Quality of the References
The references were classified using methodology established by the Agency for Health Care Policy and Research of the U.S. Department of Health and Human Services (add reference).11 Additional criteria and specifications were used for classification of articles from a tool described by Oxman et al.12 Thus, the classifications were as follows:
- Class I: Prospective, randomized controlled trials. A total of 10 Class I articles were reviewed.
- Class II: Clinical studies prospectively collected data and retrospective analyses, which were based on clearly reliable data. Fourteen articles met criteria for Class II articles and were reviewed.
- Class III: Studies based on retrospectively collected data; includes clinical series, database or registry reviews, large series of case reviews, and expert opinion. Eighteen articles were identified as class III and underwent review. Each of the above articles was reviewed and scored by a minimum of two PMG committee members. After collection of all reviews, the prehospital Fluid Resuscitation PMG Committee convened and developed recommendations based on the following definitions:
- Level I: The recommendation is convincingly justifiable based on the available scientific information alone. One Level I guideline was supported by the literature.
- Level II: The recommendation is reasonably justifiable by available scientific evidence and strongly supported by expert opinion. A total of eight Level II guidelines were established by the literature.
- Level III: The recommendation is supported by available data but adequate scientific evidence is lacking. Seven Level III guidelines were developed.
Should vascular access be obtained in the prehospital setting? (Table 1).7,13–28
- Level I: No level one recommendation can be made. There is insufficient data to support a Level I recommendation for placing vascular access in the prehospital setting.
- Level II: Placement of vascular access at the scene of injury should not be performed as it delays patient transport to definitive care, and there is no evidence to demonstrate any benefit to their placement.
- Level III: Placement of vascular access during transport is feasible and does not delay transport to definitive care.
If vascular access is obtained, where and how should it be placed? (Table 2).7,10,27,29–43
- Level I: No Level I recommendation can be made. There is insufficient data to support specifically where and through which approach vascular access should be obtained in the prehospital setting of trauma.
- Level II: (a) If central access is necessary, the percutaneous “Seldinger” technique is recommended over traditional “cut-down” procedures as there is evidence that percutaneous techniques are quicker and have equivalent success rates. (b) The use of intraosseous access in trauma patients requiring vascular access in which intravenous access is unobtainable or has failed two attempts is recommended.
- Level III: Attempts at peripheral intravenous access should be limited to two attempts during prehospital transport after which, alternative methods (intraosseous, central access) should be attempted if equipment and trained personnel are available.
If vascular access is obtained, should intravenous fluids be given? (Table 3).7,10,27,30–34,38–42
- Level I: No level one recommendation can be made. There is insufficient data to show that trauma patients benefit from prehospital fluid resuscitation.
- Level II: (a) Intravenous fluids should be withheld in the prehospital setting in patients with penetrating torso injuries. (b) An IV placed to “saline-lock” is equivalent in patency and function to a continuous infusion.
- Level III: (a) Intravenous fluid resuscitation should be withheld until active bleeding/hemorrhage is addressed. (b) Intravenous fluid administration in the prehospital setting (regardless of mechanism or transport time) should be titrated for palpable radial pulse using small boluses of fluid (250 mL) rather than fixed volumes or continuous administration.
If fluid is given, which type of fluid should be chosen? (Table 4).44–52
- Level I: (a) There is insufficient data to recommend one solution or type of fluid over other options in the prehospital setting. (b) Small volume boluses (250 mL) of 3% and 7.5% hypertonic saline (HTS) are equivalent, with respect to vascular expansion and hemodynamic changes, to large volume boluses (1 L) of standard solutions such as lactated Ringer’s (LR) or 0.9% normal saline (NS).
- Level II: There is insufficient data to support any recommendation at this level.
- Level III: There administration of blood in the prehospital setting is safe and feasible.
If fluid is given, how much and how fast should it be administered? (Table 5).10,39,42,50,51
- Level I: No level one recommendation can be made. There is insufficient data to recommend specific rates or volumes of fluids to be administered in the prehospital setting.
- Level II: Fluids run at “keep vein open” rates are adequate for transporting injured patients.
- Level III: Rapid infusion systems and/or pressurized systems (to deliver fluids more rapidly) should not be used in the prehospital setting.
