# is anyone here... hypertonic saline for the treatment of trauma



## Veneficus (Mar 2, 2012)

using hypertonic saline for the treatment of trauma in the *pre-hospital* environment?


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## DrankTheKoolaid (Mar 2, 2012)

*re*

Not in the Pre-hospital protocols here.  Is for the Tactical medical protocols, though I am pushing for Albumin instead of 3%NS.


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## Smash (Mar 2, 2012)

No. Trialled it a fair while ago for head injury.  I can't remember if the trial was stopped early, or whether it just showed no benefit, but whatever the case it was not taken on as standard of care. 

It seems like another one of those compelling ideas that wasn't supported by the data in the end.  That said, I haven't looked at any data for a long time, so there may be something new in the field that I'm not aware of.


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## TatuICU (Mar 2, 2012)

Corky said:


> Not in the Pre-hospital protocols here.  Is for the Tactical medical protocols, though I am pushing for Albumin instead of 3%NS.



Good luck getting the albumin, not being sarcastic.  Though I think hetastarch may be a more practical choice cost wise.


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## Rettsani (Mar 3, 2012)

Veneficus said:


> using hypertonic saline for the treatment of trauma in the *pre-hospital* environment?



Did you mean NaCl ?

We use it as a carrier solution for drugs and for the short-term volume replacement. Ringer's solution is here our preferred if it is present

Low-molecular solutions in combination with high-molecular solutions are used here in trauma patients.

Low-molecular solutions in patients with traumatic brain injury and in patients with severe burns.


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## TatuICU (Mar 3, 2012)

Rettsani said:


> Did you mean NaCl ?
> 
> We use it as a carrier solution for drugs and for the short-term volume replacement. Ringer's solution is here our preferred if it is present
> 
> ...



No, I'm sure he means actual hypertonic saline (3%), not just the 0.9% NaCl, presumably as a resuscitative fluid in TBI, therapy for intracranial htn, etc. 

I've also heard of nebulizing 7% NaCl for CF patients as an adjunctive therapy though I admittedly have very little experience with CF patients.


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## Veneficus (Mar 3, 2012)

TatuICU said:


> No, I'm sure he means actual hypertonic saline (3%), not just the 0.9% NaCl, presumably as a resuscitative fluid in TBI, therapy for intracranial htn, etc.



this


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## MedicBrew (Mar 4, 2012)

No, we looked into it but we have relatively few actual hemorrhagic/ hypovolemic shock and TBI / ICP patients that made it "cost prohibitive". Same with albumin.


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## the_negro_puppy (Mar 4, 2012)

Isotonic only


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## Farmer2DO (Mar 4, 2012)

No, and in my opinion, we are a progressive system.


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## triemal04 (Mar 4, 2012)

https://roc.uwctc.org/tiki/completed-studies

Only actual study that's been done in the US (that I know of).

And for what's it's worth never heard of anyone here carrying it outside of during a study.


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## Veneficus (Mar 4, 2012)

triemal04 said:


> https://roc.uwctc.org/tiki/completed-studies
> 
> Only actual study that's been done in the US (that I know of).
> 
> And for what's it's worth never heard of anyone here carrying it outside of during a study.



I asked because there is a growing body of conflicting evidence, with benefit edging out no effect.

The mortality in the US study that was stopped listed a 28 day mortaility being the same, but ISS was not reported.


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## Doczilla (Mar 4, 2012)

Yes, I have used it as part of an actual protocal. We were supplied 3% HTS as well as mannitol, furosemide, and other things for managing severe TBI. Mind you, this was asscrackistan, so take it with a grain of salt. 

Military medical protocols are on the cutting edge when it comes to certian things, and in the stone age when it comes to other things, so you'll have to decide for yourself. Here's the guideline where it can be found: 

http://jsomonline.org/Publications/TrainingSupplement2011.pdf

10 mins later... 

Ok, I posted that link without checking, and the online version seems to be outdated... I wish I brought the hard copy from AFG with me, because it definately had it. It was a one-time trial bolus, not to be repeated. Central pontine myelinolysis is nothing to toy with.


