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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

Fluid Resuscitation

State of the Science for Treating Combat Casualties and Civilian Injuries

Andrew Pope, Geoffrey French, and David E. Longnecker, Editors

Committee on Fluid Resuscitation for Combat Casualties

Division of Health Sciences Policy

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, DC

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

NATIONAL ACADEMY PRESS
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NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.

The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine.

This work relates to Department of Navy Grant N00014-98-1-0789 issued by the Office of Naval Research. The United States Government has a royalty-free license throughout the world in all copyrightable material contained herein. The views presented in this report are those of the Committee on Fluid Resuscitation for Combat Casualties and are not necessarily those of the funding organization.

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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

COMMITTEE ON FLUID RESUSCITATION FOR COMBAT CASUALTIES

DAVID E. LONGNECKER (Chair), Robert D. Dripps Professor and Chair,

Department of Anesthesia, University of Pennsylvania Health System

WILLIAM G. BAXT, Professor and Chair,

Department of Emergency Medicine, Chief, Emergency Services, University of Pennsylvania Health System

JOSEPH C. FRATANTONI, Vice President,

Biologics, C.L. McIntosh & Associates, Rockville, Maryland

JURETA W. HORTON, Professor and Core Lab Director,

Department of Surgery, University of Texas Southwestern Medical School, Dallas

JOHN P. KAMPINE, Professor and Chairman,

Department of Anesthesiology, Medical College of Wisconsin

HARVEY G. KLEIN, Chief,

Department of Transfusion Medicine, Warren Grant Magnuson Clinical Center, National Institutes of Health, Bethesda, Maryland

JOSEPH E. RALL, Senior Scientist, Emeritus,

National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, Maryland

GEORGE F. SHELDON, Professor and Chair,

Department of Surgery, School of Medicine, University of North Carolina at Chapel Hill

BLAINE C. WHITE, Professor,

Departments of Emergency Medicine and Physiology, Wayne State University School of Medicine

Study Staff

ANDREW POPE, Director,

Health Sciences Policy Program

GEOFFREY FRENCH, Project Officer

CHARLES EVANS, Head,

Health Sciences Section

SARAH PITLUCK, Administrative Assistant

GLEN SHAPIRO, Research and Project Assistant

MELVIN H. WORTH, Jr., Scholar-in-Residence

Consultant

KATHI HANNA

Copy Editor

MICHAEL HAYES

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

Reviewers

This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The committee wishes to thank the following individuals for their participation in the review of this report:

H. RICHARD ADAMS, College of Veterinary Medicine, Texas A&M University;

RONALD F. BELLAMY, Borden Institute, Walter Reed Army Medical Center, Washington, D.C.;

ROBERT W. BERLINER, Yale University School of Medicine;

ROBERT E. FORSTER, University of Pennsylvania School of Medicine;

LAZAR J. GREENFIELD, University of Michigan School of Medicine;

TIBOR J. GREENWALT, Hoxworth Blood Center, University of Cincinnati;

RONALD D. MILLER, University of California at San Francisco;

HELEN RANNEY, Alliance Pharmaceutical Corp., San Diego, California;

PETER ROSEN, University of California at San Diego Medical Center;

G. TOM SHIRES, University of Nevada School of Medicine, Trauma Institute, Las Vegas;

DONALD D. TRUNKEY, Oregon Health Sciences University;

MARY J. VASSAR, San Francisco Injury Center, University of California at San Francisco; and

ROBERT M. WINSLOW, Sangart, Inc., San Diego, California.

While the individuals listed above have provided constructive comments and suggestions, it must be emphasized that responsibility for the final content of this report rests entirely with the authoring committee and the Institute of Medicine.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

Preface

The U.S. military has a long tradition of making the safety of its troops a top priority. This goal is evident in military strategy and tactics and in the development of sophisticated technology that decreases or avoids human risk. This commitment is evident in the fostering and support of biomedical research that is applicable to the military as well. The spectrum of supported research ranges from acute through chronic care of the soldier. The U.S. Department of Veterans Affairs, for example, invests in research on long-term rehabilitation from wounds or military-related disease, whereas the armed services often focus on the acute medical needs of the injured soldier. One of the most important goals involves immediate resuscitation of the wounded soldier in the field, to support life during transport to a field facility, where definitive treatment may be instituted by highly trained medical personnel. The Office of Naval Research asked our committee to focus on this immediate resuscitation to ensure that current care is optimal and that future research is focused in the most fertile areas for advancement.