On the heels of an ever expanding Prehospital Trauma Life Support curriculum, we have seen not only an expansion in the procedural skills set of EMS providers, but also a dramatic increase in the number of procedures performed. Although there is evidence to suggest potential benefit of prehospital procedures in rural blunt trauma patients with prolonged transportation time, there is little (if any) data to justify these procedures in patients with penetrating injuries or those with short transport times (less than 30 minutes).10,27,53 Advanced Trauma Life Support guidelines for administering (up to 2 L) crystalloid to hypotensive trauma patients in the emergency room setting have been adopted into the prehospital environment without clear benefit. In addition, recent data has shown that the performance of prehospital procedures in urban and penetrating settings have a negative impact on survival.25 In light of the expanding data calling into to question the “stay and play” method of prehospital care, the EAST PMG committee conducted a review of the currently available literature on prehospital vascular access and fluid resuscitation.
Should Vascular Access Be Obtained in the Prehospital Setting?
The first issue examined was whether or not vascular access should even be attempted in the prehospital setting. Several investigators have evaluated the success rate for prehospital venous access and noted scene placement times of these lines range from a mean of 2.2 minutes to 6.3 minutes.18–20,23,27 “Time to placement” of these lines was similar in patients with normal blood pressure and primary injuries confined to the extremities.13,15,22 However, when patients were hypotensive or had primarily torso injuries, placement at the scene tended to be longer than that of en route intravenous line placement.21,26,27 Jones et al.19 noted a 91% success rate at the scene and a 94% success rate en route. Additionally, Slovis et al.26 demonstrated an en route success rate for intravenous line placement of 92%, regardless of hemodynamic status. Delaying transport to place venous access also seems to be associated with increased overall time to hospital, in some cases exceeding that of the actual transport itself.24,25,27 Should the decision be made to obtain scene access, drawing blood for laboratory samples (e.g., type and screen, etc) adds unnecessary time and should not be performed.23
Whether the committee felt it was able to recommend placement of access in the prehospital setting was predicated on demonstrating any benefit from access placement. Although several studies evaluating prehospital venous access have recommended their placement (simply because they could technically be placed), none of the investigators was able to demonstrate any benefit from their placement.18,20,23 To the contrary, scene access placement has been associated with increased risk of death.14,24,27 Seamon et al.25 evaluated 180 patients who underwent ED thoracotomy over a 6-year period. The authors stratified according to method of transport (EMS or private vehicle/police [POV]). They found that mortality in patients arriving by EMS was double that of patients transported by POV (17% vs. 8.0%). More importantly, each prehospital procedure performed reduced the odds of survival by 62% (OR, 0.38; 95% CI, 0.18–0.79; p = 0.009). Sampalis et al.25 examined the association between on-site venous access and fluid replacement and mortality in critically injured patients. The authors found that on-site access was associated with an increase in mortality (23% IV group vs. 6% no IV group) and that this association was stronger as time to hospital arrival increased (OR, 8.4; CI, 1.27–54.69; p = 0.03 for time to arrival >60 minutes). These outcomes (as well as time to placement of access and scene times) do not seem to differ whether the patient is transported by basic life support (BLS) or advanced life support ambulance crews.
In light of increasing experience in management of military injuries (both penetrating and blunt), a UK consensus group was recently convened to reconcile differences in practice with respect to prehospital fluid resuscitation.7 The expert panel formulated an algorithm to assist in the early resuscitation of critically injured patients that consisted of the following: (1) access should not be obtained for superficial wounds, (2) if the patient’s mental status is appropriate and a radial pulse is present, prehospital personnel may place venous access but fluids should be held, (3) venous access should be obtained and fluids initiated if no radial pulse or mental status is incoherent, (4) a 500 mL bolus of hetastarch should be given if no radial pulse or mental status is incoherent, (5) fluids should be discontinued if pulse and mental status return, and (6) if no response, repeat 500 mL of colloid (hetastarch).7
If Access Is Obtained, Where Should It Be Placed?
