The best fluid therapy pre-hospital is enough pressure on the petrol pedal of the ambulance to get the patient to the definitve care hosptial in the quickest and safest manner. Having said that the underlying injury pattern must dictate the fluid regimen: in blunt trauma with mainly fractures and a small risk of severe uncontrolled bleeding - fluid is useful. While in penetrating trauma, especially tot he torso it is potentially harmful - popping the tenacious clot and making the patient more coagulopathic - in these cases small fluid bolusses with titration to a mentating level of consciousness and a palpable radial pulse have been shown to have a better overall survival. The same would apply to case with abdominal blunt trauma where a liver or splenic bleed is possible. For head trauma (TBI) is would be best to aim for a more normal MAP, around 70mmHg, rahter than a systolic of 90mmHg.

The only treatment regiments that has a positive effect on hypovolemic trauma patients in the pre-hospital setting is rapid transfer to definitive trauma care. Small amounts of fluid may help get them there, but these patients need: assessment by a dedicated trauma team, blood, and surgery.

For a number of years now we, in the military, have used an initial 500cc of Hetastarch or Hespan IV for fluid resuscitation, with great success in conjunction with other field actions to establish hemostasis, such as the use of tourniquets and hemostatic powders and bandages. I carry two 500cc bags of HS in my kit along with 1L of Hartman's and 2L of NS in bags. I typically reserve the use of NS for addressing dehydration and other maladies.

In an urban EMS environment, the efficacy of HS is lost in general terms simply due to the very short transport times involved. There are, however, scenarios where HS may be effectively used over Hartman's or NS but those are more the exception than the rule.

In a rural environment, it's a whole different situation since scene to hospital times might be greatly extended. In those circumstances, HS might be of some life-saving value in serious trauma patients, regardless of the etiology of the trauma.

The final answer is: depends on the service's EMS Medical Director and his sense of HS use. Those with an OIF/OEF history have seen the significant value 0f using HS in the pre-hospital care environment and will typically be in support of it. Those without it, usually aren't unless they've been convinced by their staff in its use.

I will say, however, that NS in significant hypovolemia is a recipe for a body bag in most instances since the NS essentially dilutes blood and retards the effective development of much needed hemostasis..

I agree that on priority basis the trauma patients should be transferred to nearest possible definitive trauma center but during the transport should maintain the systolic B.P. to 90 mm of hg except for TBI should be arround 100 to 110 mm of hg for cerebral per fusion. All above pre hospital care depends on type of injury, distance to be traveled from the scene and the time lag when the help arrives at the scene.

I agree with dr. pooja that is very difficult to establish which infusion regimen is a clever treatment for hypovolemic trauma patients in out-hospital care.

I agree also that a deliberate hypotension does not exclude the need to infuse 2 liters of NS in some patients and that i n ambulance or in helicopter flight it is possible to use only some parameters and responses of the patient.

In our regional HEMS, for determine the adeguate infusional regimen when there is a suspicion of compromised circulation, we are studying the possibility of using the StO2 Tissue Oxygenation Monitor, a noninvasive monitoring system for perfusion examinations of skeletal muscle.

Very good answers for a very good question!

I have the opportunity to research in this field for the last 5 years. Since than, we published somepapers

on Hetarstach solution in the Urban scenario which showed to be safe and effective.

But each case is a special case and you don't have a rule for that. May be in penetrating trauma one may adopt the "Permissive Hypotension" principles described by Mattox. I agree with what Raiston said, although there is no strong evidence showing what kind of liquids use in pre-hospital care resuscitation setting.

We also could be able to observe that some patients, mainly in the military, benefit of HS bolus in the OR.

In one way or another, in the civilian scenario, we may follow the ATLS principles (ER) or PHTLS (out-hospital) principles. Which means resuscitation with 2000 mL of crystalloid and re access your patient. If this volume is not enough to recover vitals, than may be we are dealing with hypovolemic shock grade III or IV and what we need now is blood. Considering the fact you only have blood available inside your ER, I agree with Dr Hardcastle that in the pre-hospital scenario there is nothing to do other than rush to a trauma Center.

Regarding StO2 Tissue Oxygenation Monitor we have been testing some hypothesis in the ER and ICU with critical patients and the results aren't plausible so far.

See the Handbook for Tactical Combat Casualty Care. While the military needs are clearly different from the civilian EMS system, it is interesting to see the military moving away from "magic numbers" for blood pressure or exact fluid amount. The criteria are radial pulse or patient mentating. Fact is that all fluids (Crystalloids and Colloids) worsen coagulation and don't transport oxygen.