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## triemal04 (Mar 4, 2012)

Veneficus said:


> I asked because there is a growing body of conflicting evidence, with benefit edging out no effect.
> 
> The mortality in the US study that was stopped listed a 28 day mortaility being the same, but ISS was not reported.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232054/  Link to the full study.  I had some friends taking part in this so I've heard a bit from the lectures that the various medical directors gave when this was cancelled.

The average ISS for each arm was about the same; I've never seen anything about the results being broken down specifically by ISS; I'd bet it was done but couldn't say for certain.  From what I've heard and read, part of the issue with this study was that patient's who were recieving HTS or the HTS/dextran were delayed in getting blood.  Based on what's known now, that could have potentially skewed the results.


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## Veneficus (Mar 4, 2012)

Doczilla said:


> Yes, I have used it as part of an actual protocal. We were supplied 3% HTS as well as mannitol, furosemide, and other things for managing severe TBI. Mind you, this was asscrackistan, so take it with a grain of salt.
> 
> Military medical protocols are on the cutting edge when it comes to certian things, and in the stone age when it comes to other things, so you'll have to decide for yourself. Here's the guideline where it can be found:
> 
> ...



Thanks, I have copies of the updated military guidlines.


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## Veneficus (Mar 4, 2012)

triemal04 said:


> http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3232054/  Link to the full study.  I had some friends taking part in this so I've heard a bit from the lectures that the various medical directors gave when this was cancelled.
> 
> The average ISS for each arm was about the same; I've never seen anything about the results being broken down specifically by ISS; I'd bet it was done but couldn't say for certain.  From what I've heard and read, part of the issue with this study was that patient's who were recieving HTS or the HTS/dextran were delayed in getting blood.  Based on what's known now, that could have potentially skewed the results.



I am sure there were lots of explanations, it seems most of the emergency studies show no benefit while most of the ones done by anesthesia, neurology, and various surgical disciplines showing benefit.

It seems to be a continuing trend in a number of areas that emergent studies usually find something completely different than everyone else.

It is one of the reasons I seriously doubt that any reasonable data coming out of an emergency study.


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## triemal04 (Mar 4, 2012)

Veneficus said:


> I am sure there were lots of explanations, it seems most of the emergency studies show no benefit while most of the ones done by anesthesia, neurology, and various surgical disciplines showing benefit.
> 
> It seems to be a continuing trend in a number of areas that emergent studies usually find something completely different than everyone else.
> 
> It is one of the reasons I seriously doubt that any reasonable data coming out of an emergency study.


If the data is gathered correctly, and the specific treatements are performed appropriately (and it is interpreted correctly) why discount the study?  It may be hard to do all that both prehospitally and in the ER, but when it is, that doesn't mean that the study is neccasarily wrong.

A treatement that works for a certain issue in a specific setting may not work under other conditions due to the variables involved; wouldn't it be better to know that and know that maybe some things should/shouldn't be done initially even though they work later on during the patient's care?

There was a in-hopsital study from, I think, Singapore (or maybe Italy) that was published recently that showed WORSE outcomes with post-ROSC hypothermia when it was started immedietly after ROSC versus waiting for a period of time.  Granted, there were factors involved that probably affected the outcomes, but still worth thinking about.

A single study isn't neccasarily going to be the final word on a treatement; why not repeat it under other settings to see if the results differ?


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## Veneficus (Mar 4, 2012)

triemal04 said:


> If the data is gathered correctly, and the specific treatements are performed appropriately (and it is interpreted correctly) why discount the study?  It may be hard to do all that both prehospitally and in the ER, but when it is, that doesn't mean that the study is neccasarily wrong.



Studies in emergent populations are very difficult to perform. Not because I said so, but everything from ethical considerations to confounding variables which are often unexplained or even accounted for make interpretation of the data very difficult.



triemal04 said:


> A treatement that works for a certain issue in a specific setting may not work under other conditions due to the variables involved; wouldn't it be better to know that and know that maybe some things should/shouldn't be done initially even though they work later on during the patient's care?.



I agree with this for the most part, but in the last several months, I have noticed that studies done in the emergent environment often condradict findings in other areas, whether advocating for or against a given treatment.

