
i
c

v
a
r
i
a
b
l
e
s

a
n
d

m
a
y
b
e

u
s
e
f
u
l

i
s

i
d
e
n
t
i
f
y
i
n
g
p
a
t
i
e
n
t
s

a
t

r
i
s
k

o
f

m
u
l
t
i
-
o
r
g
a
n

f
a
i
l
u
r
e

a
n
d

d
e
a
t
h
.

T
r
e
a
t
m
e
n
t
i
m
p
l
i
c
a
t
i
o
n
s

a
r
e

n
o
t

i
d
e
n
t
i
f
i
e
d

b
y

t
h
i
s

s
t
u
d
y
.
H
e
y
w
o
r
t
h
,

J
.
1
9
9
2
1
2
1
I
V
T
o

e
v
a
l
u
a
t
e

t
h
e

u
s
e

o
f

c
o
n
j
u
n
c
t
i
v
a
l
o
x
y
g
e
n

t
e
n
s
i
o
n


m
o
n
i
t
o
r

(
P
C
J
O
2
)
d
u
r
i
n
g

t
h
e

e
a
r
l
y

a
s
s
e
s
s
m
e
n
t

o
f
i
n
j
u
r
e
d

p
a
t
i
e
n
t
s
.
A

P
C
J
O
2
l
e
s
s

t
h
a
n

4
5
m
m
H
g

w
a
s

a
s
s
o
c
i
a
t
e
d
w
i
t
h

h
y
p
o
v
o
l
a
e
m
i
a
,

r
e
d
u
c
e
d

c
a
r
d
i
a
c

o
u
t
p
u
t
a
n
d

c
h
e
s
t

i
n
j
u
r
y
.
B
1


T
h
e

u
s
e
f
u
l
n
e
s
s

o
f

P
C
J
O
2
a
s

a

m
o
n
i
t
o
r
i
n
g

t
o
o
l

f
o
r

o
c
c
u
l
t
h
y
p
o
p
e
r
f
u
s
i
o
n

i
s

n
o
t

d
e
m
o
n
s
t
r
a
t
e
d

i
n

t
h
i
s

a
r
t
i
c
l
e
.
W
e
i
l
,

M
H
.
N
a
k
a
g
a
w
a
,

Y
.
1
9
9
9
1
1
7
I
I
I
-
2
T
o

i
n
v
e
s
t
i
g
a
t
e

t
h
e

p
r
e
d
i
c
t
i
v
e

v
a
l
u
e

o
f

s
u
b
l
i
n
g
u
a
l

c
a
p
n
o
m
e
t
r
y
(
P
(
S
L
)
C
O
2
)

a
s

a
n

e
a
r
l
y

i
n
d
i
c
a
t
o
r

o
f

s
y
s
t
e
m
i
c

p
e
r
f
u
s
i
o
n

f
a
i
l
u
r
e

i
n

4
6

p
a
t
i
e
n
t
s

w
i
t
h

a
c
u
t
e

l
i
f
e
-
t
h
r
e
a
t
e
n
i
n
g

i
l
l
n
e
s
s
e
s

o
r

i
n
j
u
r
y
.
P
(
S
L
)
O
2
>
7
0
m
m
H
g

h
a
d

a

p
o
s
i
t
i
v
e

p
r
e
d
i
c
t
i
v
e
v
a
l
u
e

o
f

1
.
0
0

f
o
r

t
h
e

p
r
e
s
e
n
c
e

o
f


c
l
i
n
i
c
a
l

s
i
g
n
s
o
f

s
h
o
c
k
.
B
2
S
u
b
l
i
n
g
u
a
l

c
a
p
n
o
m
e
t
r
y

c
o
r
r
e
l
a
t
e
s

w
i
t
h

s
i
g
n
s

o
f

s
h
o
c
k
.

