Category Archives: Trauma

Care of severely injured patient

Acute Med, All Updates, ICU, Resus, Trauma

Red cell transfusion guidelines

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The AABB (formerly the American Association of Blood Banks has issued guidelines on red blood cell transfusion1, providing some number-based targets which may be helpful for some practitioners or organisations. Editorialist and heavyweight intensivist Jean-Louis Vincent argues for a more individual patient-based assessment2, and highlights some of the weaknesses of existing studies, in particular the often quoted but now fairly old TRICC study3 which suffered from poor recruitment and the possible lack of applicability to modern practice now that leucodepleted products are used.
Prof Vincent states:
“Transfusion decisions need to consider individual patient characteristics, including age and the presence of CAD, to estimate a specific patient’s likelihood of benefit from transfusion. The decision to transfuse is too complex and important to be guided by a single number.”


Description: Although approximately 85 million units of red blood cells (RBCs) are transfused annually worldwide, transfusion practices vary widely. The AABB (formerly, the American Association of Blood Banks) developed this guideline to provide clinical recommendations about hemoglobin concentration thresholds and other clinical variables that trigger RBC transfusions in hemodynamically stable adults and children.

Methods: These guidelines are based on a systematic review of the literature on randomized clinical trials evaluating transfusion thresholds. We performed a literature search from 1950 to February 2011 with no language restrictions. We examined the proportion of patients who received any RBC transfusion and the number of RBC units transfused to describe the effect of restrictive transfusion strategies on RBC use. To determine the clinical consequences of restrictive transfusion strategies, we examined overall mortality, nonfatal myocardial infarction, cardiac events, pulmonary edema, stroke, thromboembolism, renal failure, infection, hemorrhage, mental confusion, functional recovery, and length of hospital stay.

Recommendation 1: The AABB recommends adhering to a restrictive transfusion strategy (7 to 8 g/dL) in hospitalized, stable patients (Grade: strong recommendation; high-quality evidence).

Recommendation 2: The AABB suggests adhering to a restrictive strategy in hospitalized patients with preexisting cardiovascular disease and considering transfusion for patients with symptoms or a hemoglobin level of 8 g/dL or less (Grade: weak recommendation; moderate-quality evidence).

Recommendation 3: The AABB cannot recommend for or against a liberal or restrictive transfusion threshold for hospitalized, hemodynamically stable patients with the acute coronary syndrome (Grade: uncertain recommendation; very low-quality evidence).

Recommendation 4: The AABB suggests that transfusion decisions be influenced by symptoms as well as hemoglobin concentration (Grade: weak recommendation; low-quality evidence).

1. Red Blood Cell Transfusion: A Clinical Practice Guideline From the AABB
Ann Intern Med. 2012 Mar 26. [Epub ahead of print] Full Text
2. Indications for Blood Transfusions: Too Complex to Base on a Single Number?
Ann Intern Med. 2012 Mar 26. [Epub ahead of print] Full Text
3. A Multicenter, Randomized, Controlled Clinical Trial of Transfusion Requirements in Critical Care
N Engl J Med 1999; 340:409-417 Full Text

All Updates, Trauma, Ultrasound

Only when I laugh

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A middle-aged martial arts enthusiast was training in Krav Maga, and participated in a high-contact punching and grappling sparring exercise in which his (younger, heavier) partner threw him to the ground and landed on him. During the throw the patient felt a ‘pop’ in his right side, and wondered whether he’d fractured a rib. During the subsequent five rounds against two additional sparring partners he noticed a clicking in the same area every time he was grappling, and pain in the right side when pushing up off the floor with his right arm. As a trained emergency physician, he assessed his own level of breathing comfort throughout the training to reassure himself he didn’t have a significant pneumothorax, and therefore elected to continue to fight in the interests of assessing his ability to defend himself while injured.
Pain on deep inspiration, coughing, and squeezing the chest suggested a fractured rib, so out of curiosity at work the next day he ultrasounded the area of maximum tenderness:

