Fluid Management in Emergency Settings

Initial Fluid Selection

The American College of Emergency Physicians recommends ordering balanced crystalloids, such as Lactated Ringer's or Plasmalyte, as the first-line fluid choice to reduce mortality and prevent hyperchloremic acidosis 1
Normal saline should be limited to a maximum of 1-1.5 L if used, due to the risk of hyperchloremic metabolic acidosis 2
The Critical Care Society advises against using hypotonic solutions like Ringer's lactate in severe head trauma patients 2

The American Heart Association recommends ordering fluids with specific parameters, including fluid type, volume per bolus, rate of administration, and reassessment triggers 1
For septic patients, the Intensive Care Medicine society suggests ordering Lactated Ringer's 30 mL/kg IV over 3 hours, then reassessing 3, 1
The American College of Emergency Physicians recommends including specific reassessment parameters after the initial bolus, such as heart rate, blood pressure, and respiratory rate 1

The Critical Care Society advises specifying clinical endpoints for nursing staff to monitor and report, including urine output, skin perfusion, and mental status changes 1
The American Heart Association recommends stopping fluids when there is no improvement in tissue perfusion after a bolus, or when signs of fluid overload develop 4, 1
The Intensive Care Medicine society suggests stopping fluids when hemodynamic parameters stabilize, such as mean arterial pressure ≥65 mmHg 3, 1

The American Diabetes Association recommends ordering 0.9% Normal Saline 1 L IV over 1 hour, then 250-500 mL/hr for diabetic ketoacidosis patients 5, 6
The Pediatric Society advises ordering 0.9% Normal Saline 10-20 mL/kg IV over 1 hour, maximum 50 mL/kg over the first 4 hours for pediatric patients [<5, 6]

The American College of Emergency Physicians warns against ordering continuous fluids without specifying reassessment intervals, which can lead to fluid overload 1
The Critical Care Society advises against using normal saline exclusively, as it can cause hyperchloremic acidosis and worse outcomes 2
The American Heart Association recommends avoiding aggressive fluid resuscitation in resource-limited settings without vasopressor/ventilator access 4