i. Any significant extremity or truncal wound (neck, chest, abdomen, and
pelvis), with or without obvious blood loss or hypotension, may require intravenous
(1) If the casualty is coherent and has a palpable radial pulse, blood loss
has likely stopped. Initiate a saline lock, hold fluids, and re-evaluate as frequently as
the situation allows.
(2) If there is significant blood loss from any wound and the casualty has no
radial pulse or is not coherent, STOP THE BLEEDING by whatever means available
(tourniquet, direct pressure, hemostatic dressing [HemConTM], or hemostatic powder
[QuikClot]). However, greater than 90 percent of hypotensive casualties suffer from
truncal injuries that are not corrected by these resuscitative measures. These
casualties will have lost a minimum of 1,500 ml of blood (30 percent of their circulating
volume). After hemorrhage is controlled to the extent possible, start 500 ml of
Hextend. If mental status improves and the radial pulse returns, maintain the saline
lock and hold fluids.
(3) If no response is seen, within 30 minutes, give an additional 500 ml. of
Hextend and monitor vital signs. If no response is seen after 1,000 ml of Hextend,
consider triaging supplies and giving attention to more salvageable casualties.
Remember, this amount is equivalent to more than 6 liters of Ringer's lactate.
(4) Because of the need to conserve existing supplies, no casualty should
receive more than 1,000 ml of Hextend.
(5) Uncontrolled thoracic or intra-abdominal hemorrhage needs rapid
evacuation and surgical intervention. If this is not possible, determine the number of
casualties verses the amount of available fluids. If supplies are limited or casualties are
numerous, determine if fluid resuscitation is recommended.
A number of studies involving uncontrolled hemorrhage models have clearly
established that aggressive fluid resuscitation in the setting of unrepaired
vascular injury is either of no benefit or results in an increase in blood loss
and/or mortality when compared to no fluid resuscitation or hypotensive
resuscitation. Several studies noted that only after uncontrolled hemorrhage
was stopped did fluid resuscitation prove to be of benefit.
j. Dress wounds to prevent further contamination and help hemostasis.
Emergency trauma dressings (Israeli bandages) are ideal for this. Check for additional
wounds (exit wounds) since the high velocity projectiles from modern assault rifles may
tumble and take erratic courses when traveling through tissues, often leading to exit
sites that are remote from the entry wound.