Fluid management in the emergency patient

1. Immediate assessment

• Hypotension, tachycardia, cold peripheries, delayed capillary refill
• Altered mental status, oliguria
• Raised lactate or metabolic acidosis
• Bleeding, vomiting, diarrhoea, burns, sepsis, dehydration
• Signs of fluid overload: raised JVP, pulmonary crackles, peripheral oedema, hypoxia

2. Choose the fluid by cause

3. Adult fluid-resuscitation method

1. Give 500 mL isotonic crystalloid over less than 15 minutes.
2. Reassess immediately using ABCDE.
3. If still fluid responsive and no overload, repeat 250-500 mL aliquots.
4. If more than approximately 2 L is needed, or the cause is uncertain, escalate to senior/emergency-critical care support and reassess the diagnosis.

• Mental state and skin perfusion
• Heart rate, BP, pulse pressure
• Capillary refill and extremity temperature
• Respiratory rate, SpO₂, lung auscultation
• Urine output, usually target at least 0.5 mL/kg/hour in adults
• Lactate trend and acid-base status
• Bedside ultrasound where expertise is available, including cardiac function, lungs, IVC, and passive-leg-raise response

4. Do not miss the major exceptions

Haemorrhagic shock

• Priority: haemorrhage control, rapid transport to definitive care, warming, tranexamic acid where indicated, and early blood products.
• Avoid large crystalloid volumes because they can worsen dilutional coagulopathy, acidosis, and bleeding.
• In uncontrolled torso haemorrhage, use permissive hypotension rather than normalising BP before surgical or interventional control, unless traumatic brain injury is present.
• Rosen describes a reasonable systolic BP target of roughly 70-90 mmHg while awaiting haemorrhage control in selected patients with uncontrolled bleeding. ROSEN's Emergency Medicine, p. 1170.

Sepsis / septic shock

• Give crystalloid promptly when there is hypoperfusion, but reassess repeatedly and move early to vasopressors if hypotension persists after an appropriate initial volume.
• A fixed 30 mL/kg approach is not appropriate for every person, especially with heart failure, renal impairment, or overt overload. The 2025 ESICM guideline summary suggests up to 30 mL/kg initially in sepsis or septic shock, adjusted to context and frequent reassessment.

Cardiogenic shock

• Fluids are not the primary treatment for left-sided cardiogenic shock and may rapidly worsen pulmonary oedema.
• If volume status is uncertain, use small aliquots only with close reassessment and consider early ultrasound, vasopressors/inotropes, and cardiology-critical care involvement.

Traumatic brain injury

• Prevent hypoxia and hypotension. Do not use permissive hypotension if significant brain injury is suspected.
• Avoid hypotonic fluid and avoid glucose-containing resuscitation fluids unless treating hypoglycaemia.

5. Paediatric principle

6. Common errors

• Giving fluid without deciding whether the patient is actually fluid responsive
• Delaying blood products and haemorrhage control in active bleeding
• Repeated blind boluses in heart failure, renal failure, or pulmonary oedema
• Not monitoring urine output and cumulative balance
• Continuing IV fluid after oral or enteral intake becomes adequate
• Adding potassium directly to an IV fluid bag rather than using a prepared prescription and safe infusion system

Practical emergency rule

Fluid therapy: A-to-Z topic map using the ROSE framework

1. R - Resuscitation: rapidly restore life-saving perfusion in shock
2. O - Optimization: fine-tune cardiac output and tissue perfusion after initial rescue
3. S - Stabilization: maintain balance, replace measured losses, prevent accumulation
4. E - Evacuation / De-resuscitation: remove excess fluid after the acute phase

1. Fluid physiology: body-water compartments, tonicity, osmolality, Starling forces, capillary leak
2. Fluid assessment: hypovolaemia, fluid responsiveness, fluid tolerance, shock classification
3. Fluid types: balanced crystalloids, normal saline, glucose solutions, hypertonic saline, albumin, blood products
4. Indications: dehydration, sepsis, haemorrhage, burns, DKA, perioperative loss, anaphylaxis
5. Monitoring: clinical perfusion, urine output, lactate, blood gas, electrolytes, bedside ultrasound, fluid balance
6. Special situations: trauma, brain injury, cardiogenic shock, renal failure, liver disease, pregnancy, children
7. Complications: pulmonary oedema, dilutional coagulopathy, hyperchloraemic acidosis, electrolyte disorders, abdominal compartment syndrome
8. Stopping rules and de-resuscitation: when to stop fluids, diuretics, ultrafiltration, negative fluid balance

Core principle

Right patient, right fluid, right dose, right rate, right endpoint, and repeated reassessment.

