Studies now show that trauma patients who receive IV fluids before they reach the hospital are more likely to die than those who have not.
Paramedics and health care professionals administer intravenous (IV) fluids to patients who suffer from particularly traumatic injuries that involve large amounts of blood loss, such as motor vehicle accidents, gunshot wounds and other forms of trauma.
Data justifying this practice have been limited since the advent of paramedic emergency medical services.
A group of scientists led by Elliott R. Haut in the Division of Acute Care Surgery at Hopkins’s School of Medicine recently discovered that the harm associated with prehospital IV fluid administration is more significant than previously thought for trauma victims.
After analyzing data from over 700,000 patients from the National Trauma Data Bank based on the patient’s demographics, mechanism of injury, physiologic and anatomic injury severity and prehospital procedures including IV fluid administration and full spinal immobilization, they discovered that almost half of the patients received prehospital IV.
Out of these patients, the data showed that 4 out of 10 died. These results were especially severe in patients with penetrating mechanism, low blood pressure, severe head injury and patients undergoing immediate surgery.
The purpose of IV fluids is to stabilize trauma patients by replacing fluid volume that has been lost through severe bleeding and maintaining blood flow to the vital organs in the body. However, studies, including this one, show that IV fluid administration can cause delays of transport to definitive care at hospitals to the point that, in some cases, the time to place an IV exceeds that of the actual transport itself.
Paramedics refer to these practices as the “scoop and run” approach, which favors minimal prehospital procedures in favor of rapid transport to definitive care, and the “stay and play” model of prehospital trauma care. Increasingly, many trauma providers are coming to favor the former over the latter.
Furthermore, another theory that seeks to explain why IVs can be more harmful than helpful is based upon the idea of “popping the clot.” This theory suggests that patients, who have stopped bleeding temporarily from natural physiological responses to injury, can begin to bleed again if IV fluids are forced into their veins without their bleeding source being surgically controlled.
Some trauma centers have begun to suggest restrictions on IV fluid administration to protect trauma patients from preventable death.
The Eastern Association for the Surgery of Trauma practice management guidelines committee has recently published new evidence-based guidelines regarding the use of prehospital IV fluids in trauma patients suggesting that IV catheters need not be placed. They also argue that IV fluids should be withheld from patients with penetrating torso trauma and in all trauma patients until active bleeding is addressed.
Also, current military teaching recommends fluid administration based on physiologic signs rather than using IV fluids for all patients. Advanced Trauma Life Support still currently recommends IV fluid administration for many patients but only when given to “maintain life until definitive care is possible” and suggesting that “a less than normal blood pressure is acceptable” in particularly severe situations.
As a compromise between time and supposed benefit, some authors suggest that prehospital providers should start IVs en route rather than in the field. The success rates for initiating IV therapy en route to the hospital are high — 92 percent for trauma patients. Otherwise, the routine use of IV placement and fluid administration for all trauma patients should be discouraged.
“Most people know about the Golden Hour, the time after an injury when there is the highest likelihood for survival if patients receive prompt medical treatment,” Haut, the study’s lead author and an associate professor of surgery, anesthesiology and critical care medicine at Hopkins, said in an interview with www.futurity.org. “But for some people it may be the Golden 20 Minutes, and, in others, 10 minutes can make the difference between life and death. Many things can be fixed if you get patients to the hospital in time, but it’s hard to change people’s practices when the change means doing less.”