T
h
i
s

s
t
u
d
y

d
o
e
s

n
o
t

s
h
o
w

t
h
a
t

P
S
L
C
O
2
w
o
u
l
d

a
d
d

a
n
y
i
n
f
o
r
m
a
t
i
o
n

t
h
a
t

i
s

n
o
t

a
l
r
e
a
d
y

r
o
u
t
i
n
e
l
y

c
o
l
l
e
c
t
e
d

t
h
r
o
u
g
h
s
t
a
n
d
a
r
d

c
i
r
c
u
l
a
t
o
r
y

m
o
n
i
t
o
r
i
n
g
.
:: EVIDENCE TABLES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 41
::
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 42
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 43
The following search terms were used in Medline
1 Shock/
2 1 and hypovol?emi$.mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer,
drug manufacturer name]
3 hypovol?emic shock.mp.
4 shock, hemorrhagic/
5 exp Hemorrhage/
6. (hemorrhag$ or haemorrhag$).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer,
drug manufacturer name]
7 Hypotension/
8 low blood pressure.mp.
9 or/2-8
10 "Wounds and Injuries"/
11 trauma.mp.
12 or/10-11
13 exp resuscitation/
14 Fluid Therapy/
15 fluid resuscitation$.mp.
16 blood transfusion/ or exp blood component transfusion/
17 exp Blood Substitutes/
18 blood expand$.mp.
19 exp colloids/
20 crystalloids.mp.
21 (volume expansion or volume expand$ or blood expansion or blood expand$).mp. [mp=title, abstract, subject headings,
drug trade name, original title, device manufacturer, drug manufacturer name]
22 exp Monitoring, Physiologic/
23 Time Factors/
24 endpoint determination/
25 (endpoint$ or end point$).mp. [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer,
drug manufacturer name]
26 (or/2-4) and 12 and di.fs.
27 (or/5-6) and (or/7-8) and 12 and et.fs.
28 (or/5-6) and (th.fs. or manage$.mp.) and (rural$ or remote$ or non?urban$).mp. [mp=title, abstract, subject headings,
drug trade name, original title, device manufacturer, drug manufacturer name]
29 (or/13-16) and 9 and 12 and 23
30 (or/13-16) and 9 and 12 and (or/17-21)
31 (or/13-16) and 12 and (or/24-25)
32 9 and 12 and 22
33 or/26-32
34 9 and 12 and (dt,th.fs. or manage$.mp.) [mp=title, abstract, subject headings, drug trade name, original title, device manufacturer,
drug manufacturer name]
35 limit 35 to english language
36 33 or 36
37 limit 37 to human
PAGE 44 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
Search strategy for
the identification of studies
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
blood
O-neg
APPENDI X A
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 44
The following search terms were used in Embase-
1 Hypovolemic Shock/
2 Hemorrhagic Shock/
3 ((hypovol?emic or hemorrhagic or haemorrhagic) adj shock).mp. [mp=title, abstract, cas registry/ec number word,
mesh subject heading]
4 exp Bleeding/
5 (hemorrhag$ or haemorrhag$).mp. [mp=title, abstract, cas registry/ec number word, mesh subject heading]
6 hypotension/ or hemorrhagic hypotension/
7 low blood pressure.mp.
8 or/1-7
9 Injury/
10 trauma.mp.
11 or/9-10
12 resuscitation/
13 exp fluid therapy/
14 fluid resuscitation.mp.
15 exp blood transfusion/
16 Blood Substitute/
17 (volume expansion or volume expand$ or blood expansion or blood expand$).mp. [mp=title, abstract,
cas registry/ec number word, mesh subject heading]
18 exp colloid/
19 crystalloid/
20 exp monitoring/ or hemodynamic monitoring/ or patient monitoring/
21 (time or timing).mp.
22 (endpoint$ or end point$).mp. [mp=title, abstract, cas registry/ec number word, mesh subject heading]
23 (or/1-3) and 11 and di.fs.
24 (or/4-5) and (or/6-7) and 11 and et.fs.
25 (or/4-5) and (th.fs. or manage$.mp.) and (rural$ or remote$ or non?urban$).mp. [mp=title, abstract,
cas registry/ec number word, mesh subject heading]
26 (or/12-15) and 8 and 11 and 21
27 (or/12-15) and 8 and 11 and (or/16-19)
28 (or/12-15) and 11 and 22
29 8 and 11 and 20
30 or/23-29
31 8 and 11 and (dt,th.fs. or manage$.mp.) [mp=title, abstract, cas registry/ec number word, mesh subject heading]
32 limit 31 to (english language)
33 30 or 32
34 limit 33 to human
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 45
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: SEARCH TERMS USED FOR THE IDENTIFICATION OF STUDIES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 45
1 Nolan J 2001, Fluid resuscitation for the
trauma patient, Resuscitation, 48(1):57-69.