I agree with Andreas it is very difficult to judge which fluid to be given but considering the radial pule and patients mental status it is important to run the patient to nearest trauma center for definitive treatment and could be saved with proper emergency protocols.I have no experience with military casualties. and EMS services on the field

Administration of prehospital fluid is an age old paradox, with ED physicians favoring fluid as it helps the numbers (primarily blood pressure), whilst surgeons will vote against it due to the increased uncontrolled haemorrhage associated with their end of the patients care. There have been a range of fluids in use over the years, from Haemmaccel (volume expansion) and Hartmanns (which includes nutrient and small glucose levesl) to the more popular isotonic NaCl 0.9%. This fluid moves easily between compartments, is able to nourish all of the spaces whilst also providing volume for blood pressure, and does not create issues with fluid shift into spaces where it is not wanted. However, it does not provide oxygen carrying capacity, as packed cells will. There is a misguided belief by some individuals that volume replacement and specific blood pressures can determine improved treatment in prehospital care. Essentially, if major haemmorhage is an issue, then the fix is surgical intervention. Don't delay transport by attempting to infuse a specific volume, rather look to gaining IV access en route and moving toward a surgical facility. I dont believe that there is a "clever" regimen for fluid administration, and more specifically that an algorhythm only provides guidance for those incapable of titrating to effect whilst moving toward definitive care. And of course there are also specific injuries such as TBI requiring specific therapies (MAP pressures) in order to maintain cerebral perfusion. Best to just treat what you can and always act with regard to what is definitive care.

I agree that if major haemorrhage is an issue, then the fix is surgical intervention but we must not overlook the need to provide the fluid resuscitation. To be careful only to numbers (primarily blood pressure) is certainly wrong, but it is also a mistake not to try to ensure adequate perfusion. Also is necessary to consider that the plasma constitutes 55% of blood fluid and is mostly water (92% by volume). This means that for a blood loss of 2 liters, have been lost approximately 950 ml of water that can be administered with caution to not facilitate the bleeding. The water performs many important functions within the body including regulation of pH and I think that the Normal Saline solution with acidic pH isn’t the best choice in severe trauma patients.

I worked in an ambulance equipped with 4 people, a doctor and a nurse included. we had several devices to determine the existence of a possible serious bleeding, especially internal and external because it looked. according to the protocols we drove then initiating the replacement of Normal saline or Ringer's lactate, and was assessed by the ability of other intravenous infusion of Voluven. the results were satisfactory in most cases, unless massive bleeding over 4 liters of loss due to breakage of viscera.

course, the protocols have changed over the years as new research and our own experience.

Not sure that I understand the focus on metabolic acidosis in the prehospital setting. It is neither quantifyable nor measurable (and I work in a paramedic-only staffed service with an aeromedical facet capable of infusing packed cells. We also manage blunt and penetrating trauma differently, with palpable carotid pulses accepted for penetrating trauma of the torso.). As a consequence, measuring acidosis of any kind is usually via ETCO2 (respiratory acidosis) and correcting values via ventilation. Fluid alone will not correct a metabolic acidosis in the relatively brief period in which we care for trauma patients, and correction of acidosis through respiratory means may take more time, but is less likely to result in complications of overinfusion, and therefoe is safer for our setting. Along side this, talking in terms of >2 litres (and up to 4 litres) of blood loss must represent a rare sample of patients, and the survivability from such loss is likely to be low if surgical intervention is not readily available.

As you know, outside the hospital, but doctors also work, can not be treated in the same way most pathologies. And where I worked we had a half hour at most two high-level hospitals to which patients wore. Unless the capnograph or the pulse oximeter or other apparatus being told otherwise, the treatment was to preserve limbs and apparatus, without exceeding the fluid infusion. No instilled the same thing, and anyway you will understand that most of the treatment was empirical, to the inability to determine most of the analytical values​​.

Of course, patients who lost more than two liters of blood, had little chance of surviving.

As you know, outside the hospital, but doctors also work, can not be treated in the same way most pathologies. And where I worked we had a half hour at most two high-level hospitals to which patients wore. Unless the capnograph or the pulse oximeter or other apparatus being told otherwise, the treatment was to preserve limbs and apparatus, without exceeding the fluid infusion. No instilled the same thing, and anyway you will understand that most of the treatment was empirical, to the inability to determine most of the analytical values​​.

Of course, patients who lost more than two liters of blood, had little chance of surviving.

As mentioned before in this discussion, current fluid management is based on the misconception of aiming for a normal blood pressure and avoiding acidosis. Noble causes, but hardly the only factors we should think about.

