title: Prehospital fluid resuscitation in hypotensive trauma patients: do we need a tailored approach?
abstract: OBJECTIVE
  The ideal strategy for prehospital intravenous fluid resuscitation in trauma remains unclear. Fluid resuscitation may reverse shock but aggravate bleeding by raising blood pressure and haemodilution. We examined the effect of prehospital i.v. fluid on the physiologic status and need for blood transfusion in hypotensive trauma patients after their arrival in the emergency department (ED).
  
  
  METHODS
  Retrospective analysis of trauma patients (n=941) with field hypotension presenting to a level 1 trauma centre. Regression models were used to investigate associations between prehospital fluid volumes and shock index and blood transfusion respectively in the emergency department and mortality at 24h.
  
  
  RESULTS
  A 1L increase of prehospital i.v. fluid was associated with a 7% decrease of shock index in the emergency department (p<0.001). Volumes of 0.5-1L and 1-2L were associated with reduced likelihood of shock as compared to volumes of 0-0.5L: OR 0.61 (p=0.03) and OR 0.54 (p=0.02), respectively. Volumes of 1-2L were also associated with an increased likelihood of receiving blood transfusion in ED: OR 3.27 (p<0.001). Patients who had received volumes of >2L have a much greater likelihood of receiving blood transfusion in ED: OR 9.92 (p<0.001). Mortality at 24h was not associated with prehospital i.v. fluids.
  
  
  CONCLUSIONS
  In hypotensive trauma patients, prehospital i.v. fluids were associated with a reduction of likelihood of shock upon arrival in ED. However, volumes of >1L were associated with a markedly increased likelihood of receiving blood transfusion in ED. Therefore, decision making regarding prehospital i.v. fluid resuscitation is critical and may need to be tailored to the individual situation. Further research is needed to clarify whether a causal relationship exists between prehospital i.v. fluid volume and blood transfusion. Also, prospective trials on prehospital i.v. fluid resuscitation strategies in specific patient subgroups (e.g. traumatic brain injury and concomitant haemorrhage) are warranted.
authors.affiliation: Department of Surgery and Institute for Cardiovascular Research, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands; Helicopter Emergency Medical Service, Northwestern Netherlands Trauma Area, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Electronic address: l.geeraedts@vumc.nl.
authors.forename: Leo M G
authors.initials: LM
authors.lastname: Geeraedts
authors.affiliation: Department of Surgery, Canisius-Wilhelmina Hospital, Weg door Jonkerbos 100, P.O. Box 9015, 6500 GS Nijmegen, The Netherlands. Electronic address: leoniepothof@hotmail.com.
authors.forename: Leonie A H
authors.initials: LA
authors.lastname: Pothof
authors.affiliation: Department of Trauma Services, Liverpool Hospital, Elizabeth Street, Locked Bag 7103, Liverpool BC, NSW 1871, Australia. Electronic address: erica.caldwell@sswahs.nsw.gov.au.
authors.forename: Erica
authors.initials: E
authors.lastname: Caldwell
authors.affiliation: Department of Epidemiology and Biostatistics, VU University Medical Center, De Boelelaan 1117, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands. Electronic address: esm.delange@vumc.nl.
authors.forename: Elly S M
authors.initials: ES
authors.lastname: de Lange-de Klerk
authors.affiliation: Department of Trauma Services, Liverpool Hospital, Elizabeth Street, Locked Bag 7103, Liverpool BC, NSW 1871, Australia. Electronic address: scott.damours@sswahs.nsw.gov.au.
authors.forename: Scott K
authors.initials: SK
authors.lastname: D'Amours
mesh_terms: D001315:Australia / Q000453:epidemiology; D001803:Blood Transfusion / Q000706:statistics & numerical data; D004632:Emergency Medical Services / Q000379:methods*; D005440:Fluid Therapy / Q000379:methods / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D007022:Hypotension / Q000401:mortality / Q000628:therapy*; D015601:Injury Severity Score; D017410:Practice Guidelines as Topic; D012151:Resuscitation / Q000379:methods / Q000401:mortality; D012189:Retrospective Studies; D012771:Shock, Hemorrhagic / Q000401:mortality / Q000517:prevention & control / Q000628:therapy*; D015996:Survival Rate; D013997:Time Factors; D014947:Wounds and Injuries / Q000401:mortality / Q000628:therapy*
keywords: Blood transfusion; Fluid resuscitation; Haemorrhage; Prehospital; Trauma