What's more, They do not limit their conclusions to the emergent environment. But often present the findings as globally authoritative.

I find it extraordinarily difficult to believe that the scientific priniciples of medicine suddenly change when in an emergent environment. 

I do find it reasonable that the environment will demand alteration of how those principles are applied.




triemal04 said:


> There was a in-hopsital study from, I think, Singapore (or maybe Italy) that was published recently that showed WORSE outcomes with post-ROSC hypothermia when it was started immedietly after ROSC versus waiting for a period of time.  Granted, there were factors involved that probably affected the outcomes, but still worth thinking about.



Didn't hear of it before.

However, according to your information here, it doesn't suggest hypothermia is not a valid treatment. It suggests the application of it may have to be altered.

Considering that in many disease processes radical reversal or rapid initiation of treatment has negative effects, it doesn't sound like an unreasonable conclusion.

But it doesn't authoritively denounce the treatment, as any casual observer of emergent studies seems to.



triemal04 said:


> A single study isn't neccasarily going to be the final word on a treatement; why not repeat it under other settings to see if the results differ?



That would be the goal actually.

But I still stand by my statement. The emergent studies I have read over the last year and 1/2 often differ from the conclusions of other specialists. 

Because of that ongoing observation, I am hesitant to give much credibility to them.


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## triemal04 (Mar 4, 2012)

Veneficus said:


> Studies in emergent populations are very difficult to perform. Not because I said so, but everything from ethical considerations to confounding variables which are often unexplained or even accounted for make interpretation of the data very difficult.


Sure, and there are many that aren't performed very well yet are held up as shining examples of what should be done.  The same could be said for medical studies in general, but I do agree it's probably more prevalent in ER/prehospital studes.  That doesn't mean that all are though, just that a more critical look needs to be taken before following what's recommended.



Veneficus said:


> I agree with this for the most part, but in the last several months, I have noticed that studies done in the emergent environment often condradict findings in other areas, whether advocating for or against a given treatment.
> 
> What's more, They do not limit their conclusions to the emergent environment. But often present the findings as globally authoritative.


And that's a problem.  Like I said, due to multiple variables that aren't found in every situation, a given treatement may have different results in different settings.  If one study done in an emergent setting contradicts another done in a more controlled environment, it shouldn't be held as the new standard, but 1) held as a reason that maybe that treatement isn't appropriate in the emergency setting only, and 2) cause people to start looking at why the results differ.  Granted, this doesn't always happen.  Hello EBM super-advocates.



Veneficus said:


> I find it extraordinarily difficult to believe that the scientific priniciples of medicine suddenly change when in an emergent environment.
> 
> I do find it reasonable that the environment will demand alteration of how those principles are applied.


That's what I mean.



Veneficus said:


> Didn't hear of it before.
> 
> However, according to your information here, it doesn't suggest hypothermia is not a valid treatment. It suggests the application of it may have to be altered.
> 
> ...


It came out a few monthes ago; had a relatively small number of enrolled patients as I remember.

I don't mean to say it does.  It's just an example of how a treatement that usually is seen as a benefit, when used under other cirucmstances may actually be harmful, or at best indifferent.



Veneficus said:


> That would be the goal actually.
> 
> But I still stand by my statement. The emergent studies I have read over the last year and 1/2 often differ from the conclusions of other specialists.
> 
> Because of that ongoing observation, I am hesitant to give much credibility to them.


I'll still say that as long as the study was well run there isn't any reason to discount it.  But there isn't any reason to say that it should supercede another well run study that had different results.  Just that maybe things should be done differently depending on the factors affecting the patien'ts condition and the setting of care.


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## EMT11KDL (Mar 4, 2012)

The only place i see the use is military. (hextend) we use a 6% solution... I would love to see it on the civilian side


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## Smash (Mar 4, 2012)

EMT11KDL said:


> The only place i see the use is military. (hextend) we use a 6% solution... I would love to see it on the civilian side



Why?


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## EMT11KDL (Mar 4, 2012)

Smash said:


> Why?