Here some questions to twist your brain around a little.

1. What happens during shock ?

The body reduces blood flow to the periphery, extremities, skin, guts,.. and concentrates blood flow to the vital organs such as heart, lungs and brain.

2. Where do you measure the blood pressure ?

probably one arm or the other.

3. Does the blood pressure in the arm correlate to the blood flow in the brain when the patient is in shock ? (see first question)

4. Where does the acidosis come from during shock ?

Not well perfused muscle turns to anaerobe metabolism. The muscle does the same with strenuous exercise. While acidosis is clearly bad, could it be tolerated for some time ?

5. Most of you have seen patients with a systolic blood pressure of 70 or 80mg/Hg or lower and still talking to you and mentating, so why do you aim for a higher blood pressure when the same patient is injured and anesthetized ?

That said, I think there will be a lot of changes and interesting research about this in the future. In 20 years, we will all laugh about what we now think is the best treatment.

I completely agree with what was said in the last answer, of Andreas Grabinsky. And it is clear that in the coming years is much to investigate in this field.

But not in contradiction with what has been done so far in the emergency out of hospital, because it has always worked to save lives and to be saved with a good quality of life posterir.

In every age have used the best techniques and protocols appropriate to the most advanced clinical evidence.

In Spain, in the last 30 years, many lives have been saved since the introduction of the medical and emergency rescue teams, ambulances and in both helicopters. Because until then most had not even ambulances with ambulance technicians and paramedics much less.

One of the difficulties with prehospital studies of trauma, blunt and penetrating is that the patient cohort is by definition, non-homgenous, injury patterns are not well accounted for by the various injury score tools available but it is only fair that it must be tried. Lactate measurement has been mooted as a good quantifier/predictor of injury/outcome and the technology is available to use this in the prehospital setting as we speak at relatively low cost. What do people think of this approach to decision making in terms of permissive hypotension ? I am a Flight Paramedic with 29 years health service, we have been through the old regimes of standard progressive 10/20/40 mL per kg fluid infusions for hypotensive trauma patients using Hartmanns and Normal Saline. We now use much smaller boluses (N.Saline)100-250 mL with continuous assessment, there are other options in the air such as blood and colloids but these are used more rarely in our service. We are still guessing at presenting shock state excepting in the more extreme cases which have the accompanying poor prognosis, despite the use of ultrasound and the more pedestrian assessment tools and clinical observations so Lactate measurement seems attractive on the surface, what do others think ?

Intravenous tranexamic acid, cautious use of fluids only and heading to a trauma centre should be the way to go. Blood also if available. Large volumes are more detrimental to outcomes and should be avoided unless absolutely necessary. Other than bolstering the circulation 2 litres of salty water won't carry o2 unlike blood.

Our critical care paramedics have ultrasound as do our HEMS. HEMS also carry 4 unit of O neg. All our paramedics carry tranexamic acid. CRASH2 study showed a 30% increase in survivability if given 1g TXA iv in the field

CRASH 2 only showed the following: TXA 1g IV over 15 min followed by 1g IV infusion given over an hour, was most effective when given within the first hour after injury and possibly detrimental if given after the third hour. It was not a pre-hospital based study, all of the patients in the study where given TXA in a hospital. A pre-hospital based study with a sufficient patient sample needs to be completed.

I stand by my fist statement; these patients need: rapid transfer to a Level 1 trauma center, assessment by a dedicated trauma team, blood, and early surgical intervention. And yes, ATLS (the current gold standard treatment guidelines) does indicated that 2L of IV NS is an acceptable treatment for hypotensive trauma patients.

Absolutely agree that these patients need rapid transfer to Level 1 trauma centre, blood & early surgical intervention. Luckily our HEMS carry blood. However 2 litres of NS in hypotensive trauma patients? Define hypotensive. Fluids should be titrated to response.

And yes, admittedley tthe CRASH2 trial was not a prehospital study BUT the results suggest that the first dose would probably be more beneficial if given in the prehospital enviroment. Hence why all UK Ambulance trusts are now adopting this approach.

http://download.thelancet.com/flatcontentassets/pdfs/S0140673611603966.pdf

I just struggle with the whole 2 litre of NS concept. As you know each patient will present with their own unique requirements. Some will need cautious use of fluids, some won't and some may need the full 2 litres. But that has to judged at the time. Giving 2 litres to every hypotensive trauma patient may cause more harm than good.

https://www.researchgate.net/post/Is_it_safe_to_use_normal_saline_for_pre-hospital_care_of_hypovolemic_trauma_patients?exp_tc=tprc