Goal-directed resuscitation in the prehospital setting: A propensity-adjusted analysis.

Brown JB, Cohen MJ, Minei JP, Maier RV, West MA, Billiar TR, Peitzman AB, Moore EE, Cuschieri J, Sperry JL; The Inflammation and the Host Response to Injury Investigators
J Trauma Acute Care Surg. 2013 May;74(5):1207-1214

LINK TO ABSTRACT

Surprisingly, the role of prehospital crystalloid resuscitation for those patients with severe blunt trauma is still unclear. This well done study hopes to improve our understanding of the best approach to these patients.

The optimum management of prehospital crystalloid for severe blunt trauma patients is unclear.

This is a multicenter prospective cohort study of blunt injured adults with hemorrhagic shock. This was defined as the presence of prehospital or emergency department hypotension (systolic blood pressure [SBP]

This study examined the effect on mortality and on the development of coagulopathy. Among those severe trauma patients who survive the first few hours of care, the development of coagulopathy and subsequent multi organ failure often lead to death.

  • A large number of severe blunt trauma patients who survive the first few hours later succumb to complications of coagulopathy.

Standard operating procedures were developed and implemented across all institutional centers to minimize variation in post injury care. Demographics, injury characteristics, resuscitation requirements, and outcomes were compared. Prehospital crystalloid volume was defined as High when more than 500 mL was given.

  • Among blunt trauma patients without prehospital hypotension, giving more than 500 mL of crystalloid more than doubled mortality and coagulopathy.

In subjects without prehospital hypotension, HIGH (>500 mL) crystalloid was associated with an increase in the risk of mortality (hazard ratio, 2.5; p < 0.01) and worsened acute coagulopathy (odds ratio [OR], 2.2; p = 0.04). When separated out into quartiles, it was demonstrated that the more fluid that was given, the worse the outcome.

Among blunt trauma patient with prehospital hypotension, crystalloids improved blood pressure and increased survival.

Take Home Points

  • Prehospital crystalloid resuscitation of blunt trauma patients should be goal directed

  • Hypotensive Blunt Trauma Patients benefit from fluid resuscitation

  • Normotensive Blunt Trauma Patients are harmed from fluid resuscitation

  • Paramedics should be aware that their interventions may cause complications of trauma, such as severe coagulopathy and multi organ failure

Dr. Sporer is the EMS Medical Director for Alameda County

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