The National Academy of Sciences (NAS) has a long history of assisting the military in the evaluation of methods of resuscitation and shock. NAS volunteered its expertise to President Woodrow Wilson in 1916, and he responded by asking NAS to organize scientific agencies for national defense. At the conclusion of World War I in 1918, the president, by executive order, asked the Academy to perpetuate the National Research Council (NRC) for the government to have a consulting body available for a variety of needs. NRC played an important role in the studies of shock and resuscitation prior to and during World War II and provided advice for research policy and treatment protocols.

The challenges associated with the immediate resuscitation of the wounded soldier are daunting and are often unappreciated by civilian medical personnel. Military engagements often take place in mud, rain, snow, heat, or cold, at sea or on beaches, and often at night. The field medics, who are responsible for ini-

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

tial resuscitation and treatment, can carry only very limited medical gear, and they are often engaged in battle and under fire while attempting to treat the wounded. Thus, the need for simple, compact, and effective approaches for immediate resuscitation is apparent.

Research in this area is extraordinarily challenging. First, there are few, if any, ways in which all aspects of human hemorrhagic shock can be fully reproduced in the laboratory. Various animal models can mimic specific aspects of the shock process, but no single model represents the entire spectrum of human hemorrhagic shock; there remain fundamental differences that apparently cannot be narrowed. Yet the use of unproven treatments in the field is simply unacceptable.

The committee had two goals as it thought about research in this area. First, it wanted to indicate to the Office of Naval Research which technologies were best suited for use in the immediate future. Second, it wanted to give some direction for longer-term research by identifying promising areas that might lead to leaps in the knowledge about hemorrhagic shock or care for the combat casualty. As part of the committee's review of the state of the science, the committee held a 2-day conference and heard from more than 40 scientists, medical researchers, and clinicians in the field of resuscitation research. Subsequently, the committee solicited information from several additional scientists and from the scientific community at large. In the end, the committee felt comfortable with its grasp of current research and with its view of the opportunities for future investigation. These conclusions are presented in the text of this report.

Finally, the committee wanted its work to have some relevance to the civilian medical community. Although its first responsibility was to the military, the committee understood that there are both similarities and differences between civilian emergency trauma care and acute military medicine. With this in mind, the committee was explicit in describing the similarities and differences between the combat and civilian environments, and it offered suggestions for technologies or approaches that would apply to civilian care as well. The committee hopes that this report will help energize and focus research in both military and civilian emergency medical care and help to save the lives of citizens and soldiers alike.

On behalf of the committee, I wish to express our gratitude to all who contributed to the production of this report. First, we appreciate the opportunity that was presented by the Office of Naval Research, which initiated the questions and sponsored the project. Second, a review of the science would not be possible if it were not for the many scientists and experts whose findings formed the scientific basis of this report. Third, the arduous process of conducting the complex task was made easier by the talented staff of the Institute of Medicine, especially Andy Pope, Geoff French, and Glen Shapiro. Most importantly, I want to add my personal gratitude to the rest of this committee who volunteered countless hours of their time and expertise to produce this document.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

If the work that we have done here serves to assist in resuscitating even one casualty that would have otherwise been lost, as we believe it will, then this will have been a successful and worthwhile endeavor.

DAVID E. LONGNECKER, M.D.

CHAIR

Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×

Photographs

Page xii: A bottle of blood plasma hangs on a "wounded" man's rifle during a training exercise in 1943. Photograph by Marjory Collins. Courtesy of the Library of Congress.

Page 8: Medics helping a wounded soldier in France, 1944. Courtesy of the National Archives and Records Administration.

