Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries

Bickell et al. N Engl J Med 1994; 331:1105-1109

Clinical Question

• In hypotensive patients with penetrating torso trauma, does a delayed fluid strategy, in comparison to an immediate fluid resuscitation strategy, lead to an improved survival?

Design

• Randomised controlled trial
• Randomised according to weekday presented
• Non-blinded

Setting

• Pre-hospital, serving single trauma centre, USA
• November 1989 – December 1992

Population

• Adult patients with penetrating torso trauma and BP <90 data-blogger-escaped-assessment=”” data-blogger-escaped-at=”” data-blogger-escaped-initial=”” data-blogger-escaped-li=”” data-blogger-escaped-paramedic=””>
• Excluded those for whom fluid resuscitation would not have affected outcome
• 1069 randomised patients of whom 598 included in analysis

Intervention

• Fluid resuscitation delayed until operative intervention
  • Mean 386ml given prior to operative intervention

Control

• Fluid resuscitation given before operative intervention
  • Mean 2611ml given prior to operative intervention

Outcome

• Primary outcome: survival to discharge, significantly higher in the delayed resuscitation group compared with the immediate resuscitation group (70% vs. 62%, P=0.04)
• Secondary outcomes: comparing mean values in immediate vs. delayed resuscitation group
  • BP on scene 58mmHg vs. 59mmHg
  • BP at time of initial operative intervention 112mmHg vs. 113mmHg
  • Intra-operative fluids given per minute 117ml vs. 91ml

Authors’ Conclusions

• Aggressive administration of IV fluids to hypotensive patients with penetrating torso trauma should be delayed until operative intervention

Strengths

• Randomised
• Appropriate power calculation
• Intention to treat analysis

Weaknesses

• Randomised according to day of presentation. Non-blinded and allocation concealment not maintained
• BP in both groups had improved by time of operative intervention. Not given reason for this, were they given vasopressors?
• Practices have now changed with early use of blood products
• Single centre with established trauma system in place. Results may not be generalisable to centres that do not get patients into surgery within 79 minutes of 999 call

The Bottom Line

• Aggressive fluid resuscitation in hypotensive patients following penetrating torso trauma should be avoided. This paper emphasises an important principle, that the over-riding priority in penetrating trauma patients who are bleeding is timely surgical intervention.

Links Full text pdf / abstract / doi: 10.1056/NEJM199410273311701
Editorial, Commentaries or Blogs

• None listed

Metadata
Summary author: @DavidSlessor
Summary date: 1 May 2014
Peer-review editor: @stevemathieu75