Prehospital Hypertonic Fluid Fails to Improve Outcomes in Patients with Blunt Head Trauma
In the largest randomized controlled trial to date, prehospital hypertonic fluid therapy did not improve neurological outcomes in patients with severe blunt head trauma without hypovolemic shock.
Hypertonic fluid therapy diminishes cerebral edema and enhances systemic perfusion pressure in patients with severe blunt head injury, but its effect on neurological outcome is unknown. In a multicenter, double-blind, randomized, placebo-controlled trial, researchers evaluated the effect of hypertonic fluid in patients >15 years who had sustained severe blunt closed head injury (prehospital Glasgow Coma Scale score <8) and did not have hypovolemic shock (systolic blood pressure ≤70 mm Hg or 71–90 mm Hg with a pulse ≥108 beats per minute). Patients were randomized to receive an initial fluid bolus of 250 mL of 7.5% saline, 7.5% saline/6% dextran 70, or 0.9% saline within 4 hours of the dispatch call.
Six-month outcome data were available for 1087 of 1282 patients (85%) who were enrolled from 2006 to 2009. At 6 months, there were no significant differences between the hypertonic-fluid groups and the normal-saline group in neurological outcome (as measured by the Extended Glasgow Outcome Scale and Disability Rating Scale), survival at 28 days, survival at hospital discharge, development of organ failure, or length of stay in an intensive care unit or hospital. No increase in progression of intracranial hemorrhage was noted in the hypertonic-fluid groups.
Although this study is the largest of its kind, the authors did not control for postintervention neurosurgical management or fluid administration (including additional hypertonic saline or mannitol), and 15% of patients were lost to follow-up. Currently, hypertonic saline is not recommended for prehospital treatment of patients with severe head injury. This trial should not lead to a change in practice.
John A. Marx, MD, FAAEM
Published in Journal Watch Emergency Medicine November 5, 2010
Citation(s): Bulger EM et al. Out-of-hospital hypertonic resuscitation following severe traumatic brain injury: A randomized controlled trial. JAMA 2010 Oct 6; 304:1455.