Why We Delay Volume Expansion in Penetrating Trauma

On the Shoulders of Giants

Holey torso, Batman!
This landmark study found that permissive hypotension in penetrating trauma patients in the prehospital setting led to improved survival over prehospital volume expansion to raise blood pressure (70% vs. 62% survival).  Turns out if patients have holes in their blood vessels and you give IV fluid to raise the BP before fixing said holes, they do worse than if you left them alone and allowed them to remain hypotensive in the prehospital setting.

Spoon Feed
In patients with penetrating trauma, it is better to allow prehospital hypotension and hasten transport for definitive repair prior to beginning volume resuscitation than to try to normalize vital signs in the field by giving IV fluid.


Abstract

N Engl J Med. 1994 Oct 27;331(17):1105-9.

Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.

Bickell WH1, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL.

Author information:

1Department of Emergency Services, Saint Francis Hospital, Tulsa, Okla.

Comment in

Abstract

BACKGROUND:

Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso.

METHODS:

We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room.

RESULTS:

Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group.

CONCLUSIONS:

For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

PMID: 7935634 [PubMed - indexed for MEDLINE]