Examining current trends and research in pre-hospital hypotensive resuscitation
Abstract
The main purpose of trauma care is to reverse shock or reduce its deleterious effects, and in so doing, saving life. The use of aggressive fluid resuscitation may be harmful, as the resulting increased blood pressure and circulating volume could lead to clot disruption, dilution of clotting factors as well as an alteration in the body’s natural response to haemorrhage. The concept of hypotensive resuscitation and how it has evolved is discussed in this article.
This article looks at the current trends in hypotensive resuscitation, examining research into the use of such strategies and whether evidence exists to support the implementaion of these strategies into UK paramedic practice.
A number of sources were used to assess and access the literature. Primary and secondary sources were located that incorporated seminal and classical studies, permitting a broad overview of the subject.
The paramedic has a duty and a responsibiility to provide care that is safe and effective, and this includes the use of fluids to aid resuscitation.
The initiation of fluid resuscitation in a pre-hospital setting by paramedics in the United Kingdom has been an ongoing practice for over 20 years. At the inception of paramedic practice, such practitioners were able to administer both colloids and crystalloid fluids for resuscitation purposes. However, over the past decade paramedic practice has been dictated by national clinical guidelines, namely that from the Joint Royal Colleges Ambulance Liason Committee (JRCALC) (2006), and fluid resuscitation restricted to crystalloid administration only.
It has become commonplace for paramedics to gain intravascular access and infuse crystalloid fluids in trauma patients, while using other noninvasive patient assessment techniques and incorporating management strategies from the aforementioned clinical guidelines. Thus JRCALC (2006) suggests that when there is visible external blood loss of over 500 ml, fluid replacement must be commenced with an initial bolus of 250 ml through a large bore cannula.
Conversely, there exists an expanding body of literature and research on the utilisation of permissive hypotensive resuscitation, with the drivers for such research stemming from recent military conflicts in Iraq and Afghanistan. Such research tends to highlight that limiting volume replacement can negate the often lethal triad seen in trauma patients, namely acute coagulopathy, metabolic acidosis, and hypothermia.
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