Fluid resuscitation

Capabilities for fluid resuscitation include the equipment, the fluids themselves and the skills to administer them, monitor the response (including accurately monitoring fluid intake and output) and treat potential complications. The insertion of peripheral intravenous (IV) lines, percutaneously and by cutdown, and the use of crystalloid are deemed essential at all hospital levels. These are desirable at even the most basic levels at which seriously injured patients are seen. This is especially the case in locations where the basic level is at such a distance that evacuation to a higher level of care will entail a delay of several hours or more. The insertion of central lines (including the lines themselves and the expertise to insert them safely) is deemed essential at the upper two hospital levels and desirable at GP-level hospitals. However, in the setting of GP hospitals, given the potential for complications, the insertion of central lines should really only be considered for emergency situations in which access cannot be achieved by any other means.

The use of colloid is deemed desirable at higher hospital levels and should comply with existing WHO Essential Drug Programme guidelines. Intraosseous lines for children, especially for those under 5 years, are deemed essential at all hospital levels. Formal intraosseous needles would be ideal, but the ability to establish intraosseous access using any suitable large-bore metal needle (e.g. spinal needle) is acceptable.

Capabilities for blood transfusion are deemed essential at all hospital levels. A formal blood bank is best. However, if not available, capabilities for immediate donation and administration of fresh whole blood are acceptable. Such capabilities are also needed for the treatment of obstetric haemorrhage and severe anaemia. Most GP-level hospitals need to provide transfusions for these indications as well as for trauma. A small minority of GP-level hospitals might not be expected to have such capabilities. These would include smaller facilities in less remote areas, with easy access to referral centres. Such facilities might be considered to more closely represent the basic level than the GP-level hospitals considered in these guidelines.

Any time that blood is administered, there should be capabilities to assure its safety, including screening for HIV, hepatitis B and C, and other blood borne diseases, depending on the geographic area. Use of blood should follow existing WHO Blood Transfusion Safety guidelines and associated national policies (http://www.who.int/eht/Main_areas_of_work/BTS/BTS.htm). The use of blood also implies that it is being ordered by a clinician who knows the indications for transfusion in a trauma patient and is capable of recognizing and treating the potential complications of transfusion, monitoring the patient's response to transfusion and other fluid resuscitation, and assessing the patient for continued bleeding and the need for surgical intervention.

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