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Year : 2007  |  Volume : 51  |  Issue : 6  |  Page : 479-485 Table of Contents     

End points in trauma management

M.D., D.A., F.C.C.P., D.C.C.M., (Cardio) M.C.A.M., Secretary, National Board for Trauma Courses, ITACCS (Indian Chapter), India

Date of Acceptance26-Sep-2007
Date of Web Publication20-Mar-2010

Correspondence Address:
N Ganapathy
Director, Dhanvantri Critical Care Center, 27, 28, Poonkundranar Street, Karungalpalayam, Erode - 638 003, Tamilnadu
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Source of Support: None, Conflict of Interest: None

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Fluid resuscitation following traumatic haemorrhage has historically been instituted as soon after injury as possible. Patients suffering from haemorrhagic shock may receive several liters of crystalloid, in addition to colloid solutions, in order to normalize blood pressure, heart rate, urine output and mental status, which are the traditional endpoints of resuscitation. Current theory and recent investigations have questioned this dogma. Resuscitation goals may be different when the patient is actively haemorrhaging and once bleeding has been controlled. Newer markers of tissue and organ system perfusion may allow a more precise determination of adequate resuscitation

Keywords: Trauma; Resuscitation; Tissue hypoxia; Occult hypoperfusion; Perfusion

How to cite this article:
Ganapathy N. End points in trauma management. Indian J Anaesth 2007;51:479-85

How to cite this URL:
Ganapathy N. End points in trauma management. Indian J Anaesth [serial online] 2007 [cited 2021 Jun 19];51:479-85. Available from: https://www.ijaweb.org/text.asp?2007/51/6/479/61184

   Introduction Top

Severely injured trauma victims are at high risk of development of the multiple organ dysfunction syndrome (MODS) or death. To maximize chances for survival, treatment priorities must focus on resuscitation from shock (defined as inadequate tissue oxygenation to meet tissue O 2 requirements), including appropriate fluid re­suscitation and rapid hemostasis. Inadequate tissue oxy­genation leads to anaerobic metabolism and resultant tis­sue acidosis. The depth and duration of shock leads to a cumulative oxygen debt. [1] Resuscitation is complete when oxygen debt has been repaid, tissue acidosis is elimi­nated and normal aerobic metabolism is restored in all tissue beds. Use of the endpoints may allow early de­tection and reversal of this state.

No fluid resuscitation may lead to death from exsanguinations,whereasaggressivefluidresuscitationmay "pop the clot" and lead to more bleeding. "limited", "hy­potensive", and/or "delayed" fluid resuscitation may be beneficial.

The traditional markers of "successful" resuscita­tion, including restoration of normal blood pressure, heart rate, and urine output, remain the standard of care as per the Advanced Trauma Life Support Course. [2] When these parameters remain abnormal, i.e., uncompensated shock, the need for additional resuscitation is clear. Af­ter normalizing these parameters, up to 85% of severely injured trauma victims still have evidence of inadequate tissue oxygenation based on findings of an ongoing meta­bolic acidosis or evidence of gastric mucosal is­chaemia. [3],[4] This condition has been described as com­pensated shock. Recognition of this state and its rapid reversal are critical to minimize risk of MODS or death.

   Goals of resuscitation Top

  1. Management of resuscitation prior to control of haemorrhage
  2. Management of resuscitation following control of haemorrhage

   Management of resuscitation prior to control of haemorrhage Top

The first priority or sine qua non of any hypoten­sive trauma patient is recognition and control of haemorrhage.

Life threatening haemorrhage occurs into one or more of five compartments.

Possible sites for exsanguinating haemorrhage are shown in [Table 1].

Using computerised tomography (CT) or operative explorationfor occultbleedingmaytake significantamount oftime, duringwhichthepatient will stillbe activelybleed­ing.

   Fluids for control of haemorrhage Top

Fluids must be administered to stave (to stop some­thingbad fromhappening) off exsanguination. Howmuch fluid to give? What kind of fluid? These questions are at the core of modern resuscitation research. Given the analogy of fluid into a bucket with a hole in the bottom, what level of resuscitation produces the best clinical re­sults?

The degree of ischaemia sustained by the body and the duration over which the ischaemia occurs determines the development of multiple organ dysfunction syndrome (MODS) or death. Fluid therapy is directed towards re­establishment and maintenance of a normal blood pres­sure.