Page 18: An American soldier receives blood plasma in Sicily, 1943. Courtesy of the National Archives and Records Administration.

Page 46: A blood transfusion underway aboard a DUKW during the fighting on Iwo Jima, 1945. Courtesy of the Bureau of Medicine Historical Archives.

Page 78: Water and plasma being given to a marine at Eniwetok Atoll. Courtesy of the Bureau of Medicine Historical Archives.

Page 96: Soldiers at a battalion aid station await evacuation while being transfused in Korea, 1952. Reprinted with permission of the American Red Cross. All rights reserved.

Page 108: Wounded soldiers are evacuated aboard a tank in Vietnam, 1968. Photograph by John Olson. Copyright 1968 by Time, Inc. All rights reserved.

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×
   

Blood Substitutes and Alternatives to Transfusion

 

41

   

Disseminated Intravascular Coagulation

 

42

   

Conclusions and Recommendations

 

43

3

 

Experience With And Complications of Fluid Resuscitation

 

47

   

Overview of Colloid and Crystalloid Resuscitation

 

47

   

Complications of Resuscitation In General

 

51

   

Effects of Fluid Resuscitation on Coagulation

 

51

   

Oxygen Toxicity Associated with Resuscitation

 

53

   

Reperfusion-Mediated Injury

 

54

   

Complications of Late Resuscitation of Shock

 

59

   

Complications of Colloid Resuscitation

 

60

   

Complications of Crystalloid Resuscitation

 

62

   

Effects of Crystalloid Resuscitation on Immune Function

 

62

   

Effects of Crystalloid Resuscitation on Cytokine Response

 

67

   

Adverse Effects of Large-Volume Crystalloid Resuscitation

 

68

   

Adverse Effects of Lactated Ringer's Solution

 

69

   

Safety and Efficacy of Hypertonic Saline Solutions

 

71

   

Alternative Resuscitation Approaches

 

73

   

Summary

 

74

   

Conclusions and Recommendation

 

75

4

 

Novel Approaches To Treatment Of Shock

 

79

   

Prevention

 

80

   

Oxygen Therapeutics

 

80

   

First-, Second-, and Third-Generation Therapeutics

 

82

   

Perfluorochemicals

 

83

   

Liposomes

 

83

   

Other Novel Approaches

 

84

   

Intervention

 

84

   

Targets for Intervention

 

84

   

Therapies for Reperfusion-Mediated Free-Radical Damage

 

86

   

Hormonal Influences

 

92

   

Diagnostic Instrumentation

 

92

   

Tolerance

 

92

   

Recommendation

 

93

5

 

Protocols of Care At The Site Of Injury

 

97

   

The Combat Environment

 

97

   

Expected Condition of Combatant on the Battlefield

 

98

   

Limits of Battlefield Care for the Injured Combatant

 

98

Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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PageR7
Page viii Cite
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
×
PageR8
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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PageR9
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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PageR10
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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PageR11
Suggested Citation:"Front Matter." Institute of Medicine. 1999. Fluid Resuscitation: State of the Science for Treating Combat Casualties and Civilian Injuries. Washington, DC: The National Academies Press. doi: 10.17226/9625.
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PageR12
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Historically, 20% of all injured combatants die on the battlefield before they can be evacuated to a field hospital. Blood loss—hemorrhage—is the single major cause of death among those killed in action whose lives might otherwise be saved. Fluid resuscitation and the treatment of hypovolemia (the abnormally decreased volume of circulating fluid in the body) offer the greatest opportunity for reducing mortality and morbidity associated with battlefield casualties.

In Fluid Resuscitation, a committee of experts assess current resuscitation fluids and protocols for the treatment of combat casualties and make recommendations for future research. Chapters focus on the pathophysiology of acute hemorrhagic shock, experience with and complications of fluid resuscitation, novel approaches to the treatment of shock, protocols of care at the site of injury, and future directions for research.

The committee explicitly describes the similarities and differences between acute medical care during combat and civilian emergency trauma care. Fluid Resuscitation should help energize and focus research in both civilian and military emergency care and help save the lives of citizens and soldiers alike.

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