In asking where to place venous access, it is important not only to determine where anatomically should this access be obtained, but also what approach should be used (percutaneous, cut-down) and what size catheter should be placed. As well, it is critical to evaluate whether there are alternatives to traditional intravenous catheter access (intraosseous lines). No clinical trials were found to suggest superiority of one anatomic location for venous access versus another. Peripheral access has been the standard location for placement in the prehospital setting; most commonly being placed in the upper extremity in the forearm and antecubital area. An animal study by Rosa et al. examined the efficacy of intravenous access site on delivery of a bolus injection to the heart during shock and resuscitation.54 The authors noted that femoral access significantly prolongs bolus transit time when compared with central or brachial access regardless of intravascular status (euvolemic, hypovolemic, or aggressively resuscitated). Brachial access was advocated as the preferred route for bolus injection delivery in the emergency setting as it provides expedient bolus delivery equal to central access and is superior to femoral access.
A few authors have evaluated the time-to-placement and efficiency of traditional peripheral access, cut-down placement, and percutaneous (Seldinger) approaches in the prehospital setting.29,36,43 Westfall et al.43 conducted a prospective, randomized, multicentered trial to compare the speed of IV access and the rate of infusion for saphenous vein cut-down and percutaneous femoral catheterization. Seventy-eight trauma patients were randomized to either saphenous cut-down or percutaneous femoral line placement, followed by passive infusion of 1.0 L of crystalloid. Mean procedure time for the cut-down group was 5.6 minutes ± 2.6 minutes compared with 3.2 minutes ± 1.2 minutes for the femoral line group (p < 0.001). The mean infusion time for the cut-down group was 6.6 minutes ± 4.3 minutes compared with 4.6 minutes ± 2.5 minutes for the femoral line group (p = 0.03). As the rate of flow increases with larger diameter and shorter length of the catheter (Poiseuille’s law), several investigators have examined the impact of placing larger bore lines in the prehospital setting. Benumof et al.29 measured the infusion pressure-flow characteristics of the side ports of 8.0 and 8.5 Fr introducer catheters against equivalent pressure-flow relationship through standard 22- to 14-gauge peripheral venous catheters. Although the 8.5 Fr introducers were superior to the 8.0 Fr catheters, none was superior to 14- and 16-gauge standard peripherally placed catheters. Other authors evaluated the ability to place extremely large bore peripheral lines (10- and 12-gauge catheters) and to rapidly exchange smaller peripheral lines out to large introducer catheters (over a wire).36,37 However, none demonstrated superiority to standard large bore (14–18 gauge) peripheral lines.
Over the last several years, intraosseous lines have been met with increasing enthusiasm and favor in the prehospital resuscitation of trauma patients. However, this enthusiasm is based on increasing provider “experiences” and not on any clinical trials. These studies are, for the most part, are limited to “how I do it” or device comparisons, using historical flow rates of intravenous catheters as reference values.55 Others are pharmacokinetic drug studies or trials conducted in nontrauma patients. Frascone et al.35 studied provider performance for obtaining intraosseous access with two FDA-approved intraosseous devices in two sequential field trials. They evaluated 178 insertions in adult trauma patients, with success rates of 72% to 87%. Time to insertion was similar to that of historical data on intravenous access. The site most often used for adult intraosseous access is the proximal tibia (medial and inferior to the tibial tuberosity) and the sternum and humeral head.55 Although the pharmacokinetic delivery of drugs seems equal to that of the intravenous route, infusion volume rates are only that of a 21-gauge catheter in the absence of a high-pressure infusion system.55,56
If Access Is Obtained, Should Fluid Be Administered in the Prehospital Setting?