Discontinuity in cortex signifies rib fracture

Examination of the lung confirmed pleural sliding, B-lines, and ‘pearls on a string’, which excluded pneumothorax.
Sonography is more sensitive than radiography for the detection of rib fractures and may also detect costochondral junction injuries and disruption of costal cartilage1. This video from Hennepin County Medical Centre takes you through the simple procedure:

Although the management of rib fractures is no different from that of chest wall contusion, knowledge of the presence of fracture in this case is helpful to this patient in deciding when to return to the questionably sane ‘hobby’ of fighting bigger guys half his age.
The patient’s consent was obtained prior to the publication of the ultrasound image.

1. Sonography Compared with Radiography in Revealing Acute Rib Fracture
AJR Am J Roentgenol. 1999 Dec;173(6):1603-9.
Full text article
[EXPAND Click to read abstract]


OBJECTIVE: This study was undertaken to compare the sensitivities of sonography and radiography for revealing acute rib fracture.

SUBJECTS AND METHODS: Chest radiography and rib sonography were performed on 50 patients with suspected rib fractures. Sonography was performed with a 9- or 12-MHz linear transducer. Fractures were identified by a disruption of the anterior margin of the rib, costochondral junction, or costal cartilage. The incidence, location, and degree of displacement of fractures revealed by radiography and sonography were compared. Sonography was performed again after 3 weeks in 37 subjects.

RESULTS: At presentation, radiographs revealed eight rib fractures in six (12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all reexamined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture.

CONCLUSION: Sonography reveals more fractures than does radiography and will reveal fractures in most patients presenting with suspected rib fracture. Further scientific studies are needed to clarify the appropriate role for sonography in rib fracture detection.

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Acute Med, All Updates, Guidelines, ICU, PHARM, Resus, Trauma, Ultrasound

International recommendations for lung ultrasound

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A multidisciplinary panel of 28 experts from eight countries reviewed the literature and came up with consensus guidelines in point-of-care lung ultrasound. There were some big names involved – all the big players in emergency/critical care ultrasound from around the World. Conspicuously absent were Matt and Mike from the Emergency Ultrasound Podcast, but maybe there was a maximum awesomeness limit or something.

Here are some snippets, taken out of context and without the grade of recommendation attached. Try to get hold of the original if you can, which might not be easy. I never understand it when ‘international recommendations’ are published as subscription-only articles. Either they want people to follow them or not. Oh well – here are some of their recommendations:
Pneumothorax

  • The sonographic signs of pneumothorax include the following: Presence of lung point(s); Absence of lung sliding; Absence of B-lines; Absence of lung pulse
  • The lung pulse refers to the subtle rhythmic movement of the visceral upon the parietal pleura with cardiac oscillations and is a rule-out sign for pneumothorax
  • In the supine patient, the sonographic technique consists of exploration of the least gravitationally dependent areas progressing more laterally.
  • Bedside lung ultrasound is a useful tool to differentiate between small and large pneumothorax, using detection of the lung point.

Interstitial syndrome

  • B-lines are defined as discrete laser-like vertical hyperechoic reverberation artifacts that arise from the pleural line (previously described as ‘‘comet tails’’), extend to the bottom of the screen without fading, and move synchronously with lung sliding.
  • The presence of multiple diffuse bilateral B-lines indicates interstitial syndrome. Causes of interstitial syndrome include the following conditions: Pulmonary edema of various causes; Interstitial pneumonia or pneumonitis; Diffuse parenchymal lung disease (pulmonary fibrosis)

Lung consolidation

  • The sonographic sign of lung consolidation is a subpleural echo-poor region or one with tissue-like echotexture.
  • Lung ultrasound is a clinically useful tool to rule in pneumonia; however, lung ultrasound does not rule out consolidations that do not reach the pleura.
  • In mechanically ventilated patients lung ultrasound should be considered as it is more accurate than portable chest radiography in the detection of consolidation.

