# IV Fluids increase death rate for trauma victims



## webster44 (Jan 17, 2011)

http://www.nytimes.com/2011/01/18/health/research/18regimens.html?ref=science

Title says it all


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## Shishkabob (Jan 17, 2011)

Except the study doesn't go in to detail as to WHY it caused possible harm, the fluid used, if the agency in question had permissive hypotension etc etc



4.8% mortality vs 4.5% is not that big of a difference, even with the big sample body.  That's 1,000 more people... in a single study, with many variables that I doubt they took in to account.


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## mc400 (Jan 17, 2011)

I have this conversation with co workers all the time and so many still believe in the 2 large bore IV massive fluid infusion theory fopr trauma victims. With the wars in Iraq and Afghanistan we are learning a lot. 18 gauge is plenty good and limit fluids only enough to keep cerebral perfusion if patient is hypotensive.


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## Bieber (Jan 17, 2011)

I'm with Linuss, too many relevant variables not addressed in this study.


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## usafmedic45 (Jan 17, 2011)

http://www.ncbi.nlm.nih.gov/pubmed/21178760

That's the actual article in question.....



> OBJECTIVE: Prehospital intravenous (IV) fluid administration is common in trauma patients, although little evidence supports this practice. We hypothesized that trauma patients who received prehospital IV fluids have higher mortality than trauma patients who did not receive IV fluids in the prehospital setting.
> 
> METHODS: We performed a retrospective cohort study of patients from the National Trauma Data Bank. Multiple logistic regression was used with mortality as the primary outcome measure. We compared patients with versus without prehospital IV fluid administration, using patient demographics, mechanism, physiologic and anatomic injury severity, and other prehospital procedures as covariates. Subset analysis was performed based on mechanism (blunt/penetrating), hypotension, immediate surgery, severe head injury, and injury severity score.
> 
> ...


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## Shishkabob (Jan 17, 2011)

Especially since they, atleast per the artcle (I can't see it in the study) say "The researchers suggest that inserting an IV can mean critical delays in getting to the hospital", yet provide no proof that such delay exists, let alone attributed to the mortality.


I've started IVs en route.  Every medic has.  I don't know of any (though I know some exists... they always do) medic that stayed on scene just for an IV.


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## jrm818 (Jan 17, 2011)

The title almost never says it all.

Titles from the NYT rarely say anything, especially about complicated medical issues, although I am very surprised to see an article about this issue in a newspaper.

I think that interpreting this study is very difficult, something that is probably true for all  retrospective studies that rely on complicated statistical analyses of large datasets.  There are many variables that may not be appreciated and may have contributed to outcomes here(transport time, setting, true injury severity, IV en route or on scene, air vs. ground, etc. etc.).  The authors couldn’t even determine if fluids were given through the IV or if a lock was placed without fluids given (never mind determining how much fluid was given).  Side note: Irksome to me is that their less than precise labeling which sometimes implies that they are looking at actual fluid administration.  

I think in this case the top of page 6 really says it all.  “This retrospective study suffers from some inherent limitations, largely due to potential residual confounders […long list of very important confounders, as mentioned…].  Due to these limitations, we could not determine the potential causal pathway of the higher mortality.”

Sorry, but I don’t really see what this adds to our knowledge.  I think this would be great to provide lots of hypotheses to test in prospective studies, as this study does suggest that there _may _be harm due to IV placement in many groups of patients.  However, such hypotheses have already been generated, and in some cases tested, and this study is certainly not sufficient to provide strong evidence for or against the use of IV’s in any cohort.  I don’t think we needed the authors to tell us that we need more data about fluid administration in trauma, and I don’t think they gave us any new perspective.

The authors say that they were spurred to analyze the data based on other prospective studies of fluid administration, but the logic of performing a retrospective sort-of-controlled analysis to add credence to a prospective, randomized, controlled trial escapes me a bit.  The discussion is interesting but really is just a very stripped down review of the literature.

Side rant 2: I’m also very irked by their repeated use of the term “harm” to describe the interaction between prehospital IV’s and outcome.  It is very possible that in many patients here the prehospital IV did cause harm, but the word harm implies a causal relationship between the intervention and the outcome, and this study did NOT establish causality, as they acknowledge.


