Elsevier

Injury

Volume 36, Issue 9, September 2005, Pages 1001-1010
Injury

REVIEW
Pre-hospital fluid therapy in the critically injured patient—a clinical update

https://doi.org/10.1016/j.injury.2005.01.002Get rights and content

Summary

Venous access and fluid therapy should still be considered to be essential elements of pre-hospital advanced life support (ALS) in the critically injured patient. Initiation of fluid therapy should be based on a clinical assessment, most importantly the presence, or otherwise, of a radial pulse. The goal in penetrating injury is to avoid hypovolaemic cardiac arrest during transport, but at the same time not to delay transport, or increase systolic blood pressure. The goal in blunt injury is to secure safe perfusion of the injured brain through an adequate cerebral perfusion pressure, which generally requires a systolic blood pressure well above 100 mmHg. Patients without severe brain injury tolerate lower blood pressures (hypotensive resuscitation). Importantly, using systolic blood pressure targets to titrate therapy is not as easy as it seems. Automated (oscillometric) blood pressure measurement devices frequently give erroneously high values. The concept of hypotensive resuscitation has not been validated in the few studies done in humans. Hence, the suggested targeted systolic blood pressures should only provide a mental framework for the decision-making. The ideal pre-hospital fluid regimen may be a combination of an initial hypertonic solution given as a 10–20 minutes infusion, followed by crystalloids and, in some cases, artificial colloids. This review is intended to help the clinician to balance the pros and cons of fluid therapy in the individual patient.

Introduction

As the care delivered by emergency medical service (EMS) systems evolved from the basic life support of the 1960's, intravenous fluid therapy was one of the first ‘advanced’ skills to be introduced. It was regarded as an important element of pre-hospital advanced life support (ALS) in critically injured patients.12 The reasonable basic physiological premise that hypovolaemia should be corrected immediately formed the basis for aggressive pre-hospital intravenous fluid therapy for several decades, aiming to restore patients to a normovolaemic state as soon as possible. However, some of the earliest studies, examining outcome in relation to pre-hospital fluid volume, failed to show any benefit and most clinical and animal studies have been consistent with those findings. Several authors1, 19, 35, 42, 44, 45, 51, 64, 65, 72, 74, 79, 83 have challenged the concept of the liberal use of pre-hospital fluids, especially in patients with penetrating trauma. Clinical practice guidelines19, 56, 82 and some national guidelines60 are now moving away from this traditional strategy and recommending a more judicious use of fluids. Due to the lack of randomised controlled studies, these guidelines are primarily based on animal research and observational studies, combined with pathophysiological rationale and the consensus of experts in the field. It is, however, not clear to what extent these guidelines have been implemented in EMS systems world-wide. Further, it is not yet documented that the proposed changes in patient management actually will improve patient outcome.

The aim of this clinically oriented update is to present an overview of the recent controversies and developments related to pre-hospital fluid therapy in critically injured patients. We also present some suggestions for best clinical practice and further improvements.

Section snippets

Recent controversies

In all forms of trauma, tissue oxygenation is compromised not only by a reduction in tissue oxygen delivery, the result of haemorrhage, but also by the associated increase in tissue oxygen consumption, due to the inflammatory response. Trauma, however, is not a generic disease. In blunt trauma, a mixture of bleeding, tissue oedema, neurogenic factors and pain, combined with a tension pneumothorax, or spinal injury, may cause traumatic shock (circulatory failure).31, 67 Furthermore, the bleeding

Recent recommendations

Recently, several groups4, 19, 31, 56, 67, 68, 70, 82, 83 have published clinical recommendations for pre-hospital fluid therapy in trauma patients. Due to the lack of well-performed, randomised, controlled trials, the recent guidelines are based on a combination of expert opinions, pathophysiological rationale and the results of observational cohort studies in humans and controlled studies in animal models.

The pathophysiological rationale is used to strike a balance between the risks and the

Crystalloid versus colloid

The optimal type of fluid for intravenous fluid replacement is debated. Theoretical advantages of crystalloids are that they replace interstitial, as well as intravascular, fluid loss, they do not impair coagulation, do not cause allergic reactions and are inexpensive. Their limitations include limited intravascular expansion and tissue oedema, which may contribute to impaired gaseous exchange in the lungs, increased bacterial translocation in the gut and reduced capillary blood flow, impairing

Summary and future improvements

Yesterday's dogma that fluid therapy and other pre-hospital ALS interventions are always of benefit, has been replaced with a major concern that pre-hospital ALS may actually do more harm than good. This raises serious concern over the question of the widespread use of pre-hospital fluid therapy in paramedic-run EMS systems. The number of critically injured patients is limited and to secure high quality care and improve patient safety, the authors are of the view that a limited number of

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