Being able to give a pt smaller amount of fluid... Ie like hextend if i give 500ml it will end up increasing the fluid to 750ml in the cardiovascular system.. With a max of 1000ml. Maybe 1500 ml depending on how the patient presents after the first 1000. Its an easy way to help reduce the likely hood of shock and bring pressure us without having to make koolaid of the blood.


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## zmedic (Mar 4, 2012)

In the military the advantage of volume expanders is you don't have to carry as much. It's much easier to have your medic carry 500ccs of something than 2 liters of it. I'd also point out that I'm very suspicious of military research, as most of their patients are very healthy 20 year olds. I'm never sure how much that data transfers to my stateside population. Ie just because 20 year olds can handle factor 7 without too many strokes, I don't think my 60 year old who just fell down the stairs is in the same category. 

The best thing for people who are bleeding out is blood. And in most places in the US, you can get your trauma patient to the ER pretty quickly. So the patient should be able to get O negative fairly rapidly. As others have said, these patient's problem isn't really blood pressure. You can survive with a pretty low MAP. It's lack of oxygen and CO2 carrying capacity.


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## Smash (Mar 5, 2012)

EMT11KDL said:


> Being able to give a pt smaller amount of fluid... Ie like hextend if i give 500ml it will end up increasing the fluid to 750ml in the cardiovascular system.. With a max of 1000ml. Maybe 1500 ml depending on how the patient presents after the first 1000. Its an easy way to help reduce the likely hood of shock and bring pressure us without having to make koolaid of the blood.



I appreciate the rationale, but the point is that there isn't any particularly compelling evidence that hypertonic solutions confer any benefit to the patient.  That being the case, it doesn't seem like a good use of money to stock anything other than NaCl or LR.  Given your enthusiasm I thought you may have been aware of some research that demonstrated benefit. 

Zmedic makes some valid points, particularly with the weight aspect and military medicine, however this doesn't really apply to civilian EMS (possibly some Rambo Ambo, whoops, I mean tactical medic, might need it)
Ultimately if we need to replace red stuff we should be using red stuff (or parts thereof)


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## mycrofft (Mar 5, 2012)

If volume loss is through an open conduit, I fail to see where simply attracting fluid back to the conduit system will help. Recruiting fluids that way just lines them up for the egress into the autotransfusor or onto the floor (or into the third-spaces).

 I'm not sure if hypertonic solution will recruit much fluid through normal vascular conduit walls. Not supposed to. Maybe if they are teetering on the edge of collapse due to third-spacing plasma/serum, or due to poison or anaphylaxis.

Don't hypertonic salt solutions have the potential for cautery or at least vein irritation?

If something works on the battlefield as a hasty expedient measure and can be more-conveniently stored than blood, and it does't trash outcomes in the Role 3, then use it in that setting. If something does not work in the ED, then stop using it there.

Hospital retrospective studies should be to prospect for areas to fix or areas to see what's going right. Due to variances in related care, overall technique and staffing, there are too many confounders. The ED might actually be a better setting due to very limited number of potential caregivers. Devil is in the other presenting problems, such as alcoholism, concurrent trauma, etc.


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## mycrofft (Mar 5, 2012)

*One of the true advantages of EMTLIFE: FEEDBACK!*

One of my mentors points out the advantages sought by reducing the absolute volume of infused fluids through hypotonic recruitment of other fluids, thus addressing the issues of over-voluming the pt (And maybe also "diluting them pink"...the blood that is, not their skin color).

Thanks!


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## EMT11KDL (Mar 5, 2012)

I have used it for trauma. Yes main reason for needing is a compromised system. But you should be addressing that issue. Also lr and nacl  is great to carry. I come from a military back ground where we try to do a lot with very little. And on the civilian side we should have kinda the same attitude. 

With military im happy with q pressure above 80. and yes most pt i get r in there 20's and healthy but they have an increased chance of very serious injuries and my job is to stabilize and prep the pt for the best chance of survival. And volume loss is the number 1 cause of death and the number 1 most preventable if treated rapidly and correctly


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## gumby4532 (Mar 8, 2012)

I believe Northern California (?) was testing 7.5% Saline with Dextran, a HIGH hypertonic solution with osmotic and oncotic pull for trauma patients. I heard it had very positive results on the patients. But this is something that was passed through the grapevine to me.


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