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. 1991 May;213(5):482–491. doi: 10.1097/00000658-199105000-00014

Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension. The U.S.A. Multicenter Trial.

K L Mattox 1, P A Maningas 1, E E Moore 1, J R Mateer 1, J A Marx 1, C Aprahamian 1, J M Burch 1, P E Pepe 1
PMCID: PMC1358479  PMID: 1708984

Abstract

The safety and efficacy of 7.5% sodium chloride in 6% dextran 70 (HSD) in posttraumatic hypotension was evaluated in Houston, Denver, and Milwaukee. Multicentered, blinded, prospective randomized studies were developed comparing 250 mL of HSD versus 250 mL of normal crystalloid solution administered before routine prehospital and emergency center resuscitation. During a 13-month period, 422 patients were enrolled, 211 of whom subsequently underwent operative procedures. Three hundred fifty-nine patients met criteria for efficacy analysis, 51% of whom were in the HSD group. Seventy-two per cent of all patients were victims of penetrating trauma. The mean injury severity score (19), Trauma Score plus Injury Severity Score (TRISS) probability of survival, revised trauma scores (5.9), age, ambulance times, preinfusion blood pressure, and etiology distribution were identical between groups. The total amount of fluid administered, white blood cell count, arterial blood gases, potassium, or bicarbonate also were identical between groups. The HSD group had an improved blood pressure (p = 0.024). Hematocrit, sodium chloride, and osmolality levels were significantly elevated in the Emergency Center. Although no difference in overall survival was demonstrated, the HSD group requiring surgery did have a better survival (p = 0.02), with some variance among centers. The HSD group had fewer complications that the standard treatment group (7 versus 24). A greater incidence of adult respiratory distress syndrome, renal failure, and coagulopathy occurred in the standard treatment group. No anaphylactoid nor Dextran-related coagulopathies occurred in the HSD group. Although this trial demonstrated trends supportive of HSD in hypotensive hemorrhagic shock patients requiring surgery, a larger sample size will be required to establish which subgroups of trauma patients might maximally benefit from the prehospital use of a small volume of hyperosmolar solution. This study demonstrates the safety of administering 250 mL 7.5% HDS to this group of patients.