2 National Health and Medical Research Council
2000, How to use the scientific evidence:
assessment and application of scientific
evidence, Biotext Canberra, editor.
3 National Health and Medical Research Council
1999, How to review the evidence: systematic
identification and review of the scientific literature.
Biotext Canberra, editor.
4 National Health and Medical Research Council
1998, A guide to the development, implementation
and evaluation of clinical practice guidelines,
Biotext Canberra, editor.
5 Liddle J, Williamson M, Irwig L 1996, Method for
Evaluating Research Guideline Evidence (MERGE),
NSW Department of Health.
6 Jordan KS 2000, Fluid resuscitation in acutely
injured patients, Journal of Intravenous Nursing
23(2):81-7, 2000 Mar;-Apr.
7 American College of Surgeons 1997, Advanced
Trauma life support for Doctors Instruction Course
Manual Book 1, First Impression: USA.
8 Lechleuthner A, Lefering R, Bouillon B, Lentke E,
Vorweg M 1994, T. T. Prehospital detection of
uncontrolled haemorrhage in blunt trauma,
European Journal of Emergency Medicine 1(1):13-8.
9 Shippy CR, Appel P, Shoemaker WC 1984,
Reliability of clinical monitoring to assess blood
volume in critically ill patients, Critical Care
Medicine, 12(2):107-12.
10 Wo CC, Shoemaker WC, Appel PL, Bishop MH,
Kram HB, Hardin E 1993, Unreliability of blood
pressure and heart rate to evaluate cardiac
output in emergency resuscitation and critical
illness, Critical Care Medicine, 21(2):218-23.
11 Demetriades D, Chan LS, Bhasin P, Berne TV,
Ramicone E, Huicochea F, et al 1998,
Relative bradycardia in patients with traumatic
hypotension, Journal of Trauma Injury, Infection
and Critical Care, 45(3):534-9.
12 Knottenbelt JD 1991, Low initial hemoglobin
levels in trauma patients: an important indicator
of ongoing hemorrhage, Journal of Trauma-Injury
Infection & Critical Care, 31(10):1396-9.
13 Rixen D, Raum M, Bouillon B, Lefering R,
Neugebauer E 2001, Unfallchirurgie. APotDGf.
Base deficit development and its prognostic
significance in posttraumatic critical illness:
an analysis by the trauma registry of the
Deutshce Gesellschaft fur unfallchirurgie,
Shock 2001;15(2):83-9.
14 Bannon MP, O'Neill CM, Martin M, ilstrup DM,
Fish NM, Barrett J 1995, Central venous oxygen
saturation, arterial base deficit, and lactate
concentration in trauma patients, American
Surgeon 61(8):738-45.
15 Oman KS 1995, Use of hematocrit changes
as an indicator of blood loss in adult trauma
patients who receive intravenous fluids,
Journal of Emergency Nursing, 21(5):395-400.
16 McMurtry R, Walton D, Dickinson D, Kellam J,
Tile M 1980, Pelvic disruption in the
polytraumatized patient: a management
protocol. Clinical Orthopaedics & Related
Research (151):22-30, 1980 Sep.
17 Klein SR, Saroyan RM, Baumgartner F,
Bongard FS 1992, Management strategy of
vascular injuries associated with pelvic fractures,
Journal of Cardiovascular Surgery 33(3):349-57,
May-Jun.
18 Looser KG, Crombie HD, Jr 1976, Pelvic
fractures: an anatomic guide to severity of injury,
Review of 100 cases, American Journal of Surgery
132(5):638-42.
19 Flint L, Babikian G, Anders M, Rodriguez J,
Steinberg S 1990, Definitive control of mortality
from severe pelvic fracture, Annals of Surgery
211(6):703-6; discussion 706-7, 1990 Jun.
20 Lu W, Kolkman K, Seger M, Sugrue M 2000,
An evaluation of trauma team response in
a major trauma hospital in 100 patients with
predominantly minor injuries, ANZ Journal
of Surgery, (5):329-32.
PAGE 46 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
References
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
blood
O-neg
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 46
21 American College of Surgeons Committee
on Trauma 1997, Advanced Trauma Life Support
for Doctors (6th Edition).
22 Australian Resuscitation Council 2003,
Principles for controlling bleeding for
first aiders; Guideline 8.1.
23 Shoemaker WC, Peitzman AB, Bellamy RF,
Bellomo R, Bruttig SP, Capone A, et al 1996,
Resuscitation from severe hemorrhage,
Critical Care Medicine, 24(2 Suppl):12-23.
24 Feero S, Hedges JR, Simmons E, Irwin L 1995,
Does out-of-hospital EMS time affect trauma
survival? American Journal of Emergency Medicine,
