The resuscitation fluids of choice for casualties in hemorrhagic shock, listed from most to least preferred, are: whole blood^; plasma, RBCs and platelets in 1:1:1 ratio^; plasma and RBCs in 1:1 ratio; plasma or RBCs alone; Hextend; and crystalloid (Lactated Ringers or Plasma-Lyte A).
Assess for hemorrhagic shock (altered mental status in the absence of brain injury and/or weak or absent radial pulse).
If not in shock:
No IV fluids are immediately necessary.
Fluids by mouth are permissible if the casualty is conscious and can swallow.
If in shock and blood products are available under an approved command or theater blood product administration protocol:
Resuscitate with whole blood^, or, if not available
Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
Plasma and RBCs in 1:1 ratio, or, if not available;
Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.
If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:
Resuscitate with Hextend, or if not available;
Lactated Ringers or Plasma-Lyte A;
Reassess the casualty after each 500 mL IV bolus;
Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
Discontinue fluid administration when one or more of the above end points has been achieved.
If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.
If not in shock:
No IV fluids are immediately necessary.
Fluids by mouth are permissible if the casualty is conscious and can swallow.
If in shock and blood products are available under an approved command or theater blood product administration protocol:
Resuscitate with whole blood^, or, if not available
Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
Plasma and RBCs in 1:1 ratio, or, if not available;
Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.
If in shock and blood products are not available under an approved command or theater blood product administration protocol due to tactical or logistical constraints:
Resuscitate with Hextend, or if not available;
Lactated Ringers or Plasma-Lyte A;
Reassess the casualty after each 500 mL IV bolus;
Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
Discontinue fluid administration when one or more of the above end points has been achieved.
If a casualty with an altered mental status due to suspected TBI has a weak or absent peripheral pulse, resuscitate as necessary to restore and maintain a normal radial pulse. If BP monitoring is available, maintain a target systolic BP of at least 90 mmHg.
Reassess the casualty frequently to check for recurrence of shock. If shock recurs, recheck all external hemorrhage control measures to ensure that they are still effective and repeat the fluid resuscitation as outlined above.
No IV fluids are immediately necessary.
Fluids by mouth are permissible if the casualty is conscious and can swallow.
Resuscitate with whole blood^, or, if not available
Plasma, RBCs and platelets in a 1:1:1 ratio*, or, if not available
Plasma and RBCs in 1:1 ratio, or, if not available;
Reconstituted dried plasma, liquid plasma or thawed plasma alone or RBCs alone;
Reassess the casualty after each unit. Continue resuscitation until a palpable radial pulse, improved mental status or systolic BP of 80-90 mmHg is present.
Resuscitate with Hextend, or if not available;
Lactated Ringers or Plasma-Lyte A;
Reassess the casualty after each 500 mL IV bolus;
Continue resuscitation until a palpable radial pulse, improved mental status, or systolic BP of 80-90 mmHg is present.
Discontinue fluid administration when one or more of the above end points has been achieved.
^Neither whole blood nor apheresis platelets as these products are currently collected in theater are FDA-compliant. Consequently, whole blood and 1:1:1 resuscitation using apheresis platelets should be used only if all of the FDA-compliant blood products needed to support 1:1:1  resuscitation are not available, or if 1:1:1 resuscitation is not producing the desired clinical effect."
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