Small-volume fluid resuscitation for the far-forward combat environment: Current concepts

Hemorrhage remains the primary cause of death on the battlefield in conventional warfare. With modern combat operations leading to the likelihood of significant time delays in air evacuation of casualties and long transport times, the immediate goals of the Army's Science and Technology Objectives in Resuscitation are to develop limited- or small-volume fluid resuscitation strategies, including permissive hypotension, for the treatment of severe hemorrhage to improve battlefield survival and prevent early and late deleterious sequelae. As an example, the U.S. Army has invested much effort in the evaluation of hypertonic saline dextran (HSD) as a plasma volume expander, at one tenth to one twelfth the volume of conventional crystalloids, in numerous animal models of hemorrhage. These studies have identified HSD as a potentially useful field resuscitation fluid. In addition, preliminary studies have used HSD under hypotensive resuscitation conditions, and it has been administered through intraosseous infusion devices for vascular access. This research suggests that many of the difficulties and concerns associated with fluid resuscitation for treating significant hemorrhage in the field can be overcome. For the military, such observations have important implications toward the development of optimal fluid resuscitation strategies under austere battlefield conditions for stabilization of the combat casualty.