In the Journal of Trauma and Acute Care Surgery this month two new articles: Aggressive early crystalloid resuscitation adversely affects outcomes in adult blunt trauma patients: An analysis of the Glue Grant database, and Goal Directed resuscitation in the prehospital setting: A propensity adjusted analysis.
Most paramedics are no doubt aware of the concept of permissive hypotension in the setting of penetrating trauma to avoid coagulopathy, hypothermia, clot wash out, ARDS, worsened acidosis and so on. What seems to be becoming increasingly evident is that aggressive use of crystalloids in just about any traumatic setting may be bad for your patient.
From these two studies (and bear in mind that these are registry reviews) it would seem that in the severely injured blunt trauma patient with hypotension, resuscitation with crystalloid is probably going to help, but we need to be careful not to give too much. Unfortunately, what constitutes “enough” and “too much” is not really known (which doesn’t make things any easier)
The only real replacement for red stuff is red stuff (or maybe the parts thereof). Any non-blood fluid should be given with the understanding that it is possibly going to be bad for your patient in the long run, and thus due care exercised. I think that the days of opening up the drip and letting it run should well and truly be over. Fluids should be treated as a drug and as with any drug, the dangers of giving too much to any particular patient should be considered.
Whilst my protocol calls for 20ml/kg boluses in any blunt trauma patient with tachycardia and/or hypotension, I will be exercising more caution than this and giving smaller aliquots to try to minimize over-resuscitation. This, as with all interventions, needs to be considered on a case by case basis.
Bring on the synthetic, oxygen, platelet and clotting factor carrying, stable at room temperature, long shelf life blood replacements I say! (And for the love of all that is good, get TXA on your ambulances now; there is really no excuse not to)