Once access is established, another controversy arises in whether or not to initiate fluid therapy.34 Although many providers see the subsequent administration of fluids to be standard of care, the literature would not support this approach. At a minimum, prehospital fluid administration does not seem to improve outcomes in either penetrating or blunt trauma patients.27,32,39 In a study of 235 trauma patients (blunt and penetrating), Dalton32 evaluated the benefit of prehospital venous access and fluid administration. The authors noted that 80% patients receive less than 600 mL of fluid in the prehospital setting, regardless of mechanism, scene entrapment, or hypotension en route. They were unable to identify benefit from such therapy and recommended withholding fluid administration. Kaweski et al.39 conducted a retrospective study of almost 7,000 trauma patients and noted that mortality rates were similar in those patients who received fluids and those who did not (23% vs. 22%; p = NS). Comparison of groups with similar, injury severity, probability of survival, and hypotension on arrival also failed to show an influence of fluid administration on survival. Other authors have also demonstrated that prehospital fluid therapy confers no survival benefit and delays transport of critically injured patients.33,41
Although numerous animal studies have demonstrated an increased rate of hemorrhage an increased mortality with “prehospital” fluid resuscitation, clinical extrapolation of this concept has, for the most part, been confined to a single prospective randomized controlled trial by Bickell et al.10 in the early 1990s. Hypotensive patients with penetrating torso injuries were randomized in the field to receive either standard intravenous fluid resuscitation or no fluids, and the regimen was continued until the patient reached the operating theater. Despite the lack of prehospital fluid resuscitation, the mean blood pressure between the groups was similar while intraoperative blood loss was significantly less in the delayed resuscitation group. Additionally, the length of stay was shorter and the mortality rate lower in the delayed resuscitation group. Another randomized controlled trial by Turner et al.42 in the UK involved 1,309 patients, half of which were randomized to standard fluid protocols or no prehospital fluids. Unfortunately, not much can be derived from this study to make any recommendations, as there was extremely poor protocol compliance. Only 31% of standard protocol patients (who were supposed to receive fluids) received prehospital fluids and only 80% of the “no fluid” patients had fluids withheld. There was no significant difference in mortality between the groups. Despite the studies significant limitations, the authors concluded that prehospital fluid resuscitation does no harm.
Several groups and authors have developed consensus statements aimed directly at the question of whether to place venous access in the prehospital setting and whether to administer fluids before hospital arrival (and definitive hemorrhage control).7,37,55
In summary, the consensus recommendations are quite similar: (1) patients with only superficial wounds (even in combat settings) do not require immediate intravenous access or fluid resuscitation, (2) if the patient is coherent and has a palpable radial pulse, place the venous access to “saline lock,” (3) if incoherent or no radial pulse, obtain venous access and start 500 mL hetastarch, (4) repeat bolus if no response, saline lock IV if response noted, (5) in patients with suspected head injuries, fluids should be titrated for SBP >90 mm Hg. These recommendations reflect that of the groups’ evaluations of blunt and penetrating patients in both military and civilian settings.40
With respect to maintaining venous access patency, several authors have evaluated whether continuous intravenous infusion is necessary.30,31 Boyle and Kuntz30 evaluated 100 patients requiring intravenous access placement. The use of a saline lock was found to be a cost-effective means of maintaining patency of intravenous lines during transport. Carducci and Stein31 demonstrated that a saline lock device was as effective at maintaining prehospital access as were traditional continuous infusions. Additionally, paramedics found that the saline lock devices were easier to use, less time-consuming to initiate, and facilitated patient transportation.
If Fluid Is Administered, Which Solution Should Be Given?
Although “standard” fluid on prehospital vehicles is typically normal saline (0.9% sodium chloride NS) or lactated Ringer’s (LR) solution, neither has been well studied in the prehospital resuscitation of trauma and neither has been shown to be superior to other available solutions. However, their cost and provider familiarity with these solutions has likely been responsible for their “standard solution” status. Studies comparing various iso-oncotic solutions (hetastarch, dextran) and hypertonic saline (3% or 7.5% sodium chloride) to NS or LR have shown mixed results.46,47,50,52,57–61
Cooper et al.45 recently compared LR and 7.5% sodium chloride in a randomized trial of trauma patients with either brain injury or hypotension. The authors found no significant difference between the groups with respect to favorable neurologic outcomes at 6 months. Survival to discharge and 6-month survival were higher in the 7.5% sodium chloride group (55% vs. 50% and 55% vs. 47%, respectively), but this did not reach statistical significance (study powered to detect difference in neurologic outcomes). In a trial of patients undergoing air medical transport after injury, Vassar et al.51,52 compared 7.5% sodium chloride (with and without dextran) with LR solution in a randomized fashion. The authors found that patients who received the hypertonic saline solutions had less fluid requirements in the prehospital setting and arrived to the trauma center with a higher systolic blood pressure. Although overall survival was not different between the hypertonic saline and LR groups, patients with severe head injury who received hypertonic saline had a higher survival than that observed with the LR groups (32% vs. 16%; p = 0.044). The same group evaluated 0.9% sodium chloride (NS) with several hypertonic saline solutions in hypotensive patients transported by ground ambulance.52 In this randomized, controlled and prehospital blinded trial, the authors found no difference in survival between patients who received 0.9% or 7.5% sodium chloride. However, the groups were poorly matched with significantly higher injury severity scores and predicted mortality in the 7.5% groups compared with the 0.9% group (both p < 0.05). In addition, the study was severely underpowered with an estimated sample size calculation required of almost 700 patients (study had 258 patients).
