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Home > Blogs > Trauma Research Blog > Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injury

PubMed ID: 7935634
N Engl J Med. 1994 Oct 27;331(17):1105-9
Authors: Bickell WH, Wall MJ Jr, Pepe PE, Martin RR, Ginger VF, Allen MK, Mattox KL

Abstract:

BACKGROUND. Fluid resuscitation may be detrimental when given before bleeding is controlled in patients with trauma. The purpose of this study was to determine the effects of delaying fluid resuscitation until the time of operative intervention in hypotensive patients with penetrating injuries to the torso. METHODS. We conducted a prospective trial comparing immediate and delayed fluid resuscitation in 598 adults with penetrating torso injuries who presented with a pre-hospital systolic blood pressure of < or = 90 mm Hg. The study setting was a city with a single centralized system of pre-hospital emergency care and a single receiving facility for patients with major trauma. Patients assigned to the immediate-resuscitation group received standard fluid resuscitation before they reached the hospital and in the trauma center, and those assigned to the delayed-resuscitation group received intravenous cannulation but no fluid resuscitation until they reached the operating room. RESULTS. Among the 289 patients who received delayed fluid resuscitation, 203 (70 percent) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62 percent) who received immediate fluid resuscitation (P = 0.04). The mean estimated intraoperative blood loss was similar in the two groups. Among the 238 patients in the delayed-resuscitation group who survived to the postoperative period, 55 (23 percent) had one or more complications (adult respiratory distress syndrome, sepsis syndrome, acute renal failure, coagulopathy, wound infection, and pneumonia), as compared with 69 of the 227 patients (30 percent) in the immediate-resuscitation group (P = 0.08). The duration of hospitalization was shorter in the delayed-resuscitation group. CONCLUSIONS. For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.

Notes & Commentary:

Spent a surprisingly enjoyable journal club discussing this paper today.  It was in the running for most important trauma paper of all time at one point.  It's certainly perhaps the trauma paper that has generated the most controversy.  The study's been criticised on many fronts but it's often overlooked how extraordinarily difficult it is to conduct a study like this.  It marked the beginning of a sea-change in the way patients were resuscitated. The whole paper needs to be read and digested to fully appreciate the implications of the results. 

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