   Clinical problems associated with early fluid ad­ministration Top

  1. Is often colder than body temperature producing a thermal stress
  2. Reduces blood viscosity which enhances bleeding from injured vessels
  3. Lowers the hematocrit and dilutes clotting factors and red cell mass
  4. When rapidly infused may impair immune system function [5].

   Choice of resuscitation fluid Top

Research continues to define the ideal fluid for re­suscitation of trauma patients. Isotonic crystalloid solu­tions like 0.9% normal saline and Ringer's lactate rap­idly distribute throughout the extra cellular space and only 10-20% or less of the infused volume remains in the circulation. [6] Isotonic colloids like, albumin, hetastarch and dextran, expands plasma volume either slightly less, equal or more than the infused volume respectively. [7]

   The roleof 7.5% hypertonic saline (HS) in trauma resuscitation Top

There has been substantial interest and extensive pre-clinical experience in evaluating the use of hyper­tonic saline solution for volume support. [8] Hypertonic so­lutions mobilize an amount of cellular water proportional to osmotic load (2,400 mOsm.L -1 ), and increases the plasma volume three to four times the infused volume. This not only tend to reduce overall volume requirement in trauma and perioperative patients but also shows a beneficial effect by shrinking the cell volume, which is a feature of shock and surgical stress. The main source of volume expansion by hypertonic solution is from red blood and endothelial cells and this result in improved microcirculation. The main advantages of hypertonic saline resuscitation includes, haemodynamic effects through combination of volume expansion and decreased vascular resistance which increases regional blood flow to coronary, renal, intestinal and skeletal muscle circula­tion, its effects on lowering intra cranial pressure (ICP) in brain injured patients, [9] especially children, [10] and most recently, multiple studies have suggested its beneficial role in immunomodulation. [11],[12],[13] Based on these evi­dences it has been suggested that resuscitation with hy­pertonic saline (HS) present significant potential as an immunomodulatory agent for trauma victims. The in­crease in plasma volume by HS infusions occurs imme­diately but this response is short lived. The addition of dextran to hypertonic saline (HSD) not only provides slightly better volume expansion; but more importantly, it provide sustained volume expansion. [14],[15]

In summary, HS/HSD can be used safely for rapid and sustained resuscitation of trauma patient particularly for penetrating trauma requiring surgery and for those sustaining head trauma, as this may also reduce cere­bral oedema in patients with severe head injuries. Cau­tion should be exercised when treating moribund patient or those with chronic debilitating diseases.

   To summarise Top

  1. The hypotensive trauma patients at the time of medi­cal intervention has usually stopped bleeding and has formed a soft clot at the point of injury. This clot is maintained in place by systemic vasoconstric­tion and low blood pressure both of which can be easily overcome by a crystalloid bolus intend to raise the blood pressure.
  2. Attempting to achieve normal blood pressure in the actively bleeding patients is associated with disrup­tion of native hemostatic mechanisms, dilution of clotting factors and red cell mass, greatly increased blood loss and decreased survival. [16],[17],[18]
Benefits and risks of early aggressive prehospital fluid resuscitation in trauma [19] are shown in [Table 2].

   Goals of early resuscitation Top

The physician treating patient with early shock should sail a narrow course between tolerating a low blood pressure, particularly early in the patient's clinical course, while keeping a watchful eye on the indicators which will suggest that ischaemia is advancing too far.

The recommendations for resuscitation in patients who are still actively haemorrhaging are:

Blood pressure 80 systolic, 50-60 mean

Heart rate Less than 120

Oxygenation Oximeter should be working, saturation > 96%

Urine output > 20 cc.hr -1

Mentation Patients should follow com­mands accurately

Lactate level < 4mg.dl -1

Base deficit < - 5

Hematocrit 30%

   Clinical practice guideline Top

Resuscitation endpoints Global

1. Oxygen delivery

  • Supranormal oxygen
  • Mixed venous oxygen saturation (SvO 2 )
2. Haemodynamic profiles

  • Central venous pressure (CVP)
  • Pulmonary capillary wedge pressure (PCWP)
  • Right ventricular end diastolic volume index (RVEDVI)

3. Acid-base status

  • Bicarbonate concentrations
  • Arterial lactate
  • End-tidal carbon dioxide levels


