As has been alluded to above, the issue of neuro trauma remains poorly resolved. In the prehospital phase, it is generally accepted that, in the absence of active bleeding, more aggressive resuscitation may be appropriate than in other forms of trauma. Where there is a conflict of interests in a bleeding patient who also has suffered neurological injury, the situation is much less clear, but most authorities would recommend a higher arterial pressure (SBP >100 mmHg) in the prehospital phase [37]. Once the patient is in hospital, similar principles apply, with damage control resuscitation being appropriate inpatients requiring massive transfusion. Aggressive management including resuscitation with blood products and hyperosmolar therapy in gunshot wounds of the brain was associated with significant improval in survival in a recent report [93]. In less seriously bleeding patients, fluid resuscitation should probably be minimised and there is an argument in favour of hypertonic solutions, although these have not been shown to be beneficial. On the basis of subgroup analysis of the SAFE study [76] albumin was suggested to be associated with a worse outcome in head injured patients, probably on the basis of increased intracranial pressure [94]. However, the albumin used in this study was substantially hypo-osmolar with an osmolality of around 260 mosm/L [65] quite sufficient to account for worse intracranial pressures in the albumin group. Other studies of the use of HES or albumin in head injured patients have not demonstrated similar increases in intracranial pressure [95]. A retrospective study of 93 patients with severe traumatic brain injury investigated the impact of a resuscitation protocol that incorporated the use of albumin. These authors reported an early achievement of negative fluid balance in these patients with well maintained plasma albumin concentrations. Over the first 10 days for which the patients were studied, colloids constituted 40–60 % of the total fluids given daily and fluid balance was assisted by the use of furosemide. Mortality at 28 days and 18 months was 11 % and 14 % respectively. The authors contrast this with the SAFE study. In the Scandinavian study, [96] mortality in the study group was substantially lower than that in the SAFE study, but these comparisons should be viewed with caution as the resuscitation strategies, particularly the management of intracranial pressure may well have been different between the study groups. However, a reappraisal of the use of albumin in brain injury has recently been advocated [97].

Fluid resuscitation formulas, such as the Parkland formula, have found wide application around the world and form the basis for calculation of fluid resuscitation regimes in burnt patients. There have been a number of recent papers examining the use of fluids in patients suffering burns, emphasising that most patients end up receiving crystalloids well in excess of the calculated needs. This fluid overload has been called “fluid creep” and associated with worsening of burn oedema, conversion of superficial into deep burns, and compartment syndromes [98].

A recent review of this topic commented that, while crystalloid fluid has been the mainstay of resuscitation for the better part of four decades, there has been a progressive but as yet unexplained recent trend toward provision of resuscitation volumes well in excess of those predicted by the formula. This increased fluid load has been associated with numerous oedema-related complications. This review emphasizes that, in burns involving >25 % body surface area capillary, capillary permeability is increased, not only in the damaged tissue, but also in non-burnt areas. It was proposed that correction of fluid creep will likely revolve around several strategies, which may include tighter control of titration, re-emergence of colloids and hypertonic salt solutions, and possibly the use of adjunctive markers of resuscitation other than urinary output [99]. In a subsequent retrospective review, the same author concluded that this trend had not improved and that, over an 8-year period, higher than recommended urine output had been attained as a result of increased crystalloid administration [100].

In one publication, the role of hyperoncotic 10 % HES 200/0.5, was examined in a pilot trial of 30 patients. Although the numbers are small, the study was abandoned as the hyperoncotic starch was associated with an apparent increased incidence of fatal outcome [101]. These data underline the view that there is virtually no place for hyperoncotic colloids as acute resuscitation solutions. However, a number of other studies and reviews suggest that the role of colloids in the resuscitation of patients suffering burns is being re-examined.

Another review concluded that starch colloids may limit burn oedema by ameliorating capillary leak and that improved endpoints for resuscitation may help to minimize the problems of over-resuscitation [98]. A further retrospective review examined the effect of adding albumin to the resuscitation fluid strategy on fluid input/output (I/O) ratios. The administration of albumin rapidly reduced hourly fluid requirements, restored normal I/O ratios and ameliorated fluid creep [102]. A study in paediatric burns confirmed these findings showing that the use of albumin restored a normal I/O ratio in paediatric patients, adding further weight to the inclusion of colloid in burns resuscitation strategies [103].

In recent years there has been a marked shift in the concepts governing trauma resuscitation, with modern views startlingly resembling the initial findings in the First World War. In patients with severe trauma requiring massive transfusions (<10 % of all trauma patients) aggressive damage-control resuscitation and surgery carries the prospect of reducing mortality particularly amongst battle casualties with penetrating injuries. In the civilian population, these data are less conclusive, but the principles are probably still valid. Prehospital resuscitation now focuses on minimal fluid interventions with low volumes of crystalloid as the first line fluid approach. Once the patient reaches hospital, more aggressive fluid resuscitation strategies may be appropriate. In patients requiring less than massive transfusion, substantial portions of the resuscitation volume should be administered with clear fluids. No more than 2–3 L of such fluid should be given as crystalloid, preferably as a balanced crystalloid that is isotonic with plasma. The use of colloids in penetrating trauma seems to be beneficial, but there is insufficient data at present in blunt trauma and burns to make soundly-based recommendations.