HYDRATION AND NUTRITION

Nutrition and hydration are critical for the outcome and survival of trauma patients. Adequate nutrition and hydration are necessary to modulate the catabolic and inflammatory response associated with trauma and critical illness. Early nutrition intervention provides exogenous fuel to support the preservation of lean body mass and attenuate the body’s stress response.3

For reference, the average weight and height of military members are 187 pounds (85 kilograms (kg)) and 69 inches (175 centimeters) for men and 152 pounds (69 kg) and 64 inches (163 centimeters) for women.3 We use these reference weights throughout this section for ease of calculations.

Non-medical Responders

Oral hydration should be provided to any non-intubated casualty that can tolerate it. For reference, the minimum fluid needs for the average male Service Member is 2.6L/day and 2.1 L/day for female Service Members, respectively – approximately 100-125 cc per hour at rest. Injured casualties, including those with burns, wounds, diarrhea, and patients in extreme climates, may require more. As a general rule, if a casualty complains of being thirsty, they are likely dehydrated, and fluid intake should be regularly encouraged.

Hydration by mouth

- Minimum: Potable water as tolerated.
- Better: Potable water + improvised oral rehydration solution (in 1 liter of potable water: ½ tsp of table salt + 5-6 tsp of table/granulated sugar)
- Best: Potable water + commercially available balanced oral rehydration solution. If a commercial oral rehydration solution is not available, the following recipe is optimal:1L Water + 9 tsp sugar + 1 tsp salt + 1 tsp baking soda + ¼ tsp potassium chloride (per Nutrition and Diet Therapy Branch, U.S. Army Medical Center of Excellence)

Nutrition

- Minimum: If casualty is alert, encourage food intake, protein shake, or oral nutrition supplement (ONS) every 4-6 hours
- Better: Casualty consumes 50-70% of meals by mouth. Encourage the use of oral nutrition supplements and high protein food items to help meet their needs. Small, frequent (5-6) meals throughout the day are often better tolerated than three regular meals.
- Best: Casualty consumes at least 75% of their meals by mouth. If casualty cannot consume regular-sized meals, encourage small meals throughout the day. Recommend the use of ONS to supplement intake in order to meet increased nutritional demands.

Medical Responders

Adequacy of hydration should be judged by the amount of urine the casualty is making. Adult casualties’ urinary output should be approximately 0.5 ml/kg/hr.4,5

Hydration via IV or IO

Casualties who are intubated and/or sedated should receive fluids via IV or IO to meet their estimated fluid needs. These fluid needs are in addition to fluids provided for resuscitation. It is recommended to replete the volume of urine output to maintain euvolemic status. If urine output decreases, fluid provided by IV/IO may need to be adjusted/restricted to prevent fluid overload, though it is important to consider fluid losses from other sources including diarrhea, emesis, burns, wound vacs, sweat, etc. Urine color may not be an accurate indicator of hydration status in this population.

- Minimum: Normal saline maintenance infusion, typically around 100-150 mL/hr depending on goal urine output
- Better: Lactated Ringer’s maintenance infusion, typically around 100-150 mL/hr depending on goal urine output
- Best: Plasma-lyte A maintenance infusion, typically around 100-150 mL/hr depending on goal urine output

Nutrition

- Minimum: If casualty is alert, encourage food intake or protein (oral nutrition supplement) shake every 4-6 hours.
- Better: Casualty consumes 50-70% of the meals by mouth. Encourage the use of oral nutrition supplements and high protein food items to help meet their needs. Small, frequent (5-6) meals throughout the day are often better tolerated than three regular meals.
- Best: Casualty consumes at least 75% of their meals by mouth. If casualty cannot consume regular-size meals, encourage small meals throughout the day. Recommend the use of ONS to supplement intake in order to meet their increased nutritional needs.

For casualties who are intubated, please refer to Considerations for Prolonged Field Care section.