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## Veneficus (Jan 17, 2011)

If you create a "study" in order to prove a point, you are likely to succeed.

Anyone who has ever seen the studies on increased cranial volume correlating to intelligence would know that.

(Which by the way was at one time considered sound, reproducable science.)

The various methodologies were highly questionable. It is sometimes difficult to find people who will go against the prevailing accepted science at a given time. Those who do are often branded as "mad" or "heretical."


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## Bieber (Jan 17, 2011)

Without knowing the details of the patients' severity levels and how it was determined who got an IV versus who didn't, I almost wonder if this could be one of those studies that can be summed up as "sicker people die more often".  Regardless, like everyone else has said, it doesn't seem from face value to be especially weighty.



Linuss said:


> I've started IVs en route.  Every medic has.  I don't know of any (though I know some exists... they always do) medic that stayed on scene just for an IV.


I was taught during my internship to get all of my IV's en route, which is probably what I will continue to do for a while, though after having worked with at least one paramedic who got his IV's on scene for non-critical medical patients, that does seem to free up a lot of time en route to do other stuff if you get those before you get going.


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## Shishkabob (Jan 17, 2011)

For non-critical patients, I have no problem with getting the IV on site.

Heck, even if we go en route on say, an MI, and I think it's going to be a tough stick, I can and have asked my partner to pull over for a couple of seconds just so I can get the IV and not risk missing them because of bumps in the road.  



However, if they are super critical, we're constantly in motion and if I can't get the IV, they get an IO.


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## medicRob (Jan 17, 2011)

Linuss said:


> For non-critical patients, I have no problem with getting the IV on site.
> 
> Heck, even if we go en route on say, an MI, and I think it's going to be a tough stick, I can and have asked my partner to pull over for a couple of seconds just so I can get the IV and not risk missing them because of bumps in the road.
> 
> ...




When working the ground unit, I will typically get the patient to the rig after doing a quick assessment and will have my partner get a BP on the right arm while I start an IV on the left and hang a bag of whatever fluid is called for.. If it is a pain management situation like an obvious fracture with deformity, I will of course wait for the patient's vitals, ask them about drug allergies (usually I have already done my SAMPLE history at this point or at least half of it anyways), ask their pain level 1 - 10 (which in that situation is quite obvious), then push the med and then my partner will jump in the front and we will get gone. I rarely ever start an IV outside of the rig, not because there is anything wrong with it, it is just my preference.


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## Shishkabob (Jan 17, 2011)

Agreed, I usually don't do it on scene, just on site (in the ambulance... a lot more control), of course the exception being stuff like hypoglycemia / unresponsive, things of that nature.  


Heck, had a "stabbing" the other night, he didn't get an IV till about halfway through the transport.


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## Bieber (Jan 17, 2011)

The only times I would ever start an IV on scene is for cardiac arrests, unstable arrhythmias and hypoglycemia (though ironically enough I made it throughout my entire internship without ever giving dextrose).

But we may be getting off topic...

I agree completely that permissive hypotension (systolic around 90) seems to be the magic number when it comes to fluid therapy for trauma patients, and I believe that's the current (or soon to be current?) PHTLS guidelines, so to say that all prehospital IV's on trauma patients are harmful is a little hard to swallow.  Even if you're not planning on giving fluid, having that IV for the hospital saves THEM time to delivering definitive care.  As for fluid boluses, there are certainly patients who are so messed up that you're turning their blood pink just to try and maintain their pressures, but I would call those lost causes regardless of whether or not we give fluids.

Certainly the key to truly making prehospital trauma care substantially more beneficial and effective in decreasing mortality in trauma patients lies in oxygen carrying blood substitutes.


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## medicRob (Jan 17, 2011)

Bieber said:


> The only times I would ever start an IV on scene is for cardiac arrests, unstable arrhythmias and hypoglycemia (though ironically enough I made it throughout my entire internship without ever giving dextrose).
> 
> But we may be getting off topic...
> 
> ...



Yes, PHTLS says 90 mmHg last I remember.. which is good for maintaining a MAP where it needs to be.


