Article Citation: William H. Bickell, Matthew J. Wall, Jr., Paul E. Pepe, R. Russell Martin, Victoria F. Ginger, Mary K. Allen, and Kenneth L. Mattox. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries. N Engl J Med 1994; 331:1105-1109. October 27, 1994. https://www.ncbi.nlm.nih.gov/pubmed/7935634
What we already know about the topic: Early aggressive fluid resuscitation in trauma victims has, for a long time, been the standard of care. The idea was that a patient arrives hypotensive secondary to exsanguination, and fluids would restore depleted intravascular volume, thus allowing for organs to be perfused. However, this wisdom has been questioned, with recent smaller studies demonstrating that elevating blood pressure can cause disruption of burgeoning clots, and the rapid infusion of fluids may be causing hypothermia and a dilution of clotting factors, none of which ultimately benefit the patient and may actually lead to worse outcomes.
Why this study is important: This study more definitively shows that early aggressive fluid resuscitation in patients with penetrating injuries can be harmful to the patient, and that transiently treating the heart rate and blood pressure of a bleeding patient with crystalloid (rather than blood products, for example) does not seem to serve in the patient’s best interests.
Brief overview of the study: This was a randomized controlled trial (not blinded), which looked at 598 adults who presented with penetrating torso injuries who had a pre-hospital systolic BP less than or equal to 90, with the primary outcome being survival to discharge. The study took place in a single trauma center over a three-year period. The “intervention” group got, on average, 386 ml of crystalloid before operative intervention, while the “control” group got 2611 ml of crystalloid. The overall result was that survival was higher (statistically significant) in the group that had decreased and delayed crystalloid resuscitation (70% vs. 62%, P=0.04).
Limitations: While the study was well designed, there were several things that could have been done better/differently. First of all, the study was not blinded, which, while difficult, was not impossible. Another limitation was that lack of comparison to blood products, which are often given aggressively to hypotensive patients with penetrating trauma and hypotension, prior to operative management. Is comparing crystalloid to no crystalloid even definitive now, or should the real question be crystalloid vs. blood, or no crystalloid at all vs. blood. Finally, a single center has very specific trauma policies and practise, so there is some concern whether this study can be generalized to a truly impressive spectrum of practice across trauma centers in the US.
The bottom line: It seems that trauma centers have been moving away from massive infusion of crystalloid already, and this study reaffirms that practice, citing an impressive increase in survival rate. So, for now, put that saline back on the rack and get the patient to the OR ASAP.