Pleural effusion

  • Both of the following signs are present in almost all free effusions: A space (usually anechoic) between the parietal and visceral pleura; Respiratory movement of the lung within the effusion (‘‘sinusoid sign’’)
  • In opacities identified by chest radiography, lung ultrasound should be used because it is more accurate than chest radiography in distinguishing between effusion and consolidation.
  • Visualization of internal echoes, either of mobile particles or septa, is highly suggestive of exudate or hemothorax


BACKGROUND: The purpose of this study is to provide evidence-based and expert consensus recommendations for lung ultrasound with focus on emergency and critical care settings.

METHODS: A multidisciplinary panel of 28 experts from eight countries was involved. Literature was reviewed from January 1966 to June 2011. Consensus members searched multiple databases including Pubmed, Medline, OVID, Embase, and others. The process used to develop these evidence-based recommendations involved two phases: determining the level of quality of evidence and developing the recommendation. The quality of evidence is assessed by the grading of recommendation, assessment, development, and evaluation (GRADE) method. However, the GRADE system does not enforce a specific method on how the panel should reach decisions during the consensus process. Our methodology committee decided to utilize the RAND appropriateness method for panel judgment and decisions/consensus.

RESULTS: Seventy-three proposed statements were examined and discussed in three conferences held in Bologna, Pisa, and Rome. Each conference included two rounds of face-to-face modified Delphi technique. Anonymous panel voting followed each round. The panel did not reach an agreement and therefore did not adopt any recommendations for six statements. Weak/conditional recommendations were made for 2 statements, and strong recommendations were made for the remaining 65 statements. The statements were then recategorized and grouped to their current format. Internal and external peer-review processes took place before submission of the recommendations. Updates will occur at least every 4 years or whenever significant major changes in evidence appear.

CONCLUSIONS: This document reflects the overall results of the first consensus conference on “point-of-care” lung ultrasound. Statements were discussed and elaborated by experts who published the vast majority of papers on clinical use of lung ultrasound in the last 20 years. Recommendations were produced to guide implementation, development, and standardization of lung ultrasound in all relevant settings.

International evidence-based recommendations for point-of-care lung ultrasound
Intensive Care Med. 2012 Apr;38(4):577-91

All Updates, Guidelines, ICU, Resus, Trauma

Spinal imaging for the adult obtunded blunt trauma patient

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‘You can’t clear the cervical spine until the patient wakes up!’ How often have you heard this said about a patient with severe traumatic brain injury who may not ‘wake up’ for weeks, if at all?
A controversial area, but many institutions now allow collar removal if a neck CT scan is normal. Does this rule out injury with 100% sensitivity? No – but it probably pushes the balance of risk towards removing the collar – an intervention with no evidence for benefit and plenty of reasons why it may be harmful to ventilated ICU patients. For example, clearing the cervical spine based on MDCT was associated with less delirium and less ventilator associated pneumonia, both of which have been associated with increased mortality in critically ill patients (this is referenced in the paper below).
The UK’s Intensive Care Society has had pragmatic guidelines along these lines since 2005, which can be found here. This month’s Intensive Care Medicine publishes an updated literature review providing some further support to this approach.


PURPOSE: Controversy exists over how to ‘clear’ (we mean enable the clinician to safely remove spinal precautions based on imaging and/or clinical examination) the spine of significant unstable injury among clinically unevaluable obtunded blunt trauma patients (OBTPs). This review provides a clinically relevant update of the available evidence since our last review and practice recommendations in 2004.

METHODS: Medline, Embase. Google Scholar, BestBETs, the trip database, BMJ clinical evidence and the Cochrane library were searched. Bibliographies of relevant studies were reviewed.

