ASSESSING RESPONSE TO RESUSCITATION

Overview

Assessing response to resuscitation is a dynamic process that is most accurate when all available data are used to paint a composite picture of the casualty. This whole picture is more accurate than any single normal (or abnormal) component.

Casualties will follow one of three trajectories in response to resuscitation: responder, transient responder, or nonresponder.

1. Responder: Clinical and objective trends improve after resuscitation and remain stable.
2. Transient responder: Trends improve after resuscitation, then decline. This decline should prompt reassessment of hemostatic procedures, assessment for missed hemorrhage, assessment of acidosis or hypothermia, and a trial of repeated resuscitation. If bleeding and factors that affect coagulopathy are controlled, transient responders will likely respond to more resuscitation. A subset of transient responders includes casualties with slow, noncompressible hemorrhage for whom resuscitation can “keep up” with blood loss until surgical hemostasis can be obtained, provided casualty has access to enough blood products and surgery can be obtained.
3. Nonresponder: Trends do not improve or continue to worsen after initial trial of resuscitation. Before declaring a casualty to be a nonresponder, reassess hemostatic procedures, assess for missed sources of bleeding, and decompress both sides of the chest (needle decompression/finger thoracostomy/tube thoracostomy). Assess for pericardial tamponade by ultrasound or as a last resort, blind pericardiocentesis. If major bleeding cannot be controlled, it is not likely that the casualty will respond; this includes noncompressible torso hemorrhage where it is not possible for resuscitation to replace blood loss. If factors affecting coagulopathy (e.g., acidosis and hypothermia) cannot be corrected (with resuscitation and rewarming), it is also unlikely that the casualty will respond.

Note: If a casualty does not respond to resuscitation, a decision must be made whether to continue resuscitative efforts. If the casualty has worsened, further resuscitation is likely futile. If they have not responded but not worsened, a trial of additional resuscitation if resources are available can be considered to assess whether the initial resuscitation was insufficient.

Managing a nonresponding casualty is a complex decision that must balance availability of medical resources, demand of other casualties (or contingencies) for those resources, ability of the team to continue the effort of resuscitation, and other factors. It is highly advised to manage in consultation with medical experts (e.g., by telemedicine discussion).