A call for disciplined patience instead of crystalloid infusion for the trauma patient.

Hemorrhage is the leading cause of death in combat and in civilian trauma. In the interval between recognizing that a patient is in hemorrhagic shock and having blood to transfuse into the patient, a trauma team member will invariably ask the trauma team leader whether to give the patient a bolus of crystalloid fluid while awaiting blood. What should a trauma team leader do in the face of persistent hypotension during the wait for blood product delivery? Multiple approaches are possible, including the watch-and-wait approach, the judicious administration of crystalloid, or a brief infusion of vasoactive medications. The use of a refrigerator to store O-negative packed red blood cell units for immediate use is ideal where possible. Early activation of whole blood programs in combat environments is also advisable. Unfortunately, a situation in which a trauma patient is in hemorrhagic shock without immediately available blood products may still arise. The administration of crystalloid is not benign and in many circumstances may be harmful, particularly in large volumes. The dilution of clotting factors, unintentional hypothermia, and increased rate of bleeding may be deleterious to trauma patients. A judicious crystalloid bolus may be justified in specific circumstances, such as avoidance of hypotension in head-injured patients. Even in these circumstances, vasoactive medications may be preferred if available. For those long minutes between a diagnosis of hemorrhagic shock and blood transfusion, disciplined patience, rather than crystalloid, may be what is needed.