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## WTEngel (Jan 18, 2011)

MAP and CPP really are the key indicators for where our perfusion goals should be. Unfortunately most pre hospital providers are so fixated on systolic and diastolic BP they lose sight of that key piece of data.

Trauma is a difficult beast to study, even more so in the out of hospital setting. I tend to agree with Vene, if you set out to prove a point with a study, you are likely to succeed, until the next group comes along, and depending on who they are funded by, proves you wrong...


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## medicRob (Jan 18, 2011)

WTEngel said:


> MAP and CPP really are the key indicators for where our perfusion goals should be. Unfortunately most pre hospital providers are so fixated on systolic and diastolic BP they lose sight of that key piece of data.
> 
> Trauma is a difficult beast to study, even more so in the out of hospital setting. I tend to agree with Vene, if you set out to prove a point with a study, you are likely to succeed, until the next group comes along, and depending on who they are funded by, proves you wrong...




[Systolic + 2(diastolic)] / 3 is always one of the first calculations I do when I get a blood pressure on a trauma patient (I like my first blood pressure to always be manual). I like patients who are cathed as well. Urine output is a great indicator of shock, but that discussion is for another thread..

Back on track.


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## WTEngel (Jan 18, 2011)

Roger that Rob. It amazes some people that there's more to it than "a top number and a bottom number"


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## firetender (Jan 18, 2011)

*The straw that broke the camel's back!*

That's pretty much IT!

Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"

Essentially, in those years, I was an agent of Death!

Harsh reality, this site!


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## abckidsmom (Jan 18, 2011)

firetender said:


> That's pretty much IT!
> 
> Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"
> 
> ...



"Rampart, Squad 51."

"Go ahead, Johnny."

"Rampart, we have a 53 year old medic in shock.  Request orders to ship him to Australia, where all smart people head for  their no good, very bad days."

"Negative, Squad 51, continue as before, load him up and bring him in."



It does suck to hear though, doesn't it?


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## bstone (Jan 18, 2011)

Interesting study. Very interesting. I would like to see more studies confirm this basis. If they do and it's clear that pre-hospital IV fluids lead to higher mortality rates then I would be in favor or removing that from the protocol, or at least adding permissive hypotension. IV access for medical cases is obvious, however.


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## WTEngel (Jan 18, 2011)

firetender said:


> That's pretty much IT!
> 
> Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"
> 
> ...



Don't worry, in 10 or 20 years we will all be saying the exact same thing... It's the circle of life.


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## Veneficus (Jan 18, 2011)

firetender said:


> That's pretty much IT!
> 
> Essentially, EVERYTHING I used as a paramedic in 1975 has been debunked, deemed ineffective or outright banned due to "poor patient outcome"
> 
> ...



If it makes you feel any better, there are still providers who are not only using it, but defending the practice.

(Why I have no idea, some people are slow.)

The original idea of permissive hypotension is credited to a French Army surgeon in WWI. I forgot his name though.


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## jrm818 (Jan 18, 2011)

bstone said:


> Interesting study. Very interesting. I would like to see more studies confirm this basis. If they do and it's clear that pre-hospital IV fluids lead to higher mortality rates then I would be in favor or removing that from the protocol, or at least adding permissive hypotension. IV access for medical cases is obvious, however.



In the nicest way possible, I have to ask if you read the whole study or just the abstract.  I can see how one could take what the authors wrote as an abstract and think that this study provided some sort of new knowledge, but if you were looking at the full text I'm left wondering (legitimately: what did I miss?) what was so interesting.

Personally, I couldn't find much of interest.  This study would be great to give plausibility to a claim that prehospital fluid administration can be harmful for reason x,y.or z.  Unfortunately that claim has been plausable for quite a few years at this point, and better studies have given a much more detailed, nuanced, and interesting perspective.

Sorry, I think that this is a derivative, nearly meaningless study that provides an abbreviated review of the literature at best.

I would also suggest that outright removing prehospital cannulation/fluid administration from protocol is probably not the best move.  The question of whether or not to provide fluid recussitation, how much to provide, etc. are clinical questions that should be decided on the basis of assessment of a particular patient in a particular situation.  Lumping a heterogeneous group of patients together and banning a specific treatment because it may be harmful to some doesn't seem like good management of a medical system.