RESULTS: Plain radiography has low sensitivity for detecting unstable spinal injuries in OBTPs whereas multidetector-row computerised tomography (MDCT) approaches 100%. Magnetic resonance imaging (MRI) is inferior to MDCT for detecting bony injury but superior for detecting soft tissue injury with a sensitivity approaching 100%, although 40% of such injuries may be stable and ‘false positive’. For studies comparing MDCT with MRI for OBTPs; MRI following ‘normal’ CT may detect up to 7.5% missed injuries with an operative fixation in 0.29% and prolonged collar application in 4.3%. Increasing data is available on the complications associated with prolonged spinal immobilisation among a population where a minority have an actual injury.

CONCLUSIONS: Given the variability of screening performance it remains acceptable for clinicians to clear the spine of OBTPs using MDCT alone or MDCT followed by MRI, with implications to either approach. Ongoing research is needed and suggestions are made regarding this. It is essential clinicians and institutions audit their data to determine their likely screening performances in practice.

Clinical review: spinal imaging for the adult obtunded blunt trauma patient: update from 2004
Intensive Care Med. 2012 Mar 10. [Epub ahead of print]

All Updates, PHARM, Resus, Trauma

Simple emergency haemorrhage control

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I had the honour of attending trauma rounds with leading South African trauma surgeons today at Groote Schuur Hospital in Cape Town. This was the first day of an intense week-long trauma education tour that I have organised for myself and three of my Sydney HEMS colleagues.
A technique for haemorrhage control in penetrating trauma is to place a Foley catheter (FC) in the wound and inflate the balloon to try to achieve compression of bleeding vascular structures. This has been life-saving in many cases and buys time to get the patient to a trauma or vascular surgeon or in some cases an interventional radiologist.

Catheter is knotted (black arrow) to occlude lumen. The wound is sutured around the catheter (white arrow).

First described by Gilroy and colleagues from Baragwanath Hospital in Johannesburg1, another, larger case series was subsequently reported by Cape Town’s Navsaria2, the Professor who conducted today’s trauma round I attended. In his paper he describes:


An 18- or 20-G FC was introduced into the bleeding neck wound. An attempt was made to follow the wound tract. The balloon was inflated with 5 ml of water or until resistance was felt. The FC was either clamped or knotted on itself to prevent bleeding through the lumen. The neck wound was sutured in two layers around the catheter. Continued bleeding around the catheter was an indication to proceed to surgery.

There were no deaths attributable to the use of FC balloon tamponade.
Prof. Navsaria describes the following algorithm for the subsequent investigation and management of these patients:

 I’ve been teaching this technique as an option in penetrating trauma for a few years but have never actually done it for real. Nice to finally see examples of its successful implementation by people who do this all the time. I’ve seen four patients with Foleys sticking out of their necks in the first 24 hours of being here.
1. Control of life-threatening haemorrhage from the neck: a new indication for balloon tamponade.
Injury. 1992;23(8):557-9
[EXPAND Click to read abstract]


We report the use of a Foley catheter, placed through the wound, to provide balloon tamponade of major bleeding from the neck and supraclavicular fossae. In 10 consecutive explorations for exsanguinating injury in these regions balloon tamponade was used eight times, and was judged to be fully effective in four patients, partly effective in one, and ineffective in three patients.

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2. Foley catheter balloon tamponade for life-threatening hemorrhage in penetrating neck trauma
World J Surg. 2006 Jul;30(7):1265-8
[EXPAND Click to read abstract]


BACKGROUND: Foley catheter (FC) balloon tamponade is a well-recognized technique employed to arrest hemorrhage from penetrating wounds. The aim of this study was to review our experience with this technique in penetrating neck wounds and to propose a management algorithm for patients with successful FC tamponade.

METHODS: A retrospective chart review (July 2004-June 2005 inclusive) was performed of patients identified from a prospectively collected penetrating neck injury computer database in whom FC balloon tamponade was used. The units’ policy for penetrating neck injuries is one of selective nonoperative management. All patients with successful FC tamponade underwent angiography. A venous injury was diagnosed if angiography was normal. Ancillary tests were performed as indicated. Removal of the FC was performed in the OR.