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Selected References

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  1. Auler J. O., Jr, Pereira M. H., Gomide-Amaral R. V., Stolf N. G., Jatene A. D., Rocha e Silva M. Hemodynamic effects of hypertonic sodium chloride during surgical treatment of aortic aneurysms. Surgery. 1987 May;101(5):594–601. [PubMed] [Google Scholar]
  2. Baue A. E., Tragus E. T., Parkins W. M. A comparison of isotonic and hypertonic solutions and blood on blood flow and oxygen consumption in the initial treatment of hemorrhagic shock. J Trauma. 1967 Sep;7(5):743–756. doi: 10.1097/00005373-196709000-00012. [DOI] [PubMed] [Google Scholar]
  3. Bickell W. H., Shaftan G. W., Mattox K. L. Intravenous fluid administration and uncontrolled hemorrhage. J Trauma. 1989 Mar;29(3):409–409. doi: 10.1097/00005373-198903000-00028. [DOI] [PubMed] [Google Scholar]
  4. Border J. R., Lewis F. R., Aprahamian C., Haller J. A., Jacobs L. M., Luterman A. Panel: prehospital trauma care--stabilize or scoop and run. J Trauma. 1983 Aug;23(8):708–711. [PubMed] [Google Scholar]
  5. Brown J. M., Grosso M. A., Moore E. E. Hypertonic saline and dextran: impact on cardiac function in the isolated rat heart. J Trauma. 1990 Jun;30(6):646–651. [PubMed] [Google Scholar]
  6. Cone J. B., Wallace B. H., Caldwell F. T., Jr, Smith S. D., Searcey R. Beneficial effects of a hypertonic solution for resuscitation in the presence of acute hemorrhage. Am J Surg. 1987 Dec;154(6):585–588. doi: 10.1016/0002-9610(87)90221-2. [DOI] [PubMed] [Google Scholar]
  7. Ducey J. P., Mozingo D. W., Lamiell J. M., Okerburg C., Gueller G. E. A comparison of the cerebral and cardiovascular effects of complete resuscitation with isotonic and hypertonic saline, hetastarch, and whole blood following hemorrhage. J Trauma. 1989 Nov;29(11):1510–1518. doi: 10.1097/00005373-198911000-00010. [DOI] [PubMed] [Google Scholar]
  8. Ehrlich F. E., Kramer S. G., Watkins E., Jr An experimental shock model simulating clinical hemorrhagic shock. Surg Gynecol Obstet. 1969 Dec;129(6):1173–1180. [PubMed] [Google Scholar]
  9. Fischer R. P., Pepe P. E., Reed R. L., 2nd, Parks D. H., Prentice F. D., Mattox K. L. Academic consequences of a trauma system failure. J Trauma. 1990 Jul;30(7):784–791. doi: 10.1097/00005373-199007000-00004. [DOI] [PubMed] [Google Scholar]
  10. Gross D., Landau E. H., Assalia A., Krausz M. M. Is hypertonic saline resuscitation safe in 'uncontrolled' hemorrhagic shock? J Trauma. 1988 Jun;28(6):751–756. doi: 10.1097/00005373-198806000-00005. [DOI] [PubMed] [Google Scholar]
  11. Gross D., Landau E. H., Assalia A., Krausz M. M. Is hypertonic saline resuscitation safe in 'uncontrolled' hemorrhagic shock? J Trauma. 1988 Jun;28(6):751–756. doi: 10.1097/00005373-198806000-00005. [DOI] [PubMed] [Google Scholar]
  12. Gross D., Landau E. H., Klin B., Krausz M. M. Quantitative measurement of bleeding following hypertonic saline therapy in 'uncontrolled' hemorrhagic shock. J Trauma. 1989 Jan;29(1):79–83. doi: 10.1097/00005373-198901000-00016. [DOI] [PubMed] [Google Scholar]
  13. Gross D., Landau E. H., Klin B., Krausz M. M. Treatment of uncontrolled hemorrhagic shock with hypertonic saline solution. Surg Gynecol Obstet. 1990 Feb;170(2):106–112. [PubMed] [Google Scholar]
  14. Gunn M. L., Hansbrough J. F., Davis J. W., Furst S. R., Field T. O. Prospective, randomized trial of hypertonic sodium lactate versus lactated Ringer's solution for burn shock resuscitation. J Trauma. 1989 Sep;29(9):1261–1267. doi: 10.1097/00005373-198909000-00013. [DOI] [PubMed] [Google Scholar]
  15. Gunnar W. P., Merlotti G. J., Barrett J., Jonasson O. Resuscitation from hemorrhagic shock. Alterations of the intracranial pressure after normal saline, 3% saline and dextran-40. Ann Surg. 1986 Dec;204(6):686–692. doi: 10.1097/00000658-198612000-00012. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Gunnar W., Jonasson O., Merlotti G., Stone J., Barrett J. Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40. Surgery. 1988 Apr;103(4):398–407. [PubMed] [Google Scholar]
  17. Gunnar W., Jonasson O., Merlotti G., Stone J., Barrett J. Head injury and hemorrhagic shock: studies of the blood brain barrier and intracranial pressure after resuscitation with normal saline solution, 3% saline solution, and dextran-40. Surgery. 1988 Apr;103(4):398–407. [PubMed] [Google Scholar]
  18. HOWARD J. M., DeBAKEY M. E. The treatment of hemorrhagic shock with cortisone and vitamin B12. Surgery. 1951 Jul;30(1):161–165. [PubMed] [Google Scholar]
  19. Hands R., Holcroft J. W., Perron P. R., Kramer G. C. Comparison of peripheral and central infusions of 7.5% NaCl/6% dextran 70. Surgery. 1988 Jun;103(6):684–689. [PubMed] [Google Scholar]
