guidelines for pre-hospital fluid therapy in trauma pres
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Guidelines for Pre-hospital Fluid Therapy in Trauma
- do we need them?Christina Carding
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Content
• Introduction• Summary of NICE guidelines• Summary of EAST guidelines• Overall conclusions• References
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Introduction
• Currently a lack of evidence demonstrating a benefit of prehospital fluid resuscitation
• Fluid resuscitation is considered to be standard of care.
• There has been an increase in the number of prehospital procedures over the last 10 years.
• “scoop and run” v.s “Stay and play”
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Risks v.s Benefits
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NICE guidelines
7 studies
• Should you give fluids?• To which patients?• If so how much?• What type?
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NICE guidelines• IV fluids should not be administered if a radial
pulse can be felt in blunt injuries (or for penetrating torso injuries, if a central pulse can be felt)
• ADULTS - in the absence of a radial pulse fluids should be administered in boluses of ≤250ml. Patient reassessed and process repeated until radial pulse felt
• CHILDREN - insufficient evidence• Administration of fluid should not delay transport
to hospital• Crystalloid solution is recommended
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EAST guidelines42 studies
• Should injured patients have vascular access attempted prehospital?
• What location is preferred for access?• Should IV fluids be administered?• Which solution is preferable?• At what volume and rate?
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EAST guidelines• Venous access attempted at the scene delays transport - placement
of access should be enroute. Intraosseous access can be attempted• No preferred access site• Patients with penetrating injury and short transit time (<30 mins) –
fluids should be withheld in prehospital setting if palpable brachial pulses
• Fluids should only be given:In 250ml bolusesTo return the patient to coherent mental statusTo return palpable radial pulses• Patients with traumatic brain injury – fluids titrated to maintain systolic
BP >90mmHg or mean pressure >60mmHg• 0.9% sodium chloride is recommended• Rapid infusion systems and or pressurised devices should not be
used
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Summary• Insufficient evidence that blunt or
penetrating trauma patients benefit from prehospital fluid resuscitation if a brachial pulse is palpable
• In the absence of a brachial pulse fluid should be administered in 250ml boluses with continual reassessment
• If suspected head injury fluid should be administered cautiously as above
• Normal saline is recommended
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References
• EAST practice parameter workgroup for prehospital fluid resuscitation 2009. Guidelines for prehospital fluid resuscitation in the injured patient. The Journal of TRAUMA injury, infection, and critical care August 2009;67,2: 389-402.
• NICE January 2004. Pre-hospital initiation of fluid replacement therapy in trauma. National Institute for Clinical Excellence, Technology Appraisal 74.
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