Why We Delay Volume Administration in Penetrating Trauma

November 4, 2017

On the Shoulders of Giants

Spoon Feed
In patients with penetrating torso trauma, it was better to allow prehospital hypotension and hasten transport for definitive repair prior to beginning volume resuscitation than to try to normalize vital signs in the field by giving IV fluid.

Why does this matter?
We know hypotension is bad.  The impulse was to give volume resuscitation in the field when patients had penetrating trauma to normalize vital signs, but more evidence began to mount that this wasn’t working out in practice.  Since it was anathema to allow hypotension to persist, this study was badly needed to sort this out.

Holey torso, Batman!
This was a prospective trial of delayed vs. immediate prehospital volume expansion in 598 patients with penetrating torso trauma and SBP </= 90.  They found that delayed IV fluid and permissive hypotension in the prehospital setting led to improved survival over prehospital volume expansion to raise blood pressure (70% vs. 62% survival), NNT = 13.  Turns out if patients have holes in their blood vessels and you give IV fluid to raise the BP before fixing said holes, they do worse than if you left them alone and allowed them to remain hypotensive in the prehospital setting.

Source
Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries.  N Engl J Med. 1994 Oct 27;331(17):1105-9.