Intended for healthcare professionals

Clinical Review

Early fluid resuscitation in severe trauma

BMJ 2012; 345 doi: (Published 11 September 2012) Cite this as: BMJ 2012;345:e5752

This article has a correction. Please see:

  1. Tim Harris, professor of emergency medicine12,
  2. G O Rhys Thomas, Lieutenant Colonel and honorary consultant 342,
  3. Karim Brohi, professor of trauma sciences and consultant trauma and vascular surgeon 12
  1. 1Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
  2. 2Barts Health NHS Trust, London
  3. 316 Air Assault Medical Regiment
  4. 4Royal London and Queen Victoria, East Grinstead, UK
  1. Correspondence to: T Harris, Department of Emergency Medicine, Royal London Hospital, Whitechapel, London E11BB tim.harris{at}

Summary points

  • Critically injured trauma patients may have normal cardiovascular and respiratory parameters (pulse, blood pressure, respiratory rate), and no single physiological or metabolic factor accurately identifies all patients in this group

  • Initial resuscitation for severely injured patients is based on a strategy of permissive hypovolaemia (hypotension) (that is, fluid resuscitation delivered to increase blood pressure without reaching normotension, aiming for cerebration in the awake patient, or 70-80 mm Hg in penetrating trauma and 90 mm Hg in blunt trauma) and blood product based resuscitation

  • This period of hypovolaemia (hypotension) should be kept to a minimum, with rapid transfer to the operating theatre for definitive care

  • Crystalloid or colloid based resuscitation in severely injured patients is associated with worse outcome

  • Once haemostasis has been achieved, resuscitation targeted to measures of cardiac output or oxygen delivery or use improves outcome

  • Tranexamic acid administered intravenously within 3 h of injury improves mortality in patients who are thought to be bleeding

Trauma is a global health problem that affects patients in both rich and poor countries and accounts for 10 000 deaths each day.1 2 Trauma is the second leading cause of death after HIV/AIDS in the 5-45 year old age group.w1 w2 Early triage and resuscitation decisions affect outcome in trauma situations.w3 w4 The two leading causes of mortality in trauma are neurological injury and blood loss.3 4 w5 w6 There has been considerable improvement in our understanding of trauma resuscitation in the past 20 years, and data from databases and observational trials suggests outcomes are improving.w7 For patients with severe traumatic injuries (defined as <15 by the injury severity score, an anatomical scoring system), the high volume fluid resuscitation promoted by early advanced trauma life support manuals,5 followed by definitive surgical care, has given way to a damage …

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