ROSE at a glance

Important warning

1. ROSE framework in depth
2. Fluid types and composition
3. Assessment and monitoring
4. Disease-wise fluid therapy
5. Complications and de-resuscitation

Fluid Therapy: Practical Guide with the ROSE Framework

1. What is fluid therapy?

• Restore circulating volume and tissue perfusion
• Replace existing deficits and ongoing losses
• Provide daily water, electrolytes, and glucose needs
• Avoid or remove harmful fluid accumulation

1. Indication
2. Fluid type
3. Volume and rate
4. Endpoint
5. Monitoring and review time

• Does the patient need fluid?
• Will cardiac output and perfusion improve if fluid is given?
• Can the patient tolerate additional fluid without pulmonary oedema or organ congestion?
• When should fluids stop or be removed?

2. Body-fluid basics

Body water compartments

• Total body water: about 60% of body weight in men, lower in women, elderly people, and obesity
• Intracellular fluid: about two-thirds of total body water
• Extracellular fluid: about one-third
  • Interstitial fluid: about 75% of extracellular fluid
  • Intravascular plasma: about 25% of extracellular fluid

Tonicity

• Isotonic fluids mainly expand the extracellular space.
• Hypotonic fluids distribute into cells and may worsen cerebral oedema or hyponatraemia.
• Hypertonic fluids draw water from cells to extracellular fluid and must be used for specific indications with close monitoring.

3. Indications for IV fluids

A. Resuscitation

• Hypovolaemia from vomiting, diarrhoea, dehydration, diuresis, or third-space loss
• Sepsis or septic shock
• Haemorrhage
• Burns
• Anaphylaxis
• DKA or hyperosmolar hyperglycaemic state
• Perioperative or trauma-related losses

B. Maintenance

• Water: 25-30 mL/kg/day
• Sodium, potassium, chloride: roughly 1 mmol/kg/day each
• Glucose: 50-100 g/day to limit starvation ketosis

C. Replacement

• Vomiting or nasogastric drainage
• Diarrhoea
• High-output stoma or fistula
• Polyuria
• Biliary or pancreatic drainage
• Burns

4. Types of fluid

5. The ROSE framework

R: Resuscitation phase

Aim

Identify shock

• Hypotension or falling blood pressure
• Tachycardia
• Cold peripheries, capillary refill over 2 seconds, mottling
• Altered mentation
• Oliguria
• Raised lactate or worsening metabolic acidosis
• Skin, gastrointestinal, respiratory, or traumatic evidence of fluid/blood loss

Typical adult approach

• Give 500 mL isotonic crystalloid over less than 15 minutes
• Reassess immediately
• If appropriate, give a further 250-500 mL
• Escalate early if repeated boluses are needed, if total volume becomes substantial, or if shock persists

Do not delay cause-specific therapy

• Sepsis: antibiotics, source control, vasopressor when needed
• Haemorrhage: control bleeding, activate massive haemorrhage protocol
• Anaphylaxis: IM adrenaline first
• Cardiogenic shock: reperfusion/inotrope-vasopressor strategy, not routine fluid loading
• Obstructive shock: relieve tamponade, tension pneumothorax, or massive pulmonary embolic obstruction

O: Optimization phase

Aim

Assess fluid responsiveness

• Passive leg raise: transfers venous blood from legs to central circulation without giving fluid
• Small fluid challenge, such as 250 mL, with objective reassessment
• Stroke-volume or cardiac-output monitoring where available
• Echocardiography and bedside ultrasound in experienced hands

Assess fluid tolerance

• Increasing oxygen requirement
• Crackles, B-lines on lung ultrasound, new pulmonary oedema
• Raised JVP, peripheral oedema
• Worsening right-heart congestion
• Rising intra-abdominal pressure
• Falling oxygenation or poor lung compliance
• Positive cumulative fluid balance

S: Stabilization phase

Aim

• Drug diluents
• Antibiotic carriers
• Nutrition
• Blood-product carriers
• Routine maintenance fluid
• Flushes and line keep-open fluids

Actions

• Stop resuscitation boluses once perfusion endpoints are met.
• Use oral or enteral fluids as soon as feasible.
• Replace only documented ongoing losses.
• Review all IV inputs daily.
• Monitor weight, cumulative balance, creatinine, sodium, potassium, chloride, acid-base status, and respiratory status.
• Adjust maintenance fluid for kidney, heart, or liver dysfunction.

E: Evacuation or de-resuscitation phase

Aim

Method

1. Stop unnecessary IV fluid.
2. Minimize sodium and hidden fluid inputs.
3. Aim for neutral, then negative fluid balance when stable.
4. Consider diuretics if perfusion and renal function permit.
5. Use renal replacement therapy mainly when there is an independent indication, such as refractory fluid overload with kidney failure, severe hyperkalaemia, severe acidosis, or uraemic complications.