13(2):133-5.
25 Martin G, Cogbill TH, Landercasper J, Strutt P
1990, Prospective analysis of rural interhospital
transfer of injured patients to a referral trauma
centre, Journal of Trauma – Injury, Infection and
Critical Care, 30:1014-9.
26 Sampalis JS, Lavoie A, Williams JI, Mulder DS,
Kalina M 1993, Impact of on-site care,
prehospital time, and level of in-hospital care
on survival in severely injured patients, Journal
of Trauma-Injury Infection & Critical Care,
34(2):252-61.
27 Sloan EP, Callahan E, Duda J, Sheaff C, Robin A
1989, The effect of urban trauma system hospital
bypass on prehospital times and level 1 trauma
patient survival, Annals of Emergency Medicine,
18:1146-50.
28 Stewart BT, Lee V, Danne PD 1994, Laparotomy
for Trauma in a regional centre: the effect of
delay on outcome, Australian & New Zealand
Journal of Surgery, 64(7):484-7.
29 Scalea TM 1998, Massive transfusion and
haemorrhage control in the trauma patient.
30 Dantzker D 1989, Oxygen Delivery and utilisation
in sepsis, Critical Care Clinics, 5:81-98.
31 Stern SA 2001, Low-volume fluid resuscitation
for presumed hemorrhagic shock: helpful or
harmful? Current Opinion in Critical Care,
7(6):422-30.
32 Bickell WM 1993, Are victims of injury sometimes
victimised by attempts at fluid resuscitation?
Annals of Emergency Medicine 1993;22:225-6.
33 Bickell WH, Bruttig SP, Millnamov GA, al e 1991,
The detrimental effects of intravenous crystalloid
after aortotomy in swine, Surgery, 110:529-36.
34 Burris D, Rhee P, Kaufman C, al e 1999,
Controlled resuscitation for uncontrolled
hemorrhagic shock, Journal of Trauma –
Injury, Infection and Critical Care, 46:216-23.
35 Kowalenko T, Stern SA, Dronen SC 1992,
Improved outcome with hypotensive resuscitation
of uncontrolled hemorrhagic shock, Journal of
Trauma – Injury, Infection and Critical Care,
33:349-53.
36 Capone AC, Safar P, Stezoski W, al e 1995,
Improved outcome with fluid restriction in
treatment of uncontrolled haemorrhagic shock,
Journal of the American College of Surgeons,
180:49-56.
37 Stern SA, Dronen SC, Birrer P, al e 1993,
The effect of blood pressure on haemorrhage
volume and survival in a near-fatal haemorrhage
model incorporating a vascular injury, Annals of
Emergency Medicine, 22(2):155-63.
38 Solomonov E, Hirsch M, Yahiya A, al e
2000, The effect of vigorous resuscitation
in uncontrolled haemorrhagic shock after
massive splenic injury, Critical Care Medicine,
28(3):749-54.
39 Krausz MM, Bashenko Y, Hirsch M 2000,
Crystalloid or colloid resuscitation of uncontrolled
hemorrhagic shock after moderate splenic injury,
Shock, 13(3):230-5.
40 Bickell WH, Wall Jr MJ, Pepe PE, Martin RR,
Ginger VF, Allen MK, et al 1994, Immediate
versus delayed fluid resuscitation for hypotensive
patients with penetrating torso injuries, New
England Journal of Medicine, 331(17):1105-9.
41 Turner J, Nicholl J, Webber L, Cox H, Dixon S,
Yates D 2000, A randomised controlled trial of
pre-hospital intravenous fluid replacement
therapy in serious trauma, Health Technology
Assessment, 4(31).
42 Dutton RP, Mackenzie CF, Scalea TM 2002,
Hypotensive resuscitation during active
hemorrhage: impact on in-hospital mortality,
Journal of Trauma – Injury, Infection and Critical
Care, 52(6):1141-6.
43 Sampalis JS, Tamim H, Denis R, Boukas S,
Ruest SA, Nikolis A, et a 1997, Ineffectiveness
of on-site intravenous lines: is prehospital time
the culprit? Journal of Trauma-Injury Infection &
Critical Care, 43(4):608-15.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 47
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: REFERENCES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 47
44 Hambly PR, Dutton RP 1996, Excess mortality
associated with the use of a rapid infusion system
at a level 1 trauma center, Resuscitation,
31(2):127-33.
45 Kwan I, Bunn F, Roberts I, Committee, WP-HTCS
2001, Timing and Volume of fluid administration
for patients with bleeding following trauma,
Cochrane Database of Systematic Reviews,
(1):CD002245.
46 Fowler R, Pepe PE 2002, Fluid resuscitation
of the patient with major trauma, Current
Opinion in Anaesthesiology 2002, 15(2):173-8.
47 Revell M, Greaves I, Porter K 2003, Endpoints
