The Bellamy challenge: it's about time

Abstract

In 1984, Col. Ronald Bellamy launched a worldwide challenge to develop a new resuscitation fluid to aid survival after catastrophic blood loss on the battlefield. In 1996, after careful compromise among need, cube weight and efficacy, the US military and later coalition forces adopted 6% hetastarch (HES) fluids for early resuscitation. In the intervening years, evidence has amassed indicating that the HES fluids may not be safe, and in June 2013 the US Food and Drug Administration issued a warning that HES solutions should not be used to treat patients with hypovolaemia or the critically ill. We review the unique challenges of early battlefield resuscitation, why the 'Bellamy challenge' remains open and discuss a number of forward-looking strategies that may help to solve the problem. The first two pillars of resuscitation that we believe have not been adequately addressed are rescuing and stabilising the heart (and brain) and the vascular system. The 'ideal' resuscitation fluid needs to nurture the heart and body slowly back to health, and not 'shock' it a second time with unnatural colloids or large volumes of unphysiological saline-based solutions.

Mechanisms of early trauma-induced coagulopathy

“…It is a sobering thought when considering TIC and the crosstalk between coagulation and inflammation that there are an estimated 100,000 TM molecules 9 and up to 20,000,000 annexin II molecules (which bind tPA and plasminogen) located on each of the 10 13 endothelial cells lining all blood and lymphatic vessels 74 within the body covering a surface area of 3,000 to 7,000 m 2 (up to the size of an NFL football field!). 75,76 The endothelial TM-thrombin complex and fibrinolytic system are attractive drug targets because they can ''switch'' from a fibrinolytic to antifibrinolytic phenotype, and vice versa, in seconds to minutes, as shown with the use of clot-busting agents such as alteplase or antifibrinolytic tranexamic acid. 77 Finding the right balance in restoring homeostasis in vivo remains the ongoing challenge in the diagnosis and treatment of early coagulopathy following trauma.…”

Correction of acute traumatic coagulopathy with small-volume 7.5% NaCl adenosine, lidocaine, and Mg2+ occurs within 5 minutes

“…8 In trauma patients, coagulopathy has been associated with an increased incidence of multiple-organ failure and a fourfold increase in mortality. 12,13 The two major hypotheses to explain the early hemorrhagic phenotype are (1) the disseminated intravascular coagulation (DIC) hypothesis with fibrinolysis, 14 and (2) the thrombomodulinYthrombinYprotein C hypothesis. 12,13 The two major hypotheses to explain the early hemorrhagic phenotype are (1) the disseminated intravascular coagulation (DIC) hypothesis with fibrinolysis, 14 and (2) the thrombomodulinYthrombinYprotein C hypothesis.…”

Volume Resuscitation in the Acutely Hemorrhaging Patient: Historic Use to Current Applications

“…In human medicine, acute hemorrhage and its sequelae are the leading cause of preventable death in military and civilian settings ( 3 ). Over the last century, the approach to fluid resuscitation of the bleeding patient has gone through many iterations, frequently fueled by battlefield lessons, including whole blood transfusion (WWI), component therapy (WWII), synthetic and natural colloid fluids (Korean War), large volume crystalloid (Vietnam), back to whole blood (Iraq/Afghanistan conflicts) and coagulation testing guided component therapy ( 4 , 5 ).…”