Walking between the Drops: Israeli Defense Forces’ Fluid Resuscitation Protocol
Quote from the article conclusion :
data regarding optimal treatment are conflicting, the quality of prehospital fluid resuscitation will presumably remain sub-optimal. Under these cir- cumstances, offering truly balanced fluid resuscitation guidelines is a lot like walking between the drops.
For those who cannot access the full article here is a summary of the highlights!
1. The article describes a 2010 revision of a 2003 Israeli defence force prehospital protocol for managing fluid resuscitation in injured soldiers. It reviews briefly the literature on fluid resuscitation in trauma and compares their current protocol with the American Tactical combat casualty care TCCC protocol.
2. The article cites that the current paradigm of trauma fluid resuscitation care at least in the prehospital setting is that of Balanced fluid resuscitation, with the avoidance of over and under resuscitation.
3. The 2003 protocol was an attempt to set guidelines for prehospital medics to achieve this balanced resuscitation concept, but it was clear that guidelines were being interpreted towards “no fluids in the field at all” and leading to cases of underresuscitation of injured manifesting profound shocked states. Medics were being asked to diagnose poorly defined terms such as controlled or uncontrolled haemorrhage and give difficult to achieve fluid bolus volumes of 250ml in the prehospital setting. In other words, the 2003 guidelines were theoretically on target but pragmatically off target!
4. The 2010 revised protocol addresses these issues in a pragmatic manner. It is deliberately designed to favour administration of an initial IV fluid bolus of 500ml of Lactated ringers solution. The authors admit they accept a risk of overresuscitation.
There are only three decision steps to make in the new protocol. Of course the overriding principle is rapid evacuation from the battlefield and stop any bleeding if possible either with direct compression or tourniquet
Step 1 = Decide if IV placement is needed. Essentially if more than obvious superficial wounds, or penetrating injury or altered Consciousness or significant mechanism of injury = Place IV!
Step 2 = Decide if needs IV bolus 500 ml LR. Essentially if suspiscion of shock then give. They suggest some criteria like altered consciousness, HR >100, absent peripheral pulses but they do not ask the medic to decide between controlled or uncontrolled haemorrhage. Nor is there a decision point anymore between two injury groups, head injured or not. Also a novel criteria is the inability to gain peripheral IV access i.e if you cant find a peripheral vein then assume there is shock.
Step 3 = Decide if IV bolus 500ml LR needs to be repeated. Essentially if signs of profound shock exist or persist, then repeat bolus until resolution. Quote from article “Profound shock was defined as present if the casualty was not fully mentating (unless there was obvious head trauma or he had received medications that may explain his decreased mentation), heart rate >130 beats/min, non-palpable radial pulse, or SBP < 80 mm Hg" Medics are limited to 2 L maximum fluid volume in the prehospital protocol but doctors can use clinical discretion and can give radio orders for more.
The Israeli protocol favours giving an initial limited fluid bolus of crystalloid then trying to triage the severe shock group to repeated boluses up to a maximum of 2 L.
Check out the full article if you can. well worth the read!