Prehospital Treatment

There have been many debates in recent years over the extent to which patients should be resuscitated prior to operative intervention, both in the prehospital setting and the ED. The concept of field stabilization of trauma victims has been discredited for those with hemorrhagic shock. The prehospital interventions that improve survival include attention to the airway, ventilation, immobilization, and rapid transport; not fluid resuscitation. 3 Standard prehospital interventions directed at restoring blood pressure, such as application of a pneumatic antishock garment (PASG) and infusion of intravenous fluids, have not been shown to improve survival. 45

The PASG became standard prehospital treatment in the late 1970s based on anecdotal reports of efficacy and its extensive use during the Vietnam War. While there is no doubt that application of the PASG often raises blood pressure, most likely through a rise in systemic vascular resistance, there is no evidence that use of the PASG to achieve such a result actually improves outcome. Several controlled trials have failed to prove that any significant benefit is derived from its use in trauma victims.4,67 In fact, in the presence of shock and chest trauma, PASG use may actually increase the severity of hemorrhage and also mortality.8 Thus, enthusiasm for the PASG has begun to wane except for patients with unstable pelvic fractures, for whom it may stabilize the fractures and potentially tamponade retroperitoneal hemorrhage. The PASG may also prove useful for splinting of multiple lower extremity fractures and control of soft tissue bleeding from lower extremities.

There has also been debate over the efficacy of prehospital line placement and fluid resuscitation. Proponents of field resuscitation state that skilled paramedics are able to place intravenous lines with little or no delays in transport. 9 Opponents state that since blood loss cannot be controlled in the field, any delay in definitive treatment is excessive. Clinical studies have shown that the amount of fluid infused en route is usually minimal as compared with the total fluid requirement, and one randomized study of victims of penetrating trauma has failed to show any benefit associated with preoperative fluid therapy. 10 Prehospital fluid therapy probably does not affect outcome in the vast majority of cases, but it may be valuable given a specific combination of hemorrhage severity and distance from the hospital. Until conclusive data for a particular position can be obtained, it is reasonable to place intravenous lines once en route to the hospital whenever possible. This practice avoids potentially lethal delays in the field and grants patients the potential benefits of prehospital fluid therapy.

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