Numerous investigators have examined the different hypertonic solutions available, including 3% and 7.5% sodium chloride and solutions with and without added colloids (6% and 12% dextran).45–47,50–52,57–59,62–64 With respect to 3% versus 7.5% sodium chloride, there are few, if any, animal studies comparing the solutions and no clinical trials of prehospital resuscitation of trauma. In a porcine model of uncontrolled hemorrhage, Watters et al.64 recently evaluated the effect of 3% versus 7.5% sodium chloride. The authors noted that a single bolus of 3% solution produced an adequate and sustained rise in blood pressure and tissue oxygenation, whereas 7.5% sodium chloride failed to produce a sustained improvement in these variables. Also, the 7.5% sodium chloride solution resulted in a significant dilutional anemia and relative hypofibrinogenemia. Prehospital clinical trials have utilized 7.5% sodium chloride (with and without dextran) almost exclusively, thus preventing a critical comparison of and evidenced-based recommendation by the committee for one over the other.46–48,50–52,58 As to the benefit of adding colloid to hypertonic saline, solutions of 7.5% sodium chloride with 6% or 15% dextran added do not seem superior to those without dextran.50–52 Vassar et al.50 noted that the use of 7.5% sodium chloride was superior to LR in reducing the amount of prehospital fluid requirements and improving admission/emergency department blood pressure, with no additional benefit seen with the dextran solutions. Glasgow outcome scores were higher in the 7.5% group compared with lactated Ringer’s, but no further effect was observed with the dextran solutions.
Hydroxylethylstarch (HES) is a balanced electrolyte solution that is similar in ionic composition to human plasma.65,66 Although it is contraindicated in patients with bleeding disorders, HES is used and advocated by the military for prehospital, low-volume boluses of injured soldier’s in hemorrhagic shock.38,40 In fact, several near-fatal hemorrhage models have demonstrated that HES is associated with hemorrhage volume and significantly lower mortality when compared with LR.47,61–63 Compared with normal saline and lactated Ringer’s solution, HES is associated with significant decreases in release of proinflammatory cytokines.19,62–64 When compared with LR, HES solutions in animals with trauma-hemorrhagic shock has been shown to induce less inflammatory cytokines and improved immune function.
Clinical trials evaluating blood and blood substitutes in the prehospital setting are also scarce and prevented the committee from making any significant recommendation on the subject. Barkana et al.44 evaluated 40 patients who had received prehospital blood transfusions. Prolonged extrication and delayed transport were the primary indications for transfusion and the mean volume of crystalloid infused by hospital arrival was almost 4.5 L. During the study period, only 4% of blood reserved for prehospital patients was actually used (vs. 90% during that period for in-hospital use). Although the authors found it safe and feasible to transfuse blood in the prehospital setting, there was a tremendous amount of product wastage. Sumida et al.49 performed a chart review of patients receiving prehospital resuscitation with blood products and found no difference in mortality. The authors noted that the crystalloid only group, however, had shorter transport times and more “normal” vital signs in the field. As to blood substitutes, data regarding use in trauma patients are extremely limited while that for prehospital resuscitation are essentially nonexistent.67,68 Gould et al.65 conducted a prospective, randomized, open label trial of a human polymerized hemoglobin substitute. Forty-four in-hospital trauma patients were randomized to receive red cells or up to six units of the blood substitute as their initial blood replacement after trauma and during emergent operations. The total number of allogeneic red cell transfusions for the control and experimental groups was not significantly different through study day 3 (11.3 ± 4.1 units vs. 7.8 ± 4.2 units; p = 0.06).
