title: Goal-directed resuscitation in the prehospital setting: a propensity-adjusted analysis.
abstract: BACKGROUND
  The scope of prehospital (PH) interventions has expanded recently--not always with clear benefit. PH crystalloid resuscitation has been challenged, particularly in penetrating trauma. Optimal PH crystalloid resuscitation strategies remain unclear in blunt trauma as does the influence of PH hypotension. The objective was to characterize outcomes for PH crystalloid volume in patients with and without PH hypotension.
  
  
  METHODS
  Data were obtained from a multicenter prospective study of blunt injured adults transported from the scene with ISS > 15. Subjects were divided into HIGH (>500 mL) and LOW (≤500 mL) PH crystalloid groups. Propensity-adjusted regression determined the association of PH crystalloid group with mortality and acute coagulopathy (admission International Normalized Ratio, >1.5) in subjects with and without PH hypotension (systolic blood pressure [SBP], <90 mm Hg) after controlling for confounders.
  
  
  RESULTS
  Of 1,216 subjects, 822 (68%) received HIGH PH crystalloid and 616 (51%) had PH hypotension. Initial base deficit and ISS were similar between HIGH and LOW crystalloid groups in subjects with and without PH hypotension. In subjects without PH hypotension, HIGH crystalloid was associated with an increase in the risk of mortality (hazard ratio, 2.5; 95% confidence interval [95% CI], 1.3-4.9; p < 0.01) and acute coagulopathy (odds ratio [OR], 2.2; 95% CI, 1.01-4.9; p = 0.04) but not in subjects with PH hypotension. HIGH crystalloid was associated with correction of PH hypotension on emergency department (ED) arrival (OR, 2.02; 95% CI, 1.06-3.88; p = 0.03). The mean corrected SBP in the ED was 104 mm Hg. Each 1 mm Hg increase in ED SBP was associated with a 2% increase in survival in subjects with PH hypotension (OR, 1.02; 95% CI, 1.01-1.03; p < 0.01).
  
  
  CONCLUSIONS
  In severely injured blunt trauma patients, PH crystalloid more than 500 mL was associated with worse outcome in patients without PH hypotension but not with PH hypotension. HIGH crystalloid was associated with corrected PH hypotension. This suggests that PH resuscitation should be goal directed based on the presence or absence of PH hypotension.
authors.affiliation: Department of Surgery, Division of General Surgery and Trauma, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
authors.forename: Joshua B
authors.initials: JB
authors.lastname: Brown
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: Joseph P
authors.initials: JP
authors.lastname: Minei
authors.forename: Ronald V
authors.initials: RV
authors.lastname: Maier
authors.forename: Michael A
authors.initials: MA
authors.lastname: West
authors.forename: Timothy R
authors.initials: TR
authors.lastname: Billiar
authors.forename: Andrew B
authors.initials: AB
authors.lastname: Peitzman
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: Joseph
authors.initials: J
authors.lastname: Cuschieri
authors.forename: Jason L
authors.initials: JL
authors.lastname: Sperry
mesh_terms: D000328:Adult; D000077324:Crystalloid Solutions; D004632:Emergency Medical Services / Q000379:methods* / Q000706:statistics & numerical data; D005260:Female; D006801:Humans; D007022:Hypotension / Q000209:etiology / Q000401:mortality / Q000628:therapy; D015601:Injury Severity Score; D007552:Isotonic Solutions / Q000627:therapeutic use; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D057216:Propensity Score; D016016:Proportional Hazards Models; D011446:Prospective Studies; D015532:Rehydration Solutions / Q000627:therapeutic use; D012151:Resuscitation / Q000379:methods* / Q000401:mortality / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014949:Wounds, Nonpenetrating / Q000150:complications / Q000401:mortality / Q000628:therapy
chemical_list: D000077324:Crystalloid Solutions; D007552:Isotonic Solutions; D015532:Rehydration Solutions