Guidelines for Pre-hospital Fluid Therapy in Trauma

- do we need them?Christina Carding

Content

• Introduction• Summary of NICE guidelines• Summary of EAST guidelines• Overall conclusions• References

Introduction

• Currently a lack of evidence demonstrating a benefit of prehospital fluid resuscitation

• Fluid resuscitation is considered to be standard of care.

• There has been an increase in the number of prehospital procedures over the last 10 years.

• “scoop and run” v.s “Stay and play”

Risks v.s Benefits

NICE guidelines

7 studies

• Should you give fluids?• To which patients?• If so how much?• What type?

NICE guidelines• IV fluids should not be administered if a radial

pulse can be felt in blunt injuries (or for penetrating torso injuries, if a central pulse can be felt)

• ADULTS - in the absence of a radial pulse fluids should be administered in boluses of ≤250ml. Patient reassessed and process repeated until radial pulse felt

• CHILDREN - insufficient evidence• Administration of fluid should not delay transport

to hospital• Crystalloid solution is recommended

EAST guidelines42 studies

• Should injured patients have vascular access attempted prehospital?

• What location is preferred for access?• Should IV fluids be administered?• Which solution is preferable?• At what volume and rate?

EAST guidelines• Venous access attempted at the scene delays transport - placement

of access should be enroute. Intraosseous access can be attempted• No preferred access site• Patients with penetrating injury and short transit time (<30 mins) –

fluids should be withheld in prehospital setting if palpable brachial pulses

• Fluids should only be given:In 250ml bolusesTo return the patient to coherent mental statusTo return palpable radial pulses• Patients with traumatic brain injury – fluids titrated to maintain systolic

BP >90mmHg or mean pressure >60mmHg• 0.9% sodium chloride is recommended• Rapid infusion systems and or pressurised devices should not be

used

Summary• Insufficient evidence that blunt or

penetrating trauma patients benefit from prehospital fluid resuscitation if a brachial pulse is palpable

• In the absence of a brachial pulse fluid should be administered in 250ml boluses with continual reassessment

• If suspected head injury fluid should be administered cautiously as above

• Normal saline is recommended

References

• EAST practice parameter workgroup for prehospital fluid resuscitation 2009. Guidelines for prehospital fluid resuscitation in the injured patient. The Journal of TRAUMA injury, infection, and critical care August 2009;67,2: 389-402.

• NICE January 2004. Pre-hospital initiation of fluid replacement therapy in trauma. National Institute for Clinical Excellence, Technology Appraisal 74.