1. Tissue oxygenation and partial pressure of carbon dioxide (PCO
2 )

  • Tissue oxygen and carbon dioxide electrodes
  • Near infrared spectroscopy

2. Gastric mucosal ischaemia

  • Gastric tonometry
  • Sublingual monitoring of the partial pressure of carbon dioxide
  • Physical examination

Major outcomes considered
  • Survival without organ system dysfunction
  • Risk for multiple organ dysfunction syndrome or death
  • Physiologic derangement

   Oxygen delivery Top

In high risk trauma patients the survivors had sig­nificantly higher O 2 delivery and cardiac index (CI) val­ues than the non survivors. [20],[21] The parameters are: CI (>4.5 L.min -1 .m -2 ), O 2 delivery (DO 2 ³ 600 mL.min -1 .m -2 ) and O 2 consumption (VO 2 ³ 170 ml.min -1 .m -2 ). Using these parameter as goals of resuscitation resulted in de­creased compliance, length of stay and hospital costs. [22] Adding to "ABCs" of resuscitation "D" for delivery of O 2 and "E" for ensuring exraction and utilization of O 2 by tissues was included. [23] Attaining supranormal haemodynamic parameters improved survival and de­creased the frequency of organ failure. [24] Oxygen deliv­ery was augmented by volume overloading, followed by obutamine infusion if necessary and finally blood trans­fusion upto haemoglobin of 14 gm.dL -1 .

   Mixed venous oxygen saturation Top

Use of mixed venous O 2 saturation (SvO 2 ) levels should reflect the adequacy of O 2 delivery to tissue in relation to global tissue O 2 demands. Resuscitated pa­tients to a normal CI (2.5 - 3.5 L.min -1 .m -2 ), supernor­mal CI (>4.5 L.min -1 .m -2 ), or normal SvO 2 (>70%) do not result in MODS or death.

   Additional invasive haemodynamic parameters Top

Occult cardiac dysfunction is seen in many trauma patients. Early invasive haemodynamic monitoring ofhigh risk trauma victims identified occult shock early and may have helped to prevent MODS and death. [25] Fluid resus­citation is the primary treatment for trauma patients in haemorrhagic shock and the indicator of adequate vol­ume status is optimized preload. CVP and PCWP have limitations in critically ill patients due to changes in ven­tricular compliance (edema, ischaemia or contusion) and intrathoracic pressure (mechanical ventilation). In these situations RVEDVI may more accurately reflect left ven­tricular preload than CVP or PCWP. CI correlates bet­ter with RVEDVI than PCWP up to very high levels of positive end-expiratory pressure.

The haemodynamic variables left ventricular stroke work index (LVSWI = stroke index x mean arterial pres­sure x 0.0144) and left ventricular power output (LVP = cardiac index x [mean arterial pressure - central venous pressure]), that encompass blood pressure and flow with purely flow-derived haemodynamic and O 2 transport vari­ables are predictors of outcome in critically ill trauma patients. [26] The only variables that significantly corre­lated with lactate clearance and survival were heart rate, LVSWI and LVP. The desired value of LVP (>320 mm Hg x L.min -1 .m -2 ).

   Arterial base deficit Top

Inadequate tissue O 2 delivery leads to anaerobic metabolism. The degree of anaerobiosis is produced to the depth and severity of haemorrhagic shock. This should be reflected in the base deficit and lactate level.Arterial pH is not as useful as it will be "defended" by the body's compensatory mechanisms. [27] Higher base deficit was associated with lower blood pressure on admission and greater fluid requirements. Base deficit is classified as mild (base deficit 2-5 mmol.L -1 ) moderate, (base deficit 6-14 mmol.L -1 ), or severe (base deficit > 14 mmol.L -1 ). Patients with an increasingbase deficit had ongoing blood loss. [28] Trauma patients who normalized their lactate lev­els; persistently high base deficit had greater risk of MODS and death. These patients demonstrated impaired O 2 utilization, as evidenced by lower O 2 consumption and O 2 utilization coefficient. [29] Using base deficit, core temperature and ISS (Injury Severity Score), could pre­dict outcome. Severe hypothermia (<33degree C), se­vere metabolic acidosis (base deficit > 12 mmol.L -1 ), and a combination (temperature <35.5 degree C and base deficit >5 mmol.L -1 ) were strong predictors of death. [30] Elevated base deficit is not only predictive of mortality, but of complications, such as the need for blood transfu­sions and organ failure, particularly the acute respira­tory distress syndrome (ARDS). [31] Base deficit levels may be confounded by a number of factors.Alcohol intoxica­tion can worsen base deficit for similar levels of injury severity and haemodynamics after trauma. Development of a hyperchloremic metabolic acidosis from resuscita­tion with normal saline or lactated Ringer's solution can increase base deficit for the same degree of injury se­verity. [32] Administration of sodiumbicarbonate will at least transiently improve base deficit and bicarbonate levels and confound their use as endpoints for resuscitation. There is little role for sodium bicarbonate in the treat­ment of haemorrhagic shock.

