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).
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.
Available from: Ao Scholz
- "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. , while other studies were not able to confirm this effect . In blunt trauma no clear evidence Table 1 Demographic and clinical data. "
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The use of permissive hypotension includes a restrained volume preclinical therapy. However, in the elderly patients, this approach has raised concerns because of the increased cardiovascular risk profile and a higher incidence of hypertension under normal conditions. The aim of the study was to examine whether preclinical administration of restrictive volume therapy in the elderly patient can be safe.
Patients and methods:
A retrospective matched-pair analysis with the data set of the TraumaRegister DGU(®) (TR-DGU) was performed based on data of 176 pairs of totally 67,000 patients. To address elderly potentially bleeding patients without major brain injury the following inclusion criteria were chosen: patients ≥ 60 years, ISS ≥ 16, AIS head<4, preclinical blood pressure between 60 and 100 mmHg and recorded preclinical volume administration. Patients that met the inclusion criteria (908) were divided into two groups: pre-clinical volume resuscitation ≤ 1000 ml (=low volume) and >1000 ml (high volume). Patients with high- and low-volume fluid replacement were matched according to the following criteria: age group, gender, date of the accident ± 5 years, ISS, GCS, preclinical intubation, ground-/air-transport, pre-clinical blood pressure.
Preclinical volume resuscitation showed a difference of about 1000 ml between the "low volume" and "high volume" group. The "low volume" group showed a significantly elongated prothrombin time. The amount of blood products given in the emergency department was not significantly different. The ventilation was 2 days shorter in the "low volume", although the number of patients with severe thoracic trauma was greater in this group. The length of stay in the ICU differed by 3 days in favour of the "low volume" group. The overall mortality was almost the same in both groups.
Based on these data it can be assumed that the lower preclinical volume administration has a positive effect on the initial coagulation status in elderly patients. In spite of some limitations such as low number of matched pairs, we draw the cautious conclusion that a restrictive preclinical volume therapy is safe and also indicated in elderly patients.
Available from: Erica Caldwell
- "However, another study in this patient subgroup showed no difference in survival between patients that received or did not receive prehospital i.v. fluids. Sampalis et al.and Haut et al.concluded from their observational studies that the administration of prehospital i.v. "
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The ideal strategy for prehospital intravenous fluid resuscitation in trauma remains unclear. Fluid resuscitation may reverse shock but aggravate bleeding by raising blood pressure and haemodilution. We examined the effect of prehospital i.v. fluid on the physiologic status and need for blood transfusion in hypotensive trauma patients after their arrival in the emergency department (ED).
Retrospective analysis of trauma patients (n = 941) with field hypotension presenting to a level 1 trauma centre. Regression models were used to investigate associations between prehospital fluid volumes and shock index and blood transfusion respectively in the emergency department and mortality at 24 h.
A 1 L increase of prehospital i.v. fluid was associated with a 7% decrease of shock index in the emergency department (p < 0.001). Volumes of 0.5 - 1 L and 1 - 2 L were associated with reduced likelihood of shock as compared to volumes of 0-0.5 L: OR 0.61 (p = 0.03) and OR 0.54 (p = 0.02), respectively. Volumes of 1 - 2 L were also associated with an increased likelihood of receiving blood transfusion in ED: OR 3.27 (p < 0.001). Patients who had received volumes of > 2 L have a much greater likelihood of receiving blood transfusion in ED: OR 9.92 (p < 0.001). Mortality at 24 h was not associated with prehospital i.v. fluids.
In hypotensive trauma patients, prehospital i.v. fluids were associated with a reduction of likelihood of shock upon arrival in ED. However, volumes of > 1 L were associated with a markedly increased likelihood of receiving blood transfusion in ED. Therefore, decision making regarding prehospital i.v. fluid resuscitation is critical and may need to be tailored to the individual situation. Further research is needed to clarify whether a causal relationship exists between prehospital i.v. fluid volume and blood transfusion. Also, prospective trials on prehospital i.v. fluid resuscitation strategies in specific patient subgroups (e.g. traumatic brain injury and concomitant haemorrhage) are warranted.
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ABSTRACT: Hypotension is a trauma activation criterion validated by multiple studies. However, field systolic blood pressures (SBP) are still met with skepticism. How significant is the role of prehospital (PH) and emergency department (ED) SBP in the patient's overall condition? A review of the trauma registry over a 5-year period was conducted. PH SBPs were stratified into four categories: severe (SBP 80 mmHg or less), moderate (81-100 mmHg), mild hypotension (101-120 mmHg), and normotension (greater than 120 mmHg). These four groups were further subcategorized into the patients who were hypotensive, SBP 90 mmHg or less in the ED, versus those that were not (SBP greater than 90 mmHg). Data for 6964 patients were analyzed. Patients with PH SBP of 80 mmHg or less compared with patients who had PH SBP of greater than 80 mmHg had higher mortality (OR, 9; 95% CI, 6.45-12.84). Patients with both PH SBP 80 mmHg or less and ED SBP 90 mmHg or less had the highest risk of mortality (50%) and highest need for emergent operative intervention (54%). PH and ED hypotension is a strong predictor of in-hospital mortality and need for emergent surgical intervention in trauma patients. Field or ED blood pressures should serve as a significant marker of the patient's condition.
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