Immediate versus Delayed Fluid RES for Hypotensive Patients with Penetrating Torso Injuries

## William H. Bickell, MD., Matthew J. Wall, Jr., M.D., Paul E. Pepe, MD., R. Russell Martin, MD., Victoria F. Ginger, MSN., Mary K. Allen, BA., and Kenneth L. Mattox, MD.

The New England Journal of Medicine 2012;331(17):1105-1109.

#### Description with Key Points:

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.

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This was 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 less than 90 mm Hg. 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.

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Among the 289 patients who received delayed fluid resuscitation, 203 (70%) survived and were discharged from the hospital, as compared with 193 of the 309 patients (62%) who received immediate fluid resuscitation. The mean estimated intra?operative 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%) 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%) in the immediate-resuscitation group. The duration of hospitalization was shorter in the delayed-resuscitation group.

Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries
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# Take Home Message:

For hypotensive patients with penetrating torso injuries, delay of aggressive fluid resuscitation until operative intervention improves the outcome.
Patients with shock from uncontrolled hemorrhage did WORSE with aggressive prehospital fluids.
Fluids given before surgical control of bleeding lead to either accentuation of ongoing hemorrhage or hydraulic disruption of an effective thrombus, followed by a fatal secondary hemorrhage.
Intravenous infusions of crystalloid may promote hemorrhage by diluting coagulation factors and by lowering blood viscosity, thereby decreasing the resistance to flow around an incomplete thrombus.
Too much fluid volume may make internal hemorrhage worse by ?Popping the Clot.?