Reanalysis of prehospital intravenous fluid administration in patients with penetrating truncal injury and field hypotension

Department of Surgery, Harbor-UCLA Medical Center, Torrance, California 90509, USA.
The American surgeon (Impact Factor: 0.82). 11/2007; 73(10):1027-30.
Source: PubMed

ABSTRACT In 1994, Bickell et al. published a prospective study recommending restricting prehospital intravenous fluids (IVF) to less than 100 cc in patients with penetrating truncal injuries and field hypotension, reporting a 30 per cent mortality with IVF restriction and a 38 per cent mortality with liberal IVF use. However, since this study, few papers have investigated whether emergency medical systems (EMS) adhere to these IVF guidelines. The purpose of this study was to determine whether a policy of IVF restriction is being followed and whether the volume of prehospital and emergency department (ED) IVF affects outcome in patients with penetrating truncal injury and field hypotension at a Level I trauma center in Los Angeles County. A retrospective analysis of a trauma database from 1998 to 2005 of all patients with penetrating truncal injury and field hypotension (systolic blood pressure less than 90 mm Hg) was performed. Multiple variables, including originating EMS agency, mechanism of injury, transport time, Injury Severity Score, field and ED vital signs, and IVF volume infused, complications, and mortality were compared. One hundred ninety-four patients with a median age of 26 years with penetrating truncal injury and field hypotension were analyzed. The most common mechanisms of injury were gunshot (73%) and stab (22%) wounds. The median field systolic blood pressure was 80 mm Hg. The median transport time was 11 minutes. The median prehospital IVF was 500 cc with only 25 per cent receiving less than 100 cc of IVF. There were no differences in the amount of IVF administered by the degree of field hypotension or by originating EMS agency. Median ED IVF was 1000 cc. The overall mortality rate was 25 per cent. When a comparison was made of those receiving less than 100 cc prehospital IVF in comparison to those receiving greater than 100 cc, there were no differences detected with respect to median age, systolic blood pressure, Injury Severity Score, transport time, or morbidity rate. The mortality rate was 21 per cent in the group that received greater than 100 cc of IVF in comparison to a 37 per cent mortality rate in the group that received less than 100 cc IVF (P = 0.04). On multivariate analysis, after adjusting for Trauma Injury Severity Score, there were no differences in survival by the amount of prehospital or ED IVF administered. It appears that the recommendations of IVF restriction for patients with penetrating truncal injuries and field hypotension are not being followed by Los Angeles County EMS. There were no differences in survival with respect to the amount of prehospital or ED IVF. Given the retrospective nature of this study, further investigation is needed to define the role of prehospital IVF resuscitation in these patients.

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    • "Recent recommendations support the principle of a limited volume replacement in a bleeding trauma patient until surgical bleeding control. In penetrating trauma the concept of minimising the prehospital volume support is supported by a randomised trial by Bickell et al. [8], while other studies were not able to confirm this effect [9]. In blunt trauma no clear evidence Table 1 Demographic and clinical data. "
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