Rapid infusion of fluids and blood products can be a life-saving intervention in managing circulatory and hemorrhagic shock. The recent debate over the role of fluid resuscitation in sepsis and trauma management has hidden the importance of early and rapid infusion of sufficient volume to restore circulation and improve organ perfusion. Evidence from high-quality studies shows that rapid and early resuscitation enhances patient outcomes.

A recent review by Piehl M. and Park CW. beautifully provides historical context and an update on recent advancements in volume resuscitation for circulatory shock. 

The authors of this review described a clinical case scenario for a better understanding. They described a case of a 23-year-old male who presented to the emergency department (ED) after striking a tree while riding an all-terrain vehicle. The first responders found an unconscious patient with an open skull fracture and a Glasgow coma scale score of 3. He was given Bag-valve-mask (BVM) ventilation and a semi-rigid cervical collar before transport to the ED for stabilization while awaiting air transport to the nearest trauma center. On ED arrival, the patient showed no spontaneous respiratory effort, with a pulse of 140 bpm, blood pressure of 65/30 mmHg, and oxygen saturation of 85% while receiving BVM ventilation with 100% oxygen. The patient had profuse bleeding through a gauze dressing applied to the exposed dura. The prehospital team cannot establish intravenous access. 

The authors described the immediate restoration of adequate systemic arterial pressure and cerebral perfusion as critical to the patient′s survival and prevention of secondary neurologic injury in the case described above. They described that Rapid infusion of crystalloid and/or blood products can be a life-saving intervention for patients with acute circulatory failure and is the first-line treatment for the acute resuscitation of patients with shock. 

For such patients, the authors dictate reversal of shock as the immediate management priority since every minute of hypotension increases the risk of permanent neurologic sequelae and places the patient at significant risk of peri-intubation cardiac arrest. With no pre-existing vascular access at the ED arrival, the immediate establishment of IV or IO access is necessary. In the absence of a mechanical rapid infuser or whole blood, a manual rapid infusion method is necessary to restore intravascular volume while preparing for intubation. Although fresh whole blood or O-negative PRBCs are choices in such cases, crystalloid solutions may be the only fluid immediately available.

To note, the authors described that this case received a humeral head IO catheter and rapid infusion of 1000 mL of lactated Ringer′s solution with a manual rapid infusion technique, which improved the blood pressure to 85/40 mmHg and potentially prevented the peri-intubation cardiac arrest. Further, he also received Two units of emergency release O-negative PRBCs by the same method after placement of an 18 G IV. His blood pressure stabilized at 110/60 mmHg, and he received operative care with temporary hemorrhage control achieved using direct pressure. The patient subsequently achieved a full neurologic recovery.

The authors further discuss that Emergency care providers should be aware of the multiple techniques available for providing volume resuscitation in situations where minutes truly matter. Large mechanical rapid infusion devices are good when routinely used and when adequate vascular access is immediately available. In austere environments, during prehospital transport, and in community emergency departments, methods such as a pressure bag, syringe, and stopcock, or a handheld rapid infuser may be the only options, particularly when only smaller-gauge IVs or IO access is available. 

Furthermore, they mentioned that irrespective of the selected infusion method, emergency providers should remember that rapid resuscitation must accompany continuous attention to the patient′s response after each dose of fluid or blood delivered.

This review is a complete guide for Emergency Department physicians who manage critically ill patients with undifferentiated shock.

Source: Piehl M, Park CW. When Minutes Matter: Rapid Infusion in Emergency Care. CurrEmergHosp Med Rep. 2021; 9:116–125. https://doi.org/10.1007/s40138-021-00237-6