for fluid resuscitation in hemorrhagic shock,
Journal of Trauma – Injury, Infection and Critical
Care, 54(5 Suppl):63-7.
48 Champion HR. Combat fluid resuscitation:
introduction and overview of conferences 2003,
Journal of Trauma – Injury, Infection and Critical
Care, 54(5 Suppl):7-12.
49 Henry S, Scalea TM 1999, Resuscitation in the
new millennium, Surgical Clinics of North America,
79(6):1259-67.
50 Alderson P, Schierhout G, Roberts I, Bunn F 2003,
Colloids versus crystalloids for fluid resuscitation
in critically ill patients, Cochrane Database of
Systematic Reviews 2003;3.
51 Choi P, Yip G, Quinonez L, Cook D 1999,
Crystalloids vs colloids in fluid resuscitation:
A systematic review, Critical Care Medicine,
27(1):200-10.
52 Vassar MJ, Perry CA, Holcroft JW. Prehospital
resuscitation of hypotensive trauma patients with
7.5% NaCI versus 7.5% NaCl with added
dextran: a controlled trial. Journal of Trauma -
Injury, Infection and Critical Care 1993;34(5):622-
32.
53 Vassar MJ, Holcroft JW 1992, Use of Hypertonic-
hyperoncotic fluids for resuscitation of trauma
patients, Journal of Intensive Care Medicine, 7:189.
54 Younes RN, Aun R, Accioly CQ, Casale LPL,
Szanjnbok I, Birolini D 1992, Hypertonic
solutions in the treatment of hypovolemic
shock: a prospective, randomized study in
patients admitted to the emergency room,
Surgery 1992;111(4):380-5.
55 Wade CE, Kramer GC, Grady JJ, Fabian TC,
Younes RN 1997, Efficacy of hypertonic 7.5%
saline and 6% dextran-70 in treating trauma:
a meta-analysis of controlled clinical studies,
Surgery, Sep;122(3):609-16.
56 Cain JG, Smith CE 2001, Current practices in
fluid and blood component therapy in trauma,
Seminars in Anesthesia 20(1):28-35.
57 Mikhail J 1999, Resuscitation endpoints in
trauma, AACN Clinical Issues 10(1):10-21.
58 Porter JM, Ivatury RR 1998, In search of the
optimal end points of resuscitation in trauma
patients: a review, Journal of Trauma – Injury,
Infection and Critical Care, 44(5):908-14.
59 Hameed SM, Cohn SM 2001, Gastric tonometry:
the role of mucosal pH measurement in the
management of trauma, Chest, 123 (5 Suppl):
475-81.
60 Clay R, Shippy M, Paul L, Appel M, Shoemaker W
1984, Reliability of clinical monitoring to assess
blood volume in critically ill patients, Critical Care
Medicine 12(2):107-12.
61 Shoemaker WC, Wo CC, Demetriades D,
Belzberg H, Asensio JA, Cornwell EE, et al 1996,
Early physiologic patterns in acute illness and
accidents: toward a concept of circulatory
dysfunction and shock based on invasive
and noninvasive hemodynamic monitoring,
New Horizons, 4(4):395-412.
62 Davis JW, Shakford SR, Mackersie RC,
Hoyt DB 1988, Base deficit as a guide to
volume resuscitation, Journal of Trauma – Injury,
Infection and Critical Care, 28(10):1464-7.
63 Canizaro PC, Pessa ME 1990, Management of
massive hemorrhage associated with abdominal
trauma, [Review] [34 refs], Surgical Clinics of
North America, 70(3):621-34.
64 James Jr PM, Bredenberg CE, Collins JA,
Anderson RN, Levitsky S, Hardaway RM 1969,
Tolerance to long and short term lactate
infusions in men with battle casualties subjected
to hemorrhagic shock, Surgical Forum, 20:543-5.
65 Kincaid EH, Meredith JW, Chang MC 2001,
Determining optimal cardiac preload during
resuscitation using measurements of ventricular
compliance, Journal of Trauma – Injury, Infection
and Critical Care, 50(4):665-9.
66 ITACCS Seminar Panel 2003, Massive Transfusion
and control of hemorrhage in the trauma patient.
PAGE 48 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 48
67 Abramson D, Scalea TM, Hitchcock R, Trooskin
SZ, Henry SM, Greenspan J 1993, Lactate
clearance and survival following injury, Journal
of Trauma - Injury, Infection and Critical Care,
35(4):584-9.
68 Manikis P, Jankowski S, Zhang H, Kahn RJ,
Vincent JL 1995, Correlation of serial blood
lactate levels to organ failure and mortality after
trauma, American Journal of Emergency Medicine,
13(6):619-22.
69 Sauaia A, Moore FA, Moore EE, Haenel JB,
Read RA, Lezotte DC 1994, Early predictors of
postinjury multiple organ failure, Archives of
Surgery, 129(1):39-45.
70 Ivatury RR, Simon RJ, Havriliak D, Garcia C,
Greenbarg J, Stahl WM 1995, Gastric mucosal
