Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain Injury

Abstract

EVERE TRAUMATIC BRAIN INJURY (TBI) is common in patients with major trauma and typically involves young adult men. 1 Despite current management strategies, patients with severe TBI have a high mortality rate (31%-49%) and a large number of survivors have persistent severe neurological disability. 1-4 There are 80000 to 90 000 were cases of survivors with long-term disability after head injury annually in the United States. 5 The mean lifetime cost of each TBI survivor with severe disability from TBI exceeds US $2 million. 6 After initial head trauma, secondary brain injury may occur due to hypoxia, hypotension, or elevated intracranial pressure (ICP) and is associated with a worse neurological outcome. 3,7 Patients with hypotension after severe TBI have twice the mortality rate of normotensive patients. 5 Therefore, aggressive resuscitation with intravenous fluids is recommended in current guidelines for the management of patients with severe TBI. 8 Treatment of increased ICP in patients with TBI is also likely to improve outcomes. 3

The Glasgow Outcome Scale — 40 years of application and refinement

“…The GOS and GOSE have been used extensively in Australian studies that assessed early interventions [76][77][78][79][80] and examined the effects of genetic status 75,81 , psychiatric disorders 82,83 , demographics, injury severity and rehabilitation 74,84-88 on outcome. The Victorian State Trauma Registry also involves use of the GOSE to assess outcome in general trauma victims, including those with TBI 89 .…”

“…In many studies, the scale has been dichotomized, leading to reduced sensitivity. The point of dichotomization has varied: in some studies of medical interventions, a GOSE ranking of 5-8 has indicated a good outcome [76][77][78]80 , whereas in some studies of rehabilitation , rankings of 7-8 were good outcomes 74,75 . Not all of these dichotomizations are necessarily sensible:…”

Hypertonic saline in severe traumatic brain injury: a systematic review and meta-analysis of randomized controlled trials

“…[27][28][29][30][31][32][33][34][35][36][37] All studies were published in English. Of the 11 studies, only 3 included more than 100 patients 27,31,32 ( Table 1).…”

“…30 In one study, three patients (0.01% of our total population) with stroke were also included, which represented less than 15% of that study's patient population. 34 Three comparators were identified: hyperosmolar solution (mannitol or sodium bicarbonate), 28,[33][34][35]37 iso-osmolar solution (normal saline or ringer's lactate), 27,31,32 and hypo-osmolar solution 36 (see Table 1). …”

“…In general, allocation concealment was respected in most studies (63%), 27,[30][31][32][33][34][35] and the randomization method was specified in slightly more than half of them (54%). 27,[31][32][33]35,36 In six studies (63%), the research staff, patients, and medical staff were not blinded to the intervention studied.…”