Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients – Part II

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Also posted over at Rogue Medic (now at EMS Blogs) and at Research Blogging. Go check out the rest of the excellent material at these sites.

This paper is discussed in Prehospital administration of IV fluids to trauma patients: EMS Research Episode 5.

This is also discussed by Dr. Chris Russi in the podcast Russi’s Research Review – Episode Two (Fluid Administration in Traumatic Injury Patients).

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As I pointed out in Part I, using placement of an IV (IntraVenous) line on a trauma patient as a surrogate for administration of IV fluids to maintain blood pressure, or to raise blood pressure, is a mistake. We do not know how much fluid was administered. I have often stated IVs on trauma patients and not given more than a few milliliters of fluid, which is an insignificant volume of fluid regardless of blood pressure. If I have given IV fluid, it has been because there is medication in the fluid – morphine (10 mg/ml) or fentanyl (50 mcg/ml). These are not significant amounts of fluid, but they are significant treatments.

The problem with this study is that the NTDB (National Trauma Data Bank®) does not produce information that appears to be accurate. The authors stated –

Patients without complete prehospital procedure information were excluded.^[1]

This presumes that what they describe as complete prehospital procedure information is the same as accurate prehospital procedure information.

On the podcast, we all agreed that the data do not appear to reflect reality. I have worked in EMS for 20 years and I have worked in four of the five states with the largest number of EMS providers. California, New York, Pennsylvania, and I worked at a trauma center in New Jersey. The others on the podcast, Tom Bouthillet, Dr. Bill Toon, and Harry Mueller have similar, or more, experience.

Here are the numbers on the 5 most common EMS procedures as documented in the NTDB.

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Click on images to make them larger.

Only 49.3% had IV fluids starts documented?

Researchers dream of randomizing things this evenly. However, this is an unusually low rate of IV starts for trauma patients. I have never seen a protocol that does not indicate that an IV should at least be attempted on trauma patients.

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Study Protocol
During the prehospital phase, patients assigned to receive immediate fluid resuscitation were treated with a standard paramedical protocol^1-3 that included endotracheal intubation and assisted ventilation with oxygen when appropriate, rapid transport to the emergency center, and insertion of two or more 14-gauge intravenous catheters in the upper extremities for rapid infusion of isotonic crystalloid (Ringer’s acetate solution) en route to the hospital. In accordance with recent recommendations, no patients were treated with antishock garments²⁴.^[2]

Patients assigned to the delayed-resuscitation group were cared for in an identical manner with the exception that after the insertion of the intravenous catheters, the catheter lumens were covered with an infusion cap that was then flushed with 1 to 2 ml of 1 percent heparin in normal saline.^[2]

Even the no fluids group in that study did have two 14 gauge IVs started. If we evaluated that study according to the criteria of the current study, both groups received IV fluids, since both had IVs started.

We know that is not true.

In the Bickell study,^[2] we know which of the patients who had IVs started received fluids and we know how much fluid patients received.

In the current study, we assume that everyone who had an IV started received fluids and we do not seem to care how much fluid patients received.

Can this possibly answer a question about the influence of fluids on trauma?

It is also hypothesized that delays to start IVs could have been the cause of the bad outcomes.

How many medics delayed on scene to start an IV?

We don’t know.

How many medics started IVs on the move and did not delay transport?

We don’t know.

Should we even try to explain results that are based on bad data?

No.

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To be continued in Part III.

Footnotes:

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^[1] Prehospital Intravenous Fluid Administration is Associated With Higher Mortality in Trauma Patients: A National Trauma Data Bank Analysis.
Haut ER, Kalish BT, Cotton BA, Efron DT, Haider AH, Stevens KA, Kieninger AN, Cornwell EE 3rd, Chang DC.
Ann Surg. 2010 Dec 20. [Epub ahead of print]
PMID: 21178760 [PubMed - as supplied by publisher]

Full Text in PDF format from www.medicalscg

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^[2] Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.
Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL.
N Engl J Med. 1994 Oct 27;331(17):1105-9.
PMID: 7935634 [PubMed - indexed for MEDLINE]

Free Full Text from N Engl J Med. with link to Free Full Text PDF

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