Fluid Resuscitation of the Actively Bleeding Trauma Patient: What Is Our Goal?
September 1, 2002 3 minutes read
Abstract & Commentary
Source: Dutton RP, et al. Hypotensive resuscitation during active hemorrhage: Impact on in-hospital mortality. J Trauma 2002;52:1141-1146.
While there can be no doubt that hemorrhage is the leading mechanism of post-traumatic death, the approach to combating this problem is marked with dogma and controversy. Aggressive fluid administration in animal models leads to increased bleeding because of increased arterial and venous pressure, dilution of clotting factors, and decrease in blood viscosity. This is especially true when a normal systolic blood pressure (SBP) is used as the target for fluid resuscitation with a marked decrease in survival. The clinical study of controlled hypotension in the resuscitation of trauma patients has been confined to one prospective trial completed in Houston, TX, in the 1990s. In this study, hypotensive victims of penetrating torso trauma were randomized in the field either to receive intravenous fluids or not, and this therapy was continued until the end of the patient’s stay in the emergency department. This study showed a survival advantage in the no-fluid group, although the results were limited to penetrating trauma (a condition most similar to the animal models). In addition, aggressive resuscitation in the operating room followed the hypotensive phase of management. Last, the authors resuscitated patients with no fluid or aggressive fluid use, and did not limit administration when perfusion appeared to be restored. The resultant controversy called into question the value of the "stay and play" style of emergency medical service (EMS) resuscitation, and suggested that the "scoop and run" method was advantageous.1
In this study, patients presenting in hemorrhagic shock were randomized to one of two fluid resuscitation protocols: target SBP > 100 mmHg (conventional) or target SBP of 70 mmHg (low). Fluid therapy was titrated to this endpoint until definitive hemostasis was achieved. In-hospital mortality, injury severity, and probability of survival were determined for each patient. One hundred and ten patients were enrolled during 20 months, 55 in each group. The study cohort had a mean age of 31 years, and consisted of 79% male patients and 51% penetrating trauma victims. There was a significant difference in SBP observed during the study period (114 mmHg for the conventional group vs 100 mmHg for the low SBP group, p < 0.001). Injury Severity Score (19.65 ± 11.8 vs 23.64 ± l3.8, p = 0.11) and the duration of active hemorrhage (2.97 ± 1.75 hours vs 2.57 ± 1.46 hours, p = 0.20) were not different between groups. Overall survival was 92.7%, with four deaths in each group; power calculations were not reported.
The authors conclude that the titration of initial fluid therapy to a lower-than-normal SBP during active hemorrhage did not affect mortality in this study. They state that the reasons for the decreased overall mortality and the lack of differentiation between groups likely include improvements in diagnostic and therapeutic technology since prior studies, the truly heterogeneous nature of human traumatic injuries, and the imprecision of SBP as a marker for tissue oxygen delivery.
Commentary by Richard J. Hamilton, MD, FAAEM, ABMT
I think this study helps put an end to this controversy. There can be no doubt that the notion that traditional aggressive fluid resuscitation might be somehow harming patients troubled many emergency medicine physicians and trauma surgeons. This study looks at this problem but uses a more realistic population and provides a much more lucid approach to resuscitation than the study that questioned this practice in the 1990s. In fact, this current study more closely reflects the actual practice of resuscitating hypovolemic shock to a perfusing blood pressure rather than a "normal" blood pressure. For now, the "stay and play" proponents and the "scoop and run" proponents will have to "run and play" over another controversy.
Dr. Hamilton, Associate Professor of Emergency Medicine, Program Director, Emergency Medicine, MCP Hahnemann University, Philadelphia, PA, is on the Editorial Board of Emergency Medicine Alert.
References
1. Bickell WH, et al. Immediate versus delayed resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994;331:1105-1109.
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