If Fluid Is Administered, How Much Should Be Given and How Fast Should It Be Infused?
Even more poorly understood and more under-studied than the above controversies is that of “how much” and “how fast.” Basic trauma guidelines recommend an initial rapid infusion of fluid (1.0–2.0 L) in hypotensive trauma patients as a diagnostic procedure to aid treatment decisions. Although this has been interpreted (or misinterpreted) to mean that patients in the prehospital setting should receive 2.0 L of crystalloid (often regardless of hemodynamic status), this practice is not supported by the literature. Currently, there are no clinical trials to support a recommendation for rate or volume of fluid administration to trauma patients in the prehospital setting. Animal studies have been performed that suggest higher volumes and more rapid infusions of crystalloid in the prehospital setting result in higher mortality.63,64,66,69–71 Using a murine model of uncontrolled hemorrhage, Krausz et al.72 compared bolus and continuous infusion administration of lactated Ringer’s and hypertonic saline, combined with splenectomy. Continuous infusion of LR solution resulted in significantly less bleeding than bolus infusion and improved survival time, whereas there was no difference in continuous or bolus infusion of hypertonic saline. Bickell et al.10 demonstrated that patients with penetrating torso injury who received small volumes of resuscitation (<250 mL) in the prehospital setting had significantly higher survival to hospital discharge than those who received standard prehospital resuscitation (750—1,000 mL in less than 30 minutes). Vassar et al.50–52 noted that hypertonic saline boluses (on the order of 250 mL volumes) seem to be associated with improved survival.
In-patient clinical trials suggest that “lowering expectations” of resuscitation end-points may improve survival and decrease hemorrhage volume. Dutton et al.9 evaluated the concept of “hypotensive resuscitation” and noted that titration of initial fluid therapy to a lower than normal systolic blood pressure (SBP) (≥70 mm Hg instead of >100 mm Hg) during active hemorrhage did not affect mortality. Several years earlier, this same group of investigators evaluated the delivery of crystalloid and blood products through a rapid infusion system to critically injured patients in hemorrhagic shock.73 Contrary to beliefs and biases at the time, the investigators noted an almost fivefold increase in mortality in patients resuscitated with a rapid infusion system. This higher mortality remained even after matching for age, injury severity scores, and Glasgow coma scale (53% vs. 61%; p < 0.001). Even more surprising was that the mortality difference was greatest not in penetrating patients but in the blunt trauma population (48.8% vs. 63.0%; p < 0.001).
Despite the widely held belief that prehospital venous access placement and fluid resuscitation is standard of care, there is little data to support this practice. In fact, an increasing amount of data suggests that it may be quite harmful to a significant number of critically injured patients. The EAST PMG committee has found that placement of venous access at the scene delays transport and placement of access en route should be considered. In those patients in whom intravenous access has failed, intraosseous may be attempted if equipment and trained personnel are available. There is insufficient data to suggest that blunt or penetrating trauma patients benefit from prehospital fluid resuscitation. In patients with penetrating injuries and short transport times (less than 30 minutes), fluids should be withheld in the prehospital setting in patients who are alert or have a palpable radial pulse. Fluids (in the form of small boluses, i.e., 250 mL) should be given to return the patient to a coherent mental status or palpable radial pulse. In the setting of traumatic brain injury, however, fluids should be titrated to maintain systolic blood pressure greater than 90 mm Hg (or mean pressure greater than 60 mm Hg). Hypertonic saline boluses of 250 mL seem equivalent in efficacy to 1,000 mL boluses of standard solutions (lactated Ringer’s, 0.9% sodium chloride). There is insufficient evidence to show that injured patients with short transport times benefit from prehospital blood transfusions. Finally, rapid infusion systems and or pressurized devices (to deliver fluids more rapidly) should not be used in the prehospital setting.
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Keywords:© 2009 Lippincott Williams & Wilkins, Inc.
Resuscitation; Intravenous fluid; Venous access; Intraosseous; Prehospital; Field