pH and oxygen delivery and oxygen consumption
indices in the assessment of adequacy of
resuscitation after trauma: a prospective,
randomized study, Journal of Trauma-Injury
Infection & Critical Care 39(1):128-34; discussion
134-6.
71 Ivatury RR, Simon RJ, Islam S, Fueg A, Rohman
M, Stahl WM 1996, A prospective randomized
study of end points of resuscitation after major
trauma: global oxygen transport indices versus
organ-specific gastric mucosal pH, Journal of the
American College of Surgeons 183(2):145-54.
72 Weil MH, Nakagawa Y, Tang W, Sato Y, Ercoli F,
Finegan R, et al 1999, Sublingual capnometry:
a new noninvasive measurement for diagnosis
and quantitation of severity of circulatory shock,
Critical Care Medicine 27(7):1225-9.
73 Bishop MH, Shoemaker WC, Appel PL,
Meade P, Ordog GJ, Wasserberger J, et al 1995,
Prospective, randomized trial of survivor values
of cardiac index, oxygen delivery, and oxygen
consumption as resuscitation endpoints in severe
trauma.[see comment], Journal of Trauma-Injury
Infection & Critical Care 38(5):780-7.
74 Fleming A, Bishop M, Shoemaker W, Appel P,
Sufficool W, Kuvhenguwha A, et al 1992,
Prospective trial of supranormal values as goals of
resuscitation in severe trauma, Archives of Surgery
127(10):1175-9; discussion 1179-81.
75 Shoemaker WC 1996, Temporal physiologic
patterns of shock and circulatory dysfunction
based on early descriptions by invasive and
noninvasive monitoring, New Horizons,
4(2):300-18.
76 Bishop MH, Shoemaker WC, Appel PL et al 1995,
Prospective, randomized trial of survivor values
of cardiac index, oxygen delivery, and oxygen
consumption as resuscitation endpoints in
severe trauma, Journal of Trauma-Injury Infection
& Critical Care, 38(5):780-7.
77 Velmahos GC, Demetriades D, Shoemaker WC,
Chan LS, Tatevossian R, Wo CC, et al 2000,
Endpoints of resuscitation of critically injured
patients: normal or supranormal? A prospective
randomized trial, Annals of Surgery,
232(3):409-18.
78 Victorino GP, Battistella FD, Wisner DH 2003,
Does tachycardia correlate with hypotension
after trauma? Journal of the American College
of Surgeons, 196(5):679-84.
79 Shoemaker WC, Fleming AW 1986,
Resuscitation of the trauma patient: restoration
of hemodynamic functions using clinical
algorithms, Annals of Emergency Medicine
1986;15(12):1437-44.
80 Bishop MH, Shoemaker WC, Appel PL,
Wo CJ, Zwick C, Kram HB, et al 1993,
Relationship between supranormal circulatory
values, time delays and outcome in severely
traumatized patients, Critical Care Medicine
1993;21(1):56-63.
81 Ardagh MW, Hodgson T, Shaw L, Turner D 2001,
Pulse rate over pressure evaluation (ROPE) is
useful in the assessment of compensated
haemorrhagic shock, Emergency Medicine
(Fremantle WA), 13(1):43-6.
82 Tatevossian RG, Wo CC, Velmahos GC,
Demetriades D, Shoemaker WC 2000,
Transcutaneous oxygen and CO2 as early
warning of tissue hypoxia and hemodynamic
shock in critically ill emergency patients.
[comment], Critical Care Medicine, 28(7):2248-53.
83 Githaiga JW, Adwok JA 2002, Diagnostic
peritoneal lavage in the evaluation of abdominal
trauma using the dipstick, East African Medical
Journal 79(9):457-60.
84 Kaweski SM, Sise MJ, Virgilio RW 1990,
The effect of prehospital fluids on survival in
trauma patients [comment], Journal of Trauma-
Injury Infection & Critical Care, 30(10):1215-8.
85 Allen CF, Goslar PW, Barry M, Christiansen T
2000, Management guidelines for hypotensive
pelvic fracture patients, American Surgeon
66(8):735-8.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 49
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: REFERENCES
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 49
86 Blair SD, Janvrin SB, McCollum CN,
Greenhalgh RM 1986, Effect of early blood
transfusion on gastrointestinal haemorrhage,
British Journal of Surgery, 73(10):783-5.
87 Dunham CM, Belzberg H, Lyles R, Weireter L,
Skurdal D, Sullivan G, et al 1991, The rapid
infusion system: a superior method for the
resuscitation of hypovolemic trauma patients,
Resuscitation, 21(2-3):207-27.
88 Neff TA, Doelberg M, Jungheinrich C, Sauerland
A, Spahn DR, Stocker R 2003, Repetitive large-
dose infusion of the novel hydroxyethyl starch
