Prehospital interventions for trauma: helpful or harmful? The American point of view

Pre-hospital Care: The Trapped Patient

“…Overzealous positive pressure ventilation by either portable ventilator or bag-valvemask apparatus may however cause harm by increasing intrathoracic pressure and reducing venous return. This may well go unnoticed in the trapped, moribund trauma patient who may have lower ventilatory requirements (as a result of lower oxygen consumption and carbon dioxide production) (31). The resulting reduction in cardiac output may be erroneously attributed to other injuries.…”

“…The resulting reduction in cardiac output may be erroneously attributed to other injuries. Six to eight breaths per minute at tidal volumes of approximately 10ml/kg may be adequate to maintain oxygenation without impairing cardiac output (31).…”

“…Advocates of early aggressive fluid resuscitation (the current ATLS® approach) cite the proven benefits of blood pressure support in head injuries, and the value of fluid administration in animal studies of severe circulatory compromise (16,31). More recent experimental and clinical studies suggest however that intravenous fluids and other measures to reverse hypotension may be detrimental if provided before control of internal haemorrhage has been achieved.…”

“…More recent experimental and clinical studies suggest however that intravenous fluids and other measures to reverse hypotension may be detrimental if provided before control of internal haemorrhage has been achieved. Proponents of the concept of 'delayed' or 'hypotensive' fluid resuscitation argue that fluid replacement is ineffective, time consuming and leads to increased bleeding, haemodilution and impaired coagulation (31,33). Although the studies supporting these concepts are interesting, they involve patients with penetrating injuries rather than blunt trauma (34).…”

“…Aggressive fluid resuscitation may theoretically increase intra-abdominal haemorrhage from splenic injury but blood pressure support for the head injury is considered critical (16). Add to this the potentially massive blood loss and fluid sequestration from an unreduced femoral shaft fracture and the dilemma worsens (31,33) In such circumstances, attempts to maintain an adequate cerebral perfusion pressure should be balanced with the risks of continued uncontrolled bleeding if blood pressure is restored to normal.…”