Hypertonic Saline & Early Trauma Care
DuBose JJ, Kobayashi L, Lozornio A, et al. Clinical experience using 5% hypertonic saline as a safe alternative fluid for use in trauma.
J Trauma. 2010;68:1172–1177.
Fluid resuscitation is one of the cornerstones of trauma care. Crystalloids are currently used, including normal saline solution and lactated ringers. But research is evaluating the efficacy of hypertonic saline solutions. This study analyzes the use of a commercially available 5% hypertonic solution for initial trauma resuscitation. The authors compared a traditional resuscitation group with a matched group that received one 500 mL bolus of 5% hypertonic saline during the first 15 minutes of admission to the emergency department. The authors looked at length of hospital stay, intensive care unit and ventilator days, as well as mortality.
The authors found that hypertonic saline has a favorable safety profile for use in trauma patients, noting that serum sodium levels in the hypertonic saline group weren’t found to result in any seizures or coma. The data also suggested that patients receiving hypertonic saline required fewer days on a ventilator. However, one of the most important items discussed is the effectiveness of hypertonic saline in decreasing cerebral edema following a traumatic head injury.
This should spark some interest from the EMS community, because a single resuscitation fluid could benefit the traumatic brain injury and protect against adult respiratory distress syndrome.
Are Two IVs Better than One?
Li SF, Cole M, Forest R, et al. Are two smaller intravenous catheters as good as one larger intravenous catheter? Am J of Emerg Med. 2010;28:724–727.
Sometimes it’s not feasible to place a large-bore IV in a patient due to their anatomy, prior drug use or chronic illnesses, so the authors designed this study to evaluate catheter flow rates.
Eight volunteers were cannulated with three catheters; two 20-gauge and one 18-gauge. The catheters, tubing and IV bag height were equal between all participants, and nearly identical anatomic locations were used for IV placement.
Interestingly, the two 20-gauge IVs flowed statistically faster than the single 18-gauge. The authors reported that the 500 cc normal saline was infused via the two 20-gauge catheters in an average of 129 seconds (2.15 minutes) faster than through the single 18-gauge.
This is an interesting finding. But, be sure to check with your medical director and agency policies before implementing any changes in your practice.
Nakahara S, Matsuoka T, Ueno M, et al. Predictive factors for undertriage among severe blunt trauma patients: What enables them to slip through an established trauma triage protocol? J Trauma. 2010;68:1044–1051.
It’s well established that transporting trauma patients to the right hospital can affect their outcome. But transporting too many of the wrong patients to the trauma center can also result in overcrowding and poorer outcomes. We’ve developed various trauma protocols to avoid this, but what if a group of patients slips through and ends up at a non-trauma facility where they won’t receive the care and treatment they need?
The authors of this study evaluated the specific characteristics of nearly 400 blunt-injury trauma patients. The majority was male, and most were admitted during the daylight hours. As would be expected, patients with a lower Glasgow Coma Scale (GCS) score were less likely to be under-triaged, as were patients with severe lower extremity injuries. Interestingly, patients with a closed-head injury and GCS above 12 were 2.7 times more likely to be under-triaged than a similar patient with a GCS below 12. Isolated pelvic injuries were also associated with under-triage. Additionally, the authors also found that patients 45–54 years of age were more likely to be under-triaged.
So, being middle-aged and banging your head without a change in consciousness results in a significant chance of not being sent to the trauma center for evaluation. These authors conclude that trauma triage protocols may need to be reevaluated. They suggest changing the age criteria and establishing factors that might better identify a serious trauma patient.
I want to introduce you to the Emergency Clinics of North America, a tremendous resource for the EMS novice and seasoned veteran. This quarterly journal provides an in-depth review of a specific topic in each issue (e.g., airway), and introduces various well-known educators and researchers in emergency medicine. These aren’t research articles but rather a compilation of the latest trends.
Here are two recently published articles that I found to be especially informative:
This article originally appeared in October 2010 JEMS as “Research Review.”