RESULTS: During the study period, 220 patients with penetrating neck injuries were admitted to our unit. Foley catheter balloon tamponade was used in 18 patients and was successful in 17 patients. Angiography was positive in 3 patients, all of whom underwent surgery. The FC was successfully removed in 13 patients at a mean of 72 (range 48-96) hours. One patient bled after removal of the catheter, mandating emergency surgery.

CONCLUSION: Foley catheter balloon tamponade remains a useful adjunct in the management of selective patients with penetrating, bleeding neck wounds.

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All Updates, PHARM, Trauma

Body temperature in anaesthetised HEMS patients

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This study raises an important issue – how do we keep patients with major trauma warm on the way to hospital? The authors from HEMS London identified mean temperatures in hospital of 35°C in patients who had been anaesthetised in the field, although only 38% of their patients had a temperature recorded on admission!
I emailed the author Audun Langhelle for practical information on the thermal protection package they use, who was most helpful in supplying the following information. Clicking on the link will take you to online supplements to the paper describing and illustrating their technique of prehospital rewarming.

Hi Cliff,

Thank you for your request and interest in our paper. Now fully repatriated to Norway, we’re currently using the medium sized UniqueResc warming blanket (Geratherm, Germany) at my base, together with the bubble wrap. In Norway, Garatherm is the only company which has been able to provide us with the necessary paper work showing that their product complies with the rather strict pan European rules and regulations, the EN 13718-1: Requirements for medical devices used in air ambulances in particular.
Working as HEMS doc with LAA 2008-2009, we played with and introduced the policy using Diemme’s (Italy)DM EMG >> http://emj.bmj.com/content/early/2010/10/19/emj.2009.086967/suppl/DC1, but I’m not sure what blanket they currently use.

Kind regards,

Audun

We reviewed this article in one of our Sydney HEMS Clinical Governance Days last year. One of our team presented a critical appraisal and if you’re interested the deadly PowerPoint slides are here:

Body temperature of trauma patients on admission to hospital

View more presentations from nswhems.


Background Hypothermia at hospital admission has been found to independently predict increased mortality in trauma patients.

Objectives To establish if patients anaesthetised in the prehospital phase of care had a higher rate of hypothermia than non-anaesthetised patients on admission to hospital.

Methods Retrospective review of admission body temperature in 1292 consecutive prehospital trauma patients attended by a physician-led prehospital trauma service admitted to The Royal London Hospital between 1 July 2005 and 31 December 2008.

Results 38% had a temperature recorded on admission. There was a significant difference in body temperature between the anaesthetised group (N=207) and the non-anaesthetised group (N=287): mean (SD) 35.0 (2.1) vs 36.2 (1.0)°C, respectively (p <0.001). No significant seasonal body temperature variation was demonstrated.
Conclusion This study confirmed that patients anaesthetised in the prehospital phase of care had a significantly lower admission body temperature. This has led to a change in the author’s prehospital practice. Anaesthetised patients are now actively surface heated and have whole body insulation to prevent further heat loss in an attempt to conserve body temperature and improve outcome. This is an example of best in-hospital anaesthetic practice being carried out in the prehospital phase.

Body temperature of trauma patients on admission to hospital: a comparison of anaesthetised and non-anaesthetised patients
Emerg Med J. 2012 Mar;29(3):239-42
Full text link

All Updates, PHARM, Resus, Trauma

Another reason to be skeptical about collars

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More evidence that the obsession with cervical collars is founded on dogma rather than science


Background All trauma patients with a cervical spinal column injury or with a mechanism of injury with the potential to cause cervical spinal injury should be immobilised until a spinal injury is excluded. Immobilisation of the entire patient with a rigid cervical collar, backboard, head blocks with tape or straps is recommended by the Advanced Trauma Life Support guidelines. However there is insufficient evidence to support these guidelines.

Objective To analyse the effects on the range of motion of the addition of a rigid collar to head blocks strapped on a backboard.