   Arterial lactate Top

In patients with noncardiogenic circulatory shock not only were initial lactate levels important, but the re­sponse of the lactate level to an intervention, such as fluid resuscitation, would add predictive value. [33] The time needed to normalize serum lactate levels was an impor­tant prognostic factor for survival. [34] The patients were resuscitated to supranormal values of O 2 transport. [35] All patients who had normalized lactate levels at 24 hours survived. Those patients who normalized their levels be­tween 24 and 48 hours had a 25% mortality rate. Pa­tients who did not normalize by 48 hours had an 86% mortality rate. The initial and peak lactate levels, as well as the duration of hyperlactatemia, correlates with de­velopment of MODS after trauma. [36] The desired value of lactate is less than 2.5 mmol.L -1 . Serial measurement of lactate is recommended. It can be easily measured. Lactate clearance may be decreased with liver dysfunc­tion or sepsis.

   End-tidal carbon dioxide levels Top

Reduced cardiac output and/or abnormal distribu­tion of pulmonary blood flow can lead to increased pul­monary dead space. This can then lead to an increase in the difference between arterial and alveolar CO 2 , as mea­sured by end-tidal CO 2 . Survivors had higher end-tidal CO2, lower arterial-end tidal CO 2 differences, and de­crease alveolar dead space ratio (estimated as the arte­rial-end tidal CO 2 difference/arterial PCO 2 ) compared to nonsurvivors. [37]

   Gastric tonometry Top

On the regional level, compensated shock dispro­portionately decreases blood flow to the splanchnic bed to maintain cerebral and coronary blood flow. Examina­tion of the gut-related parameters may be useful as a marker of the severity of shock and also to demonstrate the pathophysiologic connection between gut ischaemia and later MODS. Gastric ischaemia is monitored using gastric tonometry.

Hypercabia is a universal indicator of critically re­duced tissue perfusion. Management of gastric PCO 2 (PgmCO 2 ) and intramucosal pH (pHi) through gastric tonometry is used in trauma patients as an indicator of restoration of blood flow. pHi correlated with sepsis score. Lower pHi correlated with development of MODS and increased mortality in critically ill patients, particularly if the low pHi persisted for >12 hours. Gastric pHi is 7.4. pHi <7.32 is a good predictor of MODS and mortality. [38]

The esophageal wall is also an important site for tissue PCO 2 measurement in haemorrhagic shock. The most proximal area of the gastrointestinal tract, the sub­lingual mucosa has become a useful site for measure­ment of PCO 2 (PSLCO 2 ) recently. The normal value of PSLCO2 is 45 mm Hg.

   Tissue oxygen and carbon dioxide electrodes Top

Skeletal muscle blood flow decreases early in the course of shock and is restored late during resuscitation, making skeletal partial pressure of oxygen a sensitive in­dicator for low flow. A fibreoptic probe with pH, PCO 2 and PO 2 sensors are placed directly into the muscle. The probe is inserted through a 20 gauge radial artery cannula sutured to the skin and extends 1cm beyond the cannula tip with the sensors in the interstitium of the skeletal muscle. Continuous monitoring of pHm, PmCO 2 . PmO 2 should reflect the gradient of these variables between intravas­cular and intracellular and not between arterial and mixed venous blood. The desired values are pHm = 7.2; PmCO 2 = 50 mm Hg; PmO 2 = 40 mm Hg; The critical PmO2 = 15 mm Hg is threshold for anaerobic metabolism.