130/0.4 in patients with severe head injury,
Anesthesia and Analgesia 2003;96(5):1453-9.
89 Buchman TG, Menker JB, Lipsett PA 1991,
Strategies for trauma resuscitation. Surgery,
Gynaecology & Obstetrics 1991;172(1):8-12.
90 Remmers DE, Wang P, Cioffi WG, Bland KI,
Chaudry IH 1998, Chronic resuscitation after
trauma-hemorrhage and acute fluid replacement
improves hepatocellular function and cardiac
output, Annals of Surgery, 227(1):112-9.
91 Wilkes MM, Navickis RJ 2001, Patient survival
after human albumin administration: A meta-
analysis of randomized controlled trials, Annals
of Internal Medicine, 135(3):149-64.
92 Wade CE, Grady JJ, Kramer GC, Younes RN,
Gehlsen K, Holcroft JW 1997, Individual patient
cohort analysis of the efficacy of hypertonic
saline/dextran in patients with traumatic brain
injury and hypotension [Review] [22 refs],
Journal of Trauma-Injury Infection & Critical
Care, 42(5:Suppl):Suppl-5.
93 Mattox KL, Maningas PA, Moore EE, Mateer JR,
Marx JA, Aprahamian C, et al 1991, Prehospital
hypertonic saline/dextran infusion for post-
traumatic hypotension, The U.S.A. Multicenter
Trial. Annals of Surgery, 213(5):482-91.
94 Maningas PA, Mattox KL, Pepe PE, Jones RL,
Feliciano DV, Burch JM 1989, Hypertonic
saline-dextran solutions for the prehospital
management of traumatic hypotension,
American Journal of Surgery, 157(5):528-33.
95 Sloan EP, Koenigsberg M, Gens D, Cipolle M,
Runge J, Mallory MN, et al 1999, Diaspirin cross-
linked hemoglobin (DCLHb) in the treatment of
severe traumatic hemorrhagic shock: a
randomized controlled efficacy trial,
JAMA, 282(19):1857-67.
96 Bouwman DL, Weaver DW, Vega J, Ledgerwood
AM, Higgins R, Lucas CE 1978, Effects of
albumin on serum protein homeostasis after
hypovolemic shock, Journal of Surgical Research,
24(4):229-34.
97 Wu JJ-K, Huang M-S, Tang G-J, Kao W-F,
Shih H-C, Su C-H, et al 2001, Hemodynamic
response of modified fluid gelatin compared with
lactated ringer's solution for volume expansion in
emergency resuscitation of hypovolemic shock
patients: Preliminary report of a prospective,
randomized trial, World Journal of Surgery
25(5):598-602.
98 Wade CE, Grady JJ, Kramer GC 2003,
Efficacy of hypertonic saline dextran fluid
resuscitation for patients with hypotension
from penetrating trauma, Journal of Trauma –
Injury, Infection and Critical Care,
54(5 Suppl.):144-8.
99 Mauritz W, Schimetta W, Oberreither S, Polz W
2002, Are hypertonic hyperoncotic solutions safe
for prehospital small-volume resuscitation?
Results of a prospective observational study,
European Journal of Emergency Medicine,
9(4):315-9.
100 Shatney CH, Deepika K, Militello PR, Majerus
TC, Dawson RB 1983, Efficacy of hetastarch in
the resuscitation of patients with multisystem
trauma and shock, Archives of Surgery,
118(7):804-9.
101 Vassar MJ, Perry CA, Gannaway WL,
Holcroft JW 1991, 7.5% sodium chloride/dextran
for resuscitation of trauma patients undergoing
helicopter transport, Archives of Surgery,
126(9):1065-72.
102 Vassar MJ, Fischer RP, O'Brien PE, Bachulis BL,
Chambers JA, Hoyt DB, et al 1993, A multicenter
trial for resuscitation of injured patients with
7.5% sodium chloride. The effect of added
dextran 70. The Multicenter Group for the Study
of Hypertonic Saline in Trauma Patients, Archives
of Surgery, 128(9):1003-11.
103 Tranbaugh RF, Lewis FR 1983, Crystalloid versus
colloid for fluid resuscitation of hypovolemic
patients, Advances in Shock Research, 9:203-16.
PAGE 50 Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM
ADULT TRAUMA CLI NI CAL PRACTI CE GUI DELI NES
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
HypovolaemicShock_FullRep.qxd 3/2/07 12:36 PM Page 50
104 Holcroft JW, Vassar MJ, Perry CA, Gannaway WL,
Kramer GC 1989, Use of a 7.5% NaC1/6%
Dextran 70 solution in the resuscitation of injured
patients in the emergency room, Progress in
Clinical & Biological Research, 299:331-8.
105 Johnson JL, Moore EE, Offner PJ, Haenel JB,
Hides GA, Tamura DY 1998, Resuscitation of
the injured patient with polymerized stroma-
free hemoglobin does not produce systemic
or pulmonary hypertension, American Journal
of Surgery, 176(6):612-7.
106 Kerner T, Ahlers O, Veit S, Riou B, Saunders M,