Method The active range of motion of the cervical spine was determined by computerised digital dual inclinometry, in 10 healthy volunteers with a rigid collar, head blocks strapped on a padded spine board and a combination of both. Maximal opening of the mouth with all types of immobiliser in place was also measured.

Results The addition of a rigid collar to head blocks strapped on a spine board did not result in extra immobilisation of the cervical spine. Opening of the mouth was significantly reduced in patients with a rigid collar.

Conclusion Based on this proof of principle study and other previous evidence of adverse effects of rigid collars, the addition of a rigid collar to head blocks is considered unnecessary and potentially dangerous. Therefore the use of this combination of cervical spine immobilisers must be reconsidered.

Value of a rigid collar in addition to head blocks: a proof of principle study.
Emerg Med J. 2012 Feb;29(2):104-7

All Updates, PHARM, Resus, Trauma

Prehospital thoracostomy tube misplacement

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An interesting study from Germany examined prehospital thoracostomy tube (TT) placement by physicians working in the field. Of 69 patients who received them, 67 underwent prehospital intubation. 88 TT were placed in the 69 patients.
There were 19/88 (22%) radiologic chest tube misplacements (defined as too far in the chest, twisted, or bent). The position of 10/88 (11%) chest tubes had to be corrected. None of the patients with a TT had a “not-decompressed” pneumothorax or a chest tube placed below the diaphragm or into a solid organ.
Roughly half were placed in the ‘Monaldi’ position (the second or third intercostal space in the midclavicular line)…..

Monaldi position

 
 
 
 
 
 
 
 
 
…..and half in the Bülau position (fourth or fifth intercostal space in the midaxillary line).
Bülau position

 
 
 
 
 
 
 
 
 
There was no difference in the misplacement rates between the two positions although interestingly helicopter doctors (as opposed to ground response) more often opted for the Monaldi position.
It is not possible to tell from the results whether the TT insertion was indicated in all cases. Also, it would be interesting to know whether TT insertion preceded or followed tracheal intubation. While it is heartening that these physicians do not routinely rely on needle decompression, I cannot fathom while simple open thoracostomy was not used, avoiding the risk of tube misplacement and saving time.
See this post for a more thorough review of open thoracostomy and the limitations of needle decompression.


Objectives. To evaluate the frequency of use, placement site, success and misplacement rates, and need for intervention for tube thoracostomies (TTs), and the complications with endotracheal intubation associated with TT in the prehospital setting.

Methods. We performed a five-year, retrospective study using the records of 1,065 patients who were admitted to the trauma emergency room at a university hospital and who had received chest radiographs or computed tomography (CT) scans within 30 minutes after admission.

Results. Seven percent of all patients received a TT (5% unilateral, 2% bilateral). Ninety-seven percent of all patients with a TT were endotracheally intubated. The success rate for correctly placed chest tubes was 78%. Twenty-two percent of the chest tubes were misplaced (i.e., too far in the chest, twisted, or bent); half of those had to be corrected, with one needing to be replaced. There were no statistical differences in the frequency of Monaldi or Bülau positions, or the frequency of left or right chest TT. In addition, the two positions did not differ in misplacement rates or the need for intervention. Helicopter emergency medical services physicians used the Monaldi position significantly more frequently than the Bülau position. In-hospital physicians performing interhospital transfer used the Bülau position significantly more frequently, whereas ground emergency medical physicians had a more balanced relationship between the two positions. Tube thoracostomy had no influence on endotracheal tube misplacement rates, and vice versa.

Conclusion. Tube thoracostomy positioning mostly depends on the discretion of the physician on scene. The Monaldi and Bülau positions do not differ in misplacement or complication rates.