6. Monitoring during fluid therapy

Clinical monitoring

• Heart rate, BP, MAP, pulse pressure
• Respiratory rate, SpO₂, oxygen requirement
• Capillary refill, temperature gradient, skin mottling
• Mental state
• JVP and peripheral oedema
• Chest examination
• Urine output
• Daily weight
• Input-output chart and cumulative fluid balance

Laboratory monitoring

• Electrolytes: sodium, potassium, chloride, bicarbonate
• Urea and creatinine
• Blood gas and lactate in shock
• Glucose
• Haemoglobin and coagulation profile if haemorrhage is possible
• Magnesium and phosphate in prolonged illness, DKA, malnutrition, or refeeding risk

Dynamic perfusion endpoints

• Improving mental status
• Falling lactate, interpreted in clinical context
• Improving capillary refill/peripheral perfusion
• Improving urine output
• Improved stroke volume/cardiac output after a reversible test
• Resolution of hypotension without evidence of congestion

7. Disease-specific essentials

Sepsis and septic shock

• Use crystalloid for hypoperfusion.
• Balanced crystalloid is commonly preferred.
• Give initial fluid in measured increments with frequent reassessment.
• Early vasopressors are appropriate if hypotension persists despite a reasonable initial fluid trial.
• Avoid persistent positive balance after initial stabilization.

Haemorrhagic shock

• Priorities are haemorrhage control, warming, calcium replacement when indicated, correction of coagulopathy, and early blood products.
• Minimize large-volume crystalloid.
• Consider permissive hypotension in selected uncontrolled haemorrhage patients.
• Do not use permissive hypotension in traumatic brain injury, where hypotension worsens secondary brain injury.

Cardiogenic shock

• Do not reflexively give fluid.
• If the patient is congested, fluid may worsen pulmonary oedema.
• Give a small, closely monitored test bolus only if true hypovolaemia or right-ventricular preload dependence is plausible.
• Obtain ECG, bedside echo, and early critical care/cardiology input.

DKA

• Start isotonic crystalloid.
• Use a protocol that integrates fluid therapy, potassium replacement, insulin, glucose, osmolality, and acid-base monitoring.
• Fluid rate and type should change as haemodynamics, sodium, glucose, and osmolality change.

Acute brain injury

• Avoid hypotension and hypoxia.
• Avoid hypotonic fluid.
• Use isotonic fluid and target adequate cerebral perfusion.
• Hypertonic saline has specific indications such as severe symptomatic hyponatraemia or selected raised intracranial-pressure management, not routine volume replacement.

Burns

• Major burns require formal burn-resuscitation calculations, frequent urine-output assessment, temperature control, and burn-centre input.
• Avoid both under-resuscitation and “fluid creep.”

Renal, cardiac, or liver disease

• Use smaller aliquots and reassess more frequently.
• Assess congestion early with clinical examination and ultrasound where available.
• Do not deny resuscitation when shock is present, but avoid routine maintenance and repeated blind boluses.

8. Complications of fluid therapy

9. Practical bedside algorithm

Step 1: Is the patient in shock or hypoperfusion?

• If yes, establish IV/IO access, monitor, obtain labs, identify the shock type, and treat the cause immediately.

Step 2: Is fluid indicated?

• Hypovolaemic/distributive shock: usually yes.
• Haemorrhage: blood products plus haemorrhage control.
• Cardiogenic/obstructive shock: fluid may be harmful or only conditionally useful.

Step 3: Give a measured trial

• Adult: 500 mL isotonic crystalloid rapidly, then reassess.
• Frail, heart failure, advanced CKD: smaller aliquots, for example 250 mL, with close monitoring.
• Children: weight-based aliquots with reassessment after every bolus.

Step 4: Reassess response and tolerance

• Better perfusion, BP, capillary refill, mentation, lactate, urine output?
• New crackles, hypoxia, raised JVP, oedema, B-lines, worsening work of breathing?

Step 5: Decide

• Responsive and tolerant: repeat a limited bolus if still indicated.
• Not responsive: stop repeated fluid and reconsider diagnosis, vasoactive therapy, inotropy, haemorrhage control, or obstruction.
• Not tolerant: stop fluids and treat congestion.

Step 6: Review daily

• Does the patient still need IV fluid?
• Is oral/enteral intake possible?
• Is there fluid accumulation requiring de-resuscitation?

10. High-yield exam points

• Crystalloids are first-line resuscitation fluids in most non-haemorrhagic shock states.
• Balanced crystalloids are often preferred for large-volume resuscitation.
• Normal saline is not “physiological” saline because of its high chloride concentration.
• In haemorrhagic shock, prioritize bleeding control and blood products, not litres of crystalloid.
• In cardiogenic shock, excessive fluid can be dangerous.
• Give fluids in boluses and reassess after each one.
• A patient may be fluid responsive but not fluid tolerant.
• Maintenance fluid must be reduced in frail patients and those with heart, renal, or liver failure.
• Stop fluids promptly when no longer needed.
• After acute resuscitation, aim to prevent positive cumulative balance and consider de-resuscitation when clinically stable.