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## jrm818 (Jan 18, 2011)

As a secondary issue, I have to wonder if studies like this contribute to the hesitation of many to try to pay attention to research and use evidence to help determine treatments.  Searches can turn up hundreds of studies on any particular topic, many of which are of poor quality and have divergent results.  

Sorting through the mountain of bad/redundant/preliminary information to find the few well done studies that establish something new can be quite a daunting task.  Determining which studies are of high quality and which are not is a time consuming task that often requires reading the entirety of low-quality studies before you decide that they were, well, junk (oh, just wasted your time, so sorry, try again tomorrow...).

Sometimes I feel like I'm looking for a needle in a haystack when I'm looking for good evidence on a particular topic, and I feel like many authors are throwing more "hay" on the stack, making reading the literature a tall order.


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## Veneficus (Jan 18, 2011)

jrm818 said:


> Sometimes I feel like I'm looking for a needle in a haystack when I'm looking for good evidence on a particular topic, and I feel like many authors are throwing more "hay" on the stack, making reading the literature a tall order.



That is exactly the problem!!!

It seems to me many MDs are of the mind that their job is not to treat patients but to do research. Not to be outdone, the nursing researchers jump on board as well. To prove that they are equal other ancillary providers start to do the same and a publish or perish environment is created. 

People of all levels feel compelled to publish something, and just like you said, there are piles and piles of garbage. What's worse is people who do not have the time to filter it all (which is becomming harder to do) either want to change practice everytime the wind blows, or suddenly give legitimacy to a practice because there is now research on it. 

On the otherside, good research has trouble floating to the top because when you tell a falsehood often enough it becomes defacto truth, and the plethora of garbage discounts the findings of well done studies. 

The solution is actually less people doing research and more intense reviews and replications of research before publication.

But everyone from EMS to physicians has their own trade publications promoting themselves by featuring this "research."

The herd needs to be culled. 

What would be great too is every undergrad or grad student who does research should be judged on its quality, not the fact his name is on it. That way, poor research is punished instead of rewarded by getting your name in print. 

There was a time in my career where sending your study to be published had to be quality, because if you sent junk once too often, whatever you sent in the future was just put in the trash.


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## rhan101277 (Jan 18, 2011)

I think there is much research that providing crystalloid is helpful, it bridges the gap until blood can get infused.  Back in the day all they did was constrict by using epi drip or whatever.  It really does not matter how much constricting you do when it is a volume issue.  People were loosing extremities and what not from that type of thing.


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## Veneficus (Jan 18, 2011)

rhan101277 said:


> I think there is much research that providing crystalloid is helpful, it bridges the gap until blood can get infused.  Back in the day all they did was constrict by using epi drip or whatever.  It really does not matter how much constricting you do when it is a volume issue.  People were loosing extremities and what not from that type of thing.



It only helps in nonprogressive shock. 

According to the ACS (and I am sure a few other sources) In stage 1 blood loss, and transiently in stage 2.

It restores volume when bleeding has been controlled or is self limiting. If there is a viable circuit, it can increase CVP. However, when the circuit is open, it can do more harm than good trying to normalize numbers with a substance that doesn't carry oxygen. 

I would like to see evidence that it bridges any gaps.

I could pour crystalloid into somebody and achieve BPs of anything I wanted. It doesn't mean it will help at all.


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## Shishkabob (Jan 18, 2011)

The thing I don't like about this study (besides what I already put)

The better / more progressive agencies aim to do permissive hypotension and maintaining MAP and CVP.


If you don't have an adequate MAP, nothing else matters, period.  Might as well let the person bleed out on scene... same outcome.


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## medicRob (Jan 18, 2011)

Linuss said:


> If you don't have an adequate MAP, nothing else matters, period.  Might as well let the person bleed out on scene... same outcome.



You should really consider moving on to critical care paramedic when you get the chance.


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## abckidsmom (Jan 18, 2011)

Linuss said:


> The thing I don't like about this study (besides what I already put)
> 
> The better / more progressive agencies aim to do permissive hypotension and maintaining MAP and CVP.
> 
> ...




