Clinical scenario

You are resuscitating a 30 year old man with a severe closed head injury. His GCS was 3 on admission. He is intubated and ventilated and a CT scan is being organised. His blood pressure is only 90/40 mm Hg. You want to improve cerebral perfusion by giving intravenous fluid but are aware that too much fluid might worsen cerebral oedema. You wonder whether there would be any advantage in giving hypertonic saline.

Three part question

In [patients with severe head injury and low blood pressure] is [hypertonic saline better than isotonic fluids] at [increasing cerebral perfusion, reducing intracranial pressure and improving outcome]?

Search strategy

Medline 1966-10/03 using the OVID interface. [exp hypertonic solutions/or exp saline solution, hypertonic/or “hypertonic saline”.mp.] AND [exp craniocerebral trauma/OR “head injury”.mp. OR “HEAD INJURIES”.mp. OR exp head injuries, closed/OR “head injured”.mp. OR exp brain injuries/OR “brain injury”.mp.]

Search outcome

Altogether 66 papers were found of which three were trials of sufficient quality that addressed the three part question. These are displayed in table 6.

Comment(s)

All three trials showed some improvements in patients with head injury treated with hypertonic saline compared with standard care. The largest showed a two times survival advantage in those treated with hypertonic saline but this was a cohort analysis rather than a PRCT. It is not established how much hypertonic saline should be given and when. A large randomised controlled trial would help to establish the role of hypertonic saline.

CLINICAL BOTTOM LINE

There is insufficient evidence at present to justify the use of hypertonic saline as resuscitation fluid in patients with severe head injury.