REVIEWPre-hospital fluid therapy in the critically injured patient—a clinical update
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
References (91)
Management of brain and spine injuries
Crit Care Clin
(2004)Controversies in resuscitation: to infuse or not to infuse (1)
Resuscitation
(1996)- et al.
Checking the carotid pulse check: diagnostic accuracy of first responders in patients with and without a pulse
Resuscitation
(1996) - et al.
Efficacy of pre-hospital critical care teams for severe blunt head injury in the Australian setting
Injury
(2001) - et al.
The life-sustaining capacity of human polymerized hemoglobin when red cells might be unavailable
J Am Coll Surg
(2002) A clinical review of bleeding dilemmas in trauma
Semin Hematol
(2004)- et al.
Reporting data following major trauma and analysing factors associated with outcome using the new Utstein style recommendations
Resuscitation
(2001) Controversies in resuscitation: to infuse or not to infuse (2)
Resuscitation
(1996)- et al.
Prehospital fluid resuscitation of the patient with major trauma
Prehosp Emerg Care
(2002) - et al.
Is the normalisation of blood pressure in bleeding trauma patients harmful?
Lancet
(2001)