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PREHOSPITAL TRAUMA CARE 3
PREHOSPITAL FLUID RESUSCITATION: WHAT TYPE, HOW MUCH AND CONTROVERSIESFluid resuscitation is a vital treatment in the care of hypotensive trauma patients. Restoration of effective circulating blood volume improves oxygen delivery, thereby diminishing the untowardeffects of shock at the cellular and organ level. However, fluid resuscitation, in and of itself, is not apanacea. Whereas restoration of effective circulating blood volume is essential, the method of supplying fluid is more controversial and complicated by several confounding factors. The inability todeliver definitive care in the field, the heterogeneity of patient populations, the variability inmechanism of injury, and the level of infield hemorrhage control make precise study of the topicchallenging. Therefore, the debate persists concerning the type, the amount, and the timing of fluidadministration. The purpose of this discussion is to provide insight in the use of fluid resuscitation of trauma patients in the prehospital setting.
If trauma is the leading cause of civilian death in Americans aged less than 45 years and the fourthleading cause of death in the United States for all ages, hemorrhagic shock is the primary physiologicdefect leading to death. Volume deficits develop not only as a result of blood loss, but also due todiffuse capillary-endothelial leak and fluid shifts from intravascular to the interstitial space. Thesedeficits, and the attendant hypoperfusion, potentially lead to multiple organ dysfunction, failure,and death.Aggressive fluid administration has been mainstay therapy in trauma patients for over 40 years.Estimates of the numbers of trauma patients in the United Kingdom given prehospital intravenousfluid range from 8.6 to 65 patients per 100,000 population per year. However, for the last 15 years,this practice, especially in the setting of uncontrolled hemorrhage, has been questioned.
CAUSES OF SIGNIFICANT HEMORRHAGE
The causes of hemorrhage vary depending on the mechanism of injury. In blunt trauma, bleedingusually emanates from solid organs such as the spleen and liver, mesenteric blood vessel tears,pelvic and femur fractures, thoracic bleeding from lung lacerations or intercostal vessel bleedingfrom rib fractures or external causes such as scalp lacerations. Uncontained bleeding from aortictransection and cardiac rupture usually leads to exsanguination at the scene. When the woundingmechanism is secondary to penetrating trauma, uncontrolled major vascular injury usually is thesource of the hemorrhage.
In the prehospital setting, emergency medical technicians perform an immediate assessment of thetrauma victim in the form of a primary and secondary survey. This assessment includes an evaluationof the patient for life-threatening conditions that need to be promptly addressed. The patency of theairway is initially evaluated. This is followed by auscultation of breath sounds assessing forpneumothoraces or hemothoraces. Attention is then turned to the circulation. Central andperipheral pulses are assessed. Obvious sources of external blee
ding are controlled. The patient’sblood pressure is measured. Because definitive care cannot be rendered at the scene, a “scoop andrun” rather than “stay and stabilize” philosophy should be evoked. Attempts at intravascular
cannulation should not delay transfer to the trauma center.