   Near infrared spectroscopy (NIRS) Top

Measurement of skeletal muscle oxyhaemoglobin levels by NIRS offers a non-invasive method for moni­toring adequacy of resuscitation in terms of normalizing tissue oxygenation. In human volunteers donating 470ml of whole blood, cerebral cortex and calf muscle O 2 satu­ration measured by NIRS decreased in proportion to blood loss. The oxygenation index ([oxygenated haemoglobin] - [deoxygenated haemoglobin]) also decreased propor­tionally. [39] In addition to monitoring tissue oxygenation, NIRS can provide information regardingmitochondrial function. Normally, tissue oxyhaemoglobin levels, reflect­ing local O 2 supply, are tightly coupled to cytochrome a, a 3 redox, reflecting mitochondrial O 2 consumption. [40]

   Physical examination Top

Despite all the interest in laboratory values, as well as data from invasive and non-invasive monitoring de­vices, used to determine the adequacy of resuscitation, one should not discount the value of a good physical ex­amination. Kalpan, et al, examined the ability of 2 intensivists to diagnose hypoperfusion by physical ex­amination of patients' extremities. [41] The intensivists de­scribed the patients' extremities as either warm or cool. Compared with patients with warm extremities, those with cool extremities had lower CI, pH, bicarbonate lev­els, and SvO2; and higher lactate levels.

   Future investigation Top

Prevention of organ ischaemia or damage may be possible in the next millenium through the administration of agents which regulate cellular function. Future possi­bilities in traumatic shock management include manipu­lation of shock-related pathophysiological alterations such as complement and granulocyte activation, endothelial activation, leukostasis and edema formation with result­ant organ injury. These may be possible through the use of oxygen carriers (fluorocarbons and modified haemoglobins), antioxidants, nitric oxide scavengers and anti-endotoxin compounds.

The search for the "holy grail", i.e., a single end­point that works for all trauma patients, may be unrealis­tic. For example, acid-base parameters may not work in patients with acid-base disturbances that are acute (alco­hol intoxication) or chronic (renal failure). For older pa­tients, beta-blockade and heart rate control may be valu­able and use of inotropes that increase myocardial work along with massive volume loading may be detrimental.

   Conclusion Top

Fluid resuscitation is an integral, mandatory com­ponent of the management of the patient in shock from traumatic haemorrhage. The classic theory of instituting resuscitative fluids early following injury is now being disputed.Adequacy of resuscitation is no longer judged by the presence of normal vital signs, but by the achieve­ment of normalization of organ and tissue specific mea­sured values. The role of the anaesthesiologist and intensivist is to recognize the presence of shock follow­ing traumatic haemorrhage and to resuscitate the pa­tient with the appropriate fluid, in the appropriate amount, at the appropriate time.