Incidence And Outcome Of Tube Thoracostomy Positioning In Trauma Patients
Prehosp Emerg Care. 2011 Oct 3. [Epub ahead of print]

All Updates, PHARM, Resus, Trauma

Training in prehospital and retrieval medicine

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I’ve been too busy to blog literature updates for a couple of weeks since I and my colleagues have been flat out running a two week training course in prehospital and retrieval medicine.
Our Helicopter Emergency Medical Service physicians and paramedics care for a wide range of adult and paediatric trauma and critical care patients in some challenging environments. We therefore need to provide a fairly comprehensive induction course for new recruits.
The new guys did us proud. They just need to stay this awesome.

All Updates, ICU, PHARM, Resus, Trauma

FIRST: Fluids in Resuscitation of Severe Trauma

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This is the first randomized, controlled, double-blind study comparing crystalloids with isotonic colloids in trauma. 0.9% saline was compared with hydroxyethyl starch, HES 130/0.4, as a resuscitation fluid in pre-defined subgroups of penetrating and blunt trauma. While a primary outcome measure of gastrointestinal recovery might not seem an obvious choice to some of us, previous research has indicated this to be an issue with crystalloid and the authors clearly defined this as a predefined outcome when registering the trial here.

I don't have any pictures of colloids. Here's where I work.

Colloids tend to require smaller volumes than crystalloid to achieve the same degree of plasma expansion. An interesting finding in this study is that the volume of saline administered was 1.5 times that of hydroxyethyl starch – a very similar ratio to that seen in the SAFE study which compared saline with 4% albumin in intensive care patients.
The authors assert: “..the better lactate clearance in the P-HES group indicated superior tissue resuscitation with the colloid.” There are a number of reasons why this might be a bit of stretch, including the use of epinephrine in some patients which is known to be a cause of hyperlactataemia.
This is a small study whose conclusions should be treated with caution, but which provides an important contribution to the pool of fluid resuscitation literature. If you have full text access to the British Journal of Anaesthesia, the letters pages provide excellent critiques and responses regarding potential flaws in this paper. Nevertheless, it’s one to know about – I’m sure the FIRST trial is going to be quoted for some time to come, including, I suspect, by the manufacturers of certain colloids.


Background The role of fluids in trauma resuscitation is controversial. We compared resuscitation with 0.9% saline vs hydroxyethyl starch, HES 130/0.4, in severe trauma with respect to resuscitation, fluid volume, gastrointestinal recovery, renal function, and blood product requirements.

Methods Randomized, controlled, double-blind study of severely injured patients requiring>3 litres of fluid resuscitation. Blunt and penetrating trauma were randomized separately. Patients were followed up for 30 days.

Results A total of 115 patients were randomized; of which, 109 were studied. For patients with penetrating trauma (n=67), the mean (sd) fluid requirements were 5.1 (2.7) litres in the HES group and 7.4 (4.3) litres in the saline group (P<0.001). In blunt trauma (n=42), there was no difference in study fluid requirements, but the HES group required significantly more blood products [packed red blood cell volumes 2943 (1628) vs 1473 (1071) ml, P=0.005] and was more severely injured than the saline group (median injury severity score 29.5 vs 18; P=0.01). Haemodynamic data were similar, but, in the penetrating group, plasma lactate concentrations were lower over the first 4 h (P=0.029) and on day 1 with HES than with saline [2.1 (1.4) vs 3.2 (2.2) mmol litre−1; P=0.017]. There was no difference between any groups in time to recovery of bowel function or mortality. In penetrating trauma, renal injury occurred more frequently in the saline group than the HES group (16% vs 0%; P=0.018). In penetrating trauma, maximum sequential organ function scores were lower with HES than with saline (median 2.4 vs 4.5, P=0.012). No differences were seen in safety measures in the blunt trauma patients.
Conclusions In penetrating trauma, HES provided significantly better lactate clearance and less renal injury than saline. No firm conclusions could be drawn for blunt trauma.

Resuscitation with hydroxyethyl starch improves renal function and lactate clearance in penetrating trauma in a randomized controlled study: the FIRST trial (Fluids in Resuscitation of Severe Trauma)

Br J Anaesth. 2011 Nov;107(5):693-702