Are there people who monitor CVP prehospitally?  How do they acheive that?


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## Veneficus (Jan 18, 2011)

abckidsmom said:


> Are there people who monitor CVP prehospitally?  How do they acheive that?



Jugular Venous Pulsation.

Cap refil. Frank-Starling law in a closed circuit what goes out must come back. If the cap refil is delayed something is very much wrong with the circuit. Now it is just a matter of inflow or outflow from the right heart.


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## clibb (Jan 19, 2011)

Depends on cold or warm fluids, right? Give a trauma victim cold fluids is like leading the patient to death.


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## usalsfyre (Jan 19, 2011)

Linuss said:


> The thing I don't like about this study (besides what I already put)
> 
> The better / more progressive agencies aim to do permissive hypotension and maintaining MAP and CVP.
> 
> ...



Except if you let them bleed out on scene you save their estate a several hundred thousand dollar healthcare bill...


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## WTEngel (Jan 20, 2011)

You both (Linuss & 187) should probably tone it down and get back on topic before the mods step in...


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## Blessed187 (Jan 20, 2011)

WTEngel said:


> You both (Linuss & 187) should probably tone it down and get back on topic before the mods step in...



It's done, I said my peace


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## ffemt8978 (Jan 20, 2011)

WTEngel said:


> You both (Linuss & 187) should probably tone it down and get back on topic before the mods step in...



Too late....

Thread closed.


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## ffemt8978 (Jan 20, 2011)

Now that this thread has been cleaned up, I've reopened only because I believe this is an important topic.  To those of you whose posts were removed simply because they quoted an offending post, I apologize but there was no way for me to leave them and still have the thread make any sense.

Let me make one thing real clear, right here and right now...

*BE POLITE*


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## AnthonyM83 (Jan 20, 2011)

Haven't these studies been around for awhile? The previous PHTLS edition basically taught the same thing. IV's en-route, not on-scene, and specific guidelines for fluids and permissive hypotension....


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## jrm818 (Jan 20, 2011)

AnthonyM83 said:


> Haven't these studies been around for awhile? The previous PHTLS edition basically taught the same thing. IV's en-route, not on-scene, and specific guidelines for fluids and permissive hypotension....



Right, that was my point about the hypothesis already having been generated.  This particular study is really nothing more than a question-poser, and the questions have already been posed, and some answers produced, as you note.

I do think sometimes a bit more specificity is called for when people say "permissive hypotension."  Does this mean no fluid at all?  Delayed fluid recussitation until in-hospital?  Targeted fluids to some SBP/MAP/clinical assessment level?  What level?

I get the impression that usually we mean "aiming for a MAP of 65 or 70", and that doesn't really strike me as "hypotensive" per se.  That said, there is even dispute over what "normotension" is, and there is some evidence that, at least in blunt trauma, the hypertensive line may begin at a systolic of 110 (as opposed to the 90 that was apparently quoted in PHTLS):

http://www.ncbi.nlm.nih.gov/pubmed/19077604
http://www.ncbi.nlm.nih.gov/pubmed/17693826

My impression is that there is no great evidence for truly hypotensive recussitation in humans, although there is a lot of animal data supporting it.


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## medicRob (Jan 20, 2011)

jrm818 said:


> Right, that was my point about the hypothesis already having been generated.  This particular study is really nothing more than a question-poser, and the questions have already been posed, and some answers produced, as you note.
> 
> I do think sometimes a bit more specificity is called for when people say "permissive hypotension."  Does this mean no fluid at all?  Delayed fluid recussitation until in-hospital?  Targeted fluids to some SBP/MAP/clinical assessment level?  What level?
> 
> ...



I've gotten to the point where I actually put pieces of black tape on the monitor in the trauma sim lab when training students that covers the systolic and diastolic, having them rely on only the MAP pressure to know when fluids and drugs like levo are appropriate. So many people neglect the little number in parenthesis beside the blood pressure on the monitor. You'd be surprised at how many paramedics when asked if they can calculate MAP from a BP say no.