Pison U, et al 2003, DCL-Hb for trauma patients
with severe hemorrhagic shock: the European
"On-Scene" multicenter study, Intensive Care
Medicine, 29(3):378-85.
107 Johnson JL, Moore EE, Offner PJ, Partrick DA,
Tamura DY, Zallen G, et al 2001, Resuscitation
with a blood substitute abrogates pathologic
post injury neutrophil cytotoxic function,
Journal of Trauma – Injury, Infection and
Critical Care, 50(3):449-55.
108 Hirshberg A, Digas M, Banez EI, Scott BG,
Wall MJJr, Mattox KL 2003, Minimizing dilutional
coagulopathy in exsanguinating hemorrhage:
a computer simulation, Journal of Trauma – Injury,
Infection and Critical Care, 54(3):454-63.
109 Gould SA, Moore EE, Hoyt DB, Burch JM, Haenel
JB, Garcia J, et al 1998, The first randomized trial
of human polymerized hemoglobin as a blood
substitute in acute trauma and emergent surgery,
Journal of the American College of Surgeons,
187(2):113-22.
110 Gould SA, Moore EE, Haenel JB, Burch JM,
Sehgal H, Sehgal L, et al 1997, Clinical utility
of human polymerized hemoglobin as a blood
substitute after acute trauma and urgent surgery,
Journal of Trauma - Injury, Infection and Critical
Care, 43(2):325-31.
111 Knudson MM, Lee S, Erickson V, Maorabito D,
Derugin N, Manley GT 2003, Tissue oxygen
monitoring during hemorrhagic shock and
resuscitation: A comparison of lactated Ringer's
solution, hypertonic saline dextran and HBOC-
201, Journal of Trauma – Injury, Infection and
Critical Care, 54(2):242-52.
112 Durham RM, Neunaber K, Mazuski JE,
Shapiro MJ, Baue AE 1996, The use of oxygen
consumption and delivery as endpoints for
resuscitation in critically ill patients, Journal
of Trauma – Injury, Infection and Critical Care,
41(1):32-9.
113 Ivatury RR, Simon RJ, Islam S, Fueg A, Rohman
M, Stahl WM 1996, A prospective randomized
study of end points of resuscitation after major
trauma: global oxygen transport indices versus
organ-specific gastric mucosal pH, Journal of the
American College of Surgeons, 183(2):145-54.
114 Fleming A, Bishop M, Shoemaker W, Appel P,
Sufficool W, Kuvhenguwha A, et al 1992,
Prospective trail of supranormal values as goals
of resuscitation in severe trauma, Archives of
Surgery 127(10):1175-81.
115 Waxman K, Annas C, Daughters K, Tominaga GT,
Scannell G 1994, A method to determine the
adequacy of resuscitation suing tissue oxygen
monitoring, Journal of Trauma – Injury, Infection
and Critical Care, 36(6):852-6.
116 Husain FA, Martin MJ, Mullenix PS, Steele SR,
Elliott DC 2003, Serum lactate and base deficit
as predictors of mortality and morbidity, American
Journal of Surgery, 185(5):485-91.
117 Weil MH, Nakagawa Y, Tang W, Sato Y, Ercoli F,
Finegan R, et al 1999, Sublingual capnometry:
A new noninvasive measurement for diagnosis
and quantitation of severity of circulatory shock,
Critical Care Medicine Vol 27(7);1225-1229.
118 Kirton OC, Windsor J, Wedderburn R, Hudson-
Civetta J, Shatz DV, Mataragas NR, et al 1998,
Failure of splanchnic resuscitation in the acutely
injured trauma patient correlates with multiple
organ system failure and length of stay in the
ICU, Chest 113(4):1064-9.
119 Roumen RM, Vreugde JP, Goris RJ 1994,
Gastric tonometry in multiple trauma patients,
Journal of Trauma-Injury Infection & Critical Care
36(3):313-6.
120 Chang MC, Cheatham ML, Nelson LD,
Rutherford EJ, Morris JA, Jr 1994, Gastric
tonometry supplements information provided
by systemic indicators of oxygen transport,
Journal of Trauma-Injury Infection & Critical
Care 37(3):488-94.
121 Heyworth J, Conjunctival oxygen monitoring
in the initial assessment of trauma, Archives
of Emergency Medicine 9(3):274-9, 1992 Sep.
122 The Brain Trauma Foundation 2000, The
American Association of Neurological Surgeons,
and The Joint Section of Neurotrauma and
Critical Care, Management and prognosis
of severe traumatic brain injury, Journal of
Neurotrauma, 17:p.6-7.
Management of Hypovolaemic Shock in the Trauma Patient :: NSW ITIM PAGE 51
H
Y
P
O
V
O
L
A
E
M
I
C

S
H
O
C
K

G
U
I
D
E
L
I
N
E
:: REFERENCES
HypovolaemicShock_FullRep.qxd 6/8/07 1:51 PM Page 51
::
SHPN (TI) 070024
HypovaolaemicShock_FullRCvR.qxd 3/2/07 12:42 PM Page 4

Sign up to vote on this title
UsefulNot useful