   References Top

1.Shoemaker WC, Appel PL, Kram HB. Tissue oxygen debt as a determinant of lethal and nonlethal postoperative organ failure. Crit Care Med 1988; 16:1117-20.  Back to cited text no. 1  [PUBMED]    
2.Bickell WH, Wall Jr MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with pen­etrating torso injuries. N Engl J Med 1994; 331:1105-1109.  Back to cited text no. 2      
3.Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resusci­tation during active haemorrhage: impact on in-hospital mor­tality. J Trauma 2002; 52:1141-1146.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]  
4.American College ofSurgeons Committee on Trauma:Advanced Trauma Life Support Course for Doctors, 1997.American Col­lege of Surgeons, Chicago, IL, USA.  Back to cited text no. 4      
5.Knoferl MW, Angele MK, Ayala A, Cioffi WG, Bland K, Chaudry IH. Do different rates of fluid resuscitation adversely or beneficially influence immune reponses after trauma hemor­rhage? J Trauma 1999;46:23-30.  Back to cited text no. 5      
6.Hambly PR, Dutton RP. Excess mortality associated with the use of rapid infusion system at a level 1 trauma center. Resus­citation 1996;31:127-133.  Back to cited text no. 6      
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10.McKinely BA, Parmely CL, Butler BD. Skeletal muscle PO2,PCO 2 and pH in hemorrhage, shock and resuscitation in dogs.J Trauma 1998; 44:119-127.  Back to cited text no. 10      
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13.Puyana JC, Soller BR, Zhang SB, Heard SO. Continuous mea­surement of gut pH with near-infrared spectroscopy during hemorrhagic shock. J Trauma 1999; 46:914.  Back to cited text no. 13      
14.SatoY, Weil MH, Tang W, et al. Esophageal PCO2 as a monitor of perfusion failure during hemorrhagic shock. J Appl Physiol 1997; 82:558-562.  Back to cited text no. 14      
15.Weil MH, Nadagawa Y, Tang W, et al. Sublingual capnometry: a new noninvasive measurement for diagnosis and quantitation of severity of circulatory shock. Crit Care Med 1999; 27:1225-1229.  Back to cited text no. 15      
16.Burris D, Rhee P, Kaufman C, et al. Controlled resuscitation for uncontrolled hemorrhagic shock. J Trauma 1999; 46:216-222.  Back to cited text no. 16      
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27.Chang MC, Cheatham ML, Nelson LD, Rutherford EJ, Morris JA. Gastric tonometry supplements information provided by systemic indicators of oxygen transport. J Trauma 1994; 37:488-94.  Back to cited text no. 27      
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29.Kincaid EH, Miller PR, Meredith JW, Rahman N, Chang MC. Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization. J Am Coll Surg 1998; 187:384-392.  Back to cited text no. 29  [PUBMED]  [FULLTEXT]  
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31.Davis JW, Parks SN, Kaups KL, Gladen HE, O'Donnell-Nicol S. Admission base deficit predicts transfusion requirements and risk of complications. J Trauma 1996; 41:769-774.  Back to cited text no. 31  [PUBMED]  [FULLTEXT]  
32.Brill SA, Schreiber MA, Stewart TR, Brundage SI. Base deficit does not predict mortality when secondary to hyperchloremic acidosis. Shock 2002; 17:459-462.  Back to cited text no. 32      
33.Vincent J-L, Dufaye P, Berre J, Leeman M, Degaute J-P, Kahn RJ. Serial lactate determinations during circulatory shock. Crit Care Med 1983; 11:449-451.  Back to cited text no. 33      
34.Abramson D, Scalea TM, Hitchcock R, et al. Lactate clearance and survival following injury. J Trauma 1993; 35:584-589.  Back to cited text no. 34  [PUBMED]    
35.Shoemaker WC, Appel P, Bland R. Use of physiologic moni­toring to predict outcome and to assist in clinical decisions in critically ill postoperative patients. Am J Surg 1983; 146:43-38.  Back to cited text no. 35  [PUBMED]  [FULLTEXT]  
36.Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent J-L. Cor­relation of serial blood lactate levels to organ failure and mortal­ity after trauma. Am J Emerg Med 1995; 13:619-622.  Back to cited text no. 36      
37.Tyburski JG, Collinge JD, Wilson RF, et al. End-tidal CO2­derived values during emergency trauma surgery correlated with outcome: A prospective study. J Trauma 2002; 53:738-743.  Back to cited text no. 37  [PUBMED]  [FULLTEXT]  
38.Chang MC, Cheatham ML, Nelson LD, Rutherford EJ, Morris JA. Gastric tonometry supplements information provided by systemic indicators of oxygen transport. J Trauma 1994; 37:488-94.  Back to cited text no. 38      
39.Torella F, Cowley RD, Thorniley MS, McCollum CN. Re­gional tissue oxygenation during haemorrhage: can near infrared spectroscopy be used to monitor blood loss? Shock 2002; 18:440-444.  Back to cited text no. 39  [PUBMED]  [FULLTEXT]  
40.Cairns CB, Moore FA, Haenel JB, et al. Evidence for early supply independent mitochondrial dysfunction in patients de­veloping multiple organ failure after trauma. J Trauma 1997; 42:532-6.  Back to cited text no. 40  [PUBMED]  [FULLTEXT]  
41.Kaplan LJ, McPartland K, Santora TA, Trooskin SZ. Start with a subjective assessment of skin temperature to identity hypoperfusion in intensive care unit patients. J Trauma 2001; 50:620-628.  Back to cited text no. 41  [PUBMED]  [FULLTEXT]  


  [Table 1], [Table 2]


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    Goals of resusci...
    Management of re...
    Fluids for contr...
    Clinical problem...
    Choice of resusc...
    The roleof 7.5% ...
    To summarise
    Goals of early r...
    Clinical practic...
    Oxygen delivery
    Mixed venous oxy...
    Additional invas...
    Arterial base de...
    Arterial lactate
    End-tidal carbon...
    Gastric tonometry
    Tissue oxygen an...
    Near infrared sp...
    Physical examination
    Future investigation
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