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## Veneficus (Jan 20, 2011)

*hemostasis vs resuscitation*

I love this topic, because even on the trauma boards it comes up on a very regular basis. There are many theories. Many studies. Much conflicting thinking.

From the surgical expert point of view, there is no question that hemostasis needs to be accomplished before resuscitation begins. (there was a study cited in the sebastion textbook of surgery on page 100, but I don't have it in front of me this second to cite, but I remember the page) It basically demonstrated a significant decrease in survival if resuscitation was begun prior to hemostasis.

But from the EMS standpoint, it is a chicken or egg question. If you cannot control the bleed, because it is occult and you can't find it or you know it is there but as of yet don't have a damage control surgery protocol (to my knowledge, nobody does) any attempt to begin resuscitation of tissue with crystaloid is going to have a negative effect. 

If you keep CVP up without a closed circuit, all you are doing is managing and treating numbers (even if you don't have them)

If you can raise MAP with crystaloid, you at least have some control of bleeding. However, the physiologic response to hypovolemia is a very excellent compensatory mechanism up to about 20-33% volume loss (depending on your favorite book) So the question becomes how much prehospital resuscitation is even required? Is the potential to reopen wounds or cause an abd compartment syndrome with arbitrary or high volume beneficial?

The answer I think is case specific, which again brings us to treating patients not protocols. 

As a potential diagnostic test, you can check the response to dopamine, but I think you will not see that as a protocol and will have a vvery hard time convincing anyone but me to let you do it.

I would offer this *opinion* on the matter:

If the mental status is altered and the curcuit is reasonably closed, carefully start fluid at a slow rate. 

If the circuit is open and uncontrolled, give no fluid.

If the mental status is intact and the circuit is closed, judiciously or precisely use fluids.

If the mental status is intact and the circuit open, focus all your attention on slowing the bleed at the expense of starting fluid.


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## medicRob (Jan 20, 2011)

Veneficus said:


> I love this topic, because even on the trauma boards it comes up on a very regular basis. There are many theories. Many studies. Much conflicting thinking.
> 
> From the surgical expert point of view, there is no question that hemostasis needs to be accomplished before resuscitation begins. (there was a study cited in the sebastion textbook of surgery on page 100, but I don't have it in front of me this second to cite, but I remember the page) It basically demonstrated a significant decrease in survival if resuscitation was begun prior to hemostasis.
> 
> ...



I suppose it is easier for me in the ICU environment, seeing as the drugs and treatments available are somewhat limitless.. For instance, if I have my patient on max levophed and they are still only able to maintain a MAP of 65, just barely, and drop their pressure as soon as the dose is taken down, then I know the patient is significantly compromised. In EMS, that luxury is not afforded, there are so many interventions that must be taken in such a little period of time you actually have with the patient that the EMS provider has to assess a patient's trending in a matter of minutes and hours as opposed to days like we can in-hospital.


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## Veneficus (Jan 20, 2011)

medicRob said:


> I suppose it is easier for me in the ICU environment, *seeing as the drugs and treatments available are somewhat limitless.. *For instance, if I have my patient on max levophed and they are still only able to maintain a MAP of 65, just barely, and drop their pressure as soon as the dose is taken down, then I know the patient is significantly compromised. In EMS, that luxury is not afforded, there are so many interventions that must be taken in such a little period of time you actually have with the patient that the EMS provider has to assess a patient's trending in a matter of minutes and hours as opposed to days like we can in-hospital.



Easier in the ICU? Perhaps for nursing.

To whom much is given, much is expected.

I extremely caution you about getting tied up with numbers. There are more variables to MAP than peripheral constriction and if you do not find out which one is causing your problem and fix it, the patient can crash on you near instantaneously when they decompensate from something like high output failure attempting to overcome the resistance.

Use numbers to build preclinical trends. Using them as the ratio of normal only works sometimes.


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## boingo (Jan 21, 2011)

There is research taking place currently using hypothermia in trauma resuscitation using a pig model, where the pig is bled out, rapidly cooled and left for a few hours, then the vascular injury is repaired and the pig is warmed up. According to the surgeon running the research the pigs are neurlogically intact after resus, after being "dead" for 2 hours.  Obviously, this is an oversimplification of the process, but interesting none the less.  A "suspended animation" if you will.


