Pre-hospital initiation of fluid replacement therapy in trauma

  • Technology appraisal guidance
  • TA74
  • Published: 

Scope: Pre-hospital initiation of fluid replacement therapy in trauma

NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE

Health Technology Appraisal

Pre-hospital initiation of fluid replacement therapy in trauma

Scope

 

Objective: : to establish the clinical and cost effectiveness of the pre-hospital initiation of fluid therapy in people suffering trauma, and to produce guidance to the NHS in England and Wales. 1

Background: Rapid blood loss caused by blunt or penetrating injury results in death in approximately 1/3 of trauma patients. Haemorrhage leads to a reduced circulatory blood volume, reduced tissue and organ perfusion, and can induce hypovolaemic shock.

The potential aims of fluid replacement therapy in trauma patients are to maintain blood pressure, blood volume and perfuse the vital organs until bleeding is controlled. Fluid replacement solutions are either crystalloid in composition (administered as hypertonic or isotonic solutions) or colloidal (containing gelatin or starch).

Technology: Current guidelines recommend that pre-hospital intravenous fluid replacement be considered in trauma patients where the benefits to the patient are likely to outweigh the delay in the time of hospital arrival.2 Pre-hospital fluid replacement therapy may be initiated at the scene of an accident or en route to hospital.

The aim of pre-hospital fluid replacement therapy in hypovolaemic trauma patients is to improve the haemodynamic state on arrival at hospital. However, fluid replacement therapy, particularly in large volumes, may be detrimental to haemostasis (i.e. increase blood pressure, dilute blood and clotting factors thereby exacerbating bleeding), and delay transport to hospital. The decision of whether to initiate pre-hospital fluid therapy in trauma involves a careful consideration of the risk of death as a result of ischaemic damage to vital organs as a result of underresuscitation, and the risk of overresuscitation exacerbating uncontrolled bleeding, or causing re-bleeding after bleeding has been controlled.

Intervention(s)

Initiation of fluid replacement therapy in pre-hospital settings, including the accident scene & in transit to hospital.

  • Different types of fluid preparations should be considered separately (isotonic and hypertonic crystalloid, and colloid fluids)
  • The volume of IV fluid administered should be considered.
Population(s)

Trauma patients (with moderate to severe penetrating or blunt injuries) including: thorax, abdomen, and limb fractures. The use of pre-hospital fluid therapy in children should also be considered.

Patients with isolated head trauma will not be considered.

Current standard treatments (comparators) Fluid replacement therapy initiated in hospital.
Other considerations

Measures of trauma severity such as the UK Abbreviated Injury Severity (AIS) Score or Triage Revised Trauma Score (T-RTS) will be taken into account where possible.

Outcomes of interest include: mortality, complications (e.g. adult respiratory distress, sepsis, acute renal failure, coagulopathy, wound infection, fat embolism and pulmonary embolism) and quality of life.

Evidence to be considered will include randomised clinical trials, and other study designs where appropriate. Evidence from animal studies may also be included where relevant.

The appraisal will take account of the time taken for patients to arrive at hospital in alternative treatment strategies, and circumstances, such as patient entrapment, where the time taken to arrive at hospital may be affected.

 

1 The remit from the Department of Health/National Assembly for Wales was "To advise on the clinical and cost effectiveness of pre-hospital initiation of fluid replacement therapy in trauma, and if the evidence allows on the selection of patients for which this may be appropriate"

2 Joint Royal Colleges Ambulance Liaison Committee Pre-Hospital Guidelines 2002

This page was last updated: 30 March 2010