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## Veneficus (Jan 21, 2011)

boingo said:


> There is research taking place currently using hypothermia in trauma resuscitation using a pig model, where the pig is bled out, rapidly cooled and left for a few hours, then the vascular injury is repaired and the pig is warmed up. According to the surgeon running the research the pigs are neurlogically intact after resus, after being "dead" for 2 hours.  Obviously, this is an oversimplification of the process, but interesting none the less.  A "suspended animation" if you will.



That has been the elusive goal for some time.


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## boingo (Jan 21, 2011)

Those Haaahvaaad docs are wicked smaaaaaht.


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## Luno (Jan 21, 2011)

I'd definitely like to review this study, there is way too much open to subjective opinion, simply based on the article.  Do we know that too much fluid kills?  Yes, absolutely, this has been studied since the military medics in vietnam were "killing" their patients with fluids.  I'll try to get my hands on that study, I reviewed it probably 5 years ago when I was working heavily in Tac-Med, and we were looking at the necessity of fluids in our medic packs, and how much.  Also is this in direct relationship to creating too much pressure in the system and blowing clots, i.e. over 93 systolic?  Or I guess another way to look at it, is that IV fluid is contraindicated in trauma patients because severe trauma patients die, and since they came in with IV access and fluids, that must be what killed them...   Sorta like the serial killers eat cornflakes arguments... I'll try to find that vietnam study about thoracic trauma and survivability with/without IV fluids.  -luno


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## Veneficus (Jan 21, 2011)

Luno said:


> I'd definitely like to review this study, there is way too much open to subjective opinion, simply based on the article.  Do we know that too much fluid kills?  Yes, absolutely, this has been studied since the military medics in vietnam were "killing" their patients with fluids.  I'll try to get my hands on that study, I reviewed it probably 5 years ago when I was working heavily in Tac-Med, and we were looking at the necessity of fluids in our medic packs, and how much.  Also is this in direct relationship to creating too much pressure in the system and blowing clots, i.e. over 93 systolic?  Or I guess another way to look at it, is that IV fluid is contraindicated in trauma patients because severe trauma patients die, and since they came in with IV access and fluids, that must be what killed them...   Sorta like the serial killers eat cornflakes arguments... I'll try to find that vietnam study about thoracic trauma and survivability with/without IV fluids.  -luno



The earliest research I have seen on it was WWI. 

We know that it is basic physics that when the pressure inside the vessle is greater than that outside, you have bleeding. 

We know from the pathophysiology of coagulation disorders that serum, defined as plasma with no blood elements is hypocoaguable. Adding fluid dilutes plasma, and basic chemistry dictates in order to have reaction there has to be contact.

But one of the major issues with fluid is the post resuscitation fluid balance. This is manifest in the increase in electrolyte imbalance when isotonic saline is used as well as the water compartment shifts in conditions like abdominal compartment syndrome.

When considering that up to 50% of vascular volume can be replaced by Intracellular volume, in up to at least 900ml of blood loss, how easy is it to lose site of total body water balance in the short term efforts of increasing intravascular volume? 

To what end?

Unfortunately there is no shorcut and limited knoweldge in reading studies without the knowledge of the basic science behind it when determining clinical practice. A mistake more and more common as time goes on.

So I don't think it is simply a question of if individuals had wounds incompatible with life and were given fluid, but who had wounds compatible with life and how much fluid was given and what exactly caused them to die? 

Uncontrolled hemorrhage or failure to reestablished biochemical homeostasis post resuscitation because of the interventions of the resuscitation?

I advocate that trauma is perhaps one of if not the most complex medical problems known to date. It is total body biochemical level manipulation with opposing therapies. If a provider doesn't understand it, the studies and practice recommendations are moot. 

I actually question whether or not a "protocol" approach is even possible considering what helps the brain hurts the heart, what helps the kidneys hurts the liver, etc. 

Best practice may require sub protocols, like injury to body region X or organ Y.


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## usalsfyre (Jan 21, 2011)

Any thoughts on the increased use of colloids vs isotonic solutions?


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