  20. Harris B. H., Shaftan G. W., Chiu C. J., Limson A. An experimental study of venous hemostasis. Surgery. 1967 Jun;61(6):891–895. [PubMed] [Google Scholar]
  21. Holcroft J. W., Vassar M. J., Perry C. A., Gannaway W. L., Kramer G. C. Use of a 7.5% NaCl/6% Dextran 70 solution in the resuscitation of injured patients in the emergency room. Prog Clin Biol Res. 1989;299:331–338. [PubMed] [Google Scholar]
  22. Holcroft J. W., Vassar M. J., Turner J. E., Derlet R. W., Kramer G. C. 3% NaCl and 7.5% NaCl/dextran 70 in the resuscitation of severely injured patients. Ann Surg. 1987 Sep;206(3):279–288. doi: 10.1097/00000658-198709000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Holcroft J. W., Vassar M. J., Turner J. E., Derlet R. W., Kramer G. C. 3% NaCl and 7.5% NaCl/dextran 70 in the resuscitation of severely injured patients. Ann Surg. 1987 Sep;206(3):279–288. doi: 10.1097/00000658-198709000-00006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Horton J. W., Dunn C. W., Burnweit C. A., Walker P. B. Hypertonic saline-dextran resuscitation of acute canine bile-induced pancreatitis. Am J Surg. 1989 Jul;158(1):48–56. doi: 10.1016/0002-9610(89)90315-2. [DOI] [PubMed] [Google Scholar]
  25. Kramer G. C., Perron P. R., Lindsey D. C., Ho H. S., Gunther R. A., Boyle W. A., Holcroft J. W. Small-volume resuscitation with hypertonic saline dextran solution. Surgery. 1986 Aug;100(2):239–247. [PubMed] [Google Scholar]
  26. Kreimeier U., Brückner U. B., Messmer K. Improvement of nutritional blood flow using hypertonic-hyperoncotic solutions for primary treatment of hemorrhagic hypotension. Eur Surg Res. 1988;20(4):277–279. doi: 10.1159/000128773. [DOI] [PubMed] [Google Scholar]
  27. Landau E. H., Gross D., Assalia A., Krausz M. M. Treatment of uncontrolled hemorrhagic shock by hypertonic saline and external counterpressure. Ann Emerg Med. 1989 Oct;18(10):1039–1043. doi: 10.1016/s0196-0644(89)80926-6. [DOI] [PubMed] [Google Scholar]
  28. Layon J., Duncan D., Gallagher T. J., Banner M. J. Hypertonic saline as a resuscitation solution in hemorrhagic shock: effects on extravascular lung water and cardiopulmonary function. Anesth Analg. 1987 Feb;66(2):154–158. [PubMed] [Google Scholar]
  29. Lewis F. R., Jr Prehospital intravenous fluid therapy: physiologic computer modelling. J Trauma. 1986 Sep;26(9):804–811. doi: 10.1097/00005373-198609000-00005. [DOI] [PubMed] [Google Scholar]
  30. Lucas C. E., Denis R., Ledgerwood A. M., Grabow D. The effects of Hespan on serum and lymphatic albumin, globulin, and coagulant protein. Ann Surg. 1988 Apr;207(4):416–420. doi: 10.1097/00000658-198804000-00008. [DOI] [PMC free article] [PubMed] [Google Scholar]
  31. Maningas P. A., Bellamy R. F. Hypertonic sodium chloride solutions for the prehospital management of traumatic hemorrhagic shock: a possible improvement in the standard of care? Ann Emerg Med. 1986 Dec;15(12):1411–1414. doi: 10.1016/s0196-0644(86)80929-5. [DOI] [PubMed] [Google Scholar]
  32. Maningas P. A., DeGuzman L. R., Tillman F. J., Hinson C. S., Priegnitz K. J., Volk K. A., Bellamy R. F. Small-volume infusion of 7.5% NaCl in 6% Dextran 70 for the treatment of severe hemorrhagic shock in swine. Ann Emerg Med. 1986 Oct;15(10):1131–1137. doi: 10.1016/s0196-0644(86)80852-6. [DOI] [PubMed] [Google Scholar]
  33. Maningas P. A., Mattox K. L., Pepe P. E., Jones R. L., Feliciano D. V., Burch J. M. Hypertonic saline-dextran solutions for the prehospital management of traumatic hypotension. Am J Surg. 1989 May;157(5):528–534. doi: 10.1016/0002-9610(89)90654-5. [DOI] [PubMed] [Google Scholar]
  34. Mattox K. L., Allen M. K., Feliciano D. V. Laparotomy in the emergency department. JACEP. 1979 May;8(5):180–183. doi: 10.1016/s0361-1124(79)80122-7. [DOI] [PubMed] [Google Scholar]
  35. Mattox K. L., Beall A. C., Jr, Jordan G. L., Jr, De Bakey M. E. Cardiorrhaphy in the emergency center. J Thorac Cardiovasc Surg. 1974 Dec;68(6):886–895. [PubMed] [Google Scholar]
  36. Mattox K. L., Bickell W. H., Pepe P. E., Mangelsdorff A. D. Prospective randomized evaluation of antishock MAST in post-traumatic hypotension. J Trauma. 1986 Sep;26(9):779–786. doi: 10.1097/00005373-198609000-00002. [DOI] [PubMed] [Google Scholar]
  37. Mattox K. L., Bickell W., Pepe P. E., Burch J., Feliciano D. Prospective MAST study in 911 patients. J Trauma. 1989 Aug;29(8):1104–1112. doi: 10.1097/00005373-198908000-00007. [DOI] [PubMed] [Google Scholar]
  38. Mattox K. L., Feliciano D. V. Role of external cardiac compression in truncal trauma. J Trauma. 1982 Nov;22(11):934–936. doi: 10.1097/00005373-198211000-00008. [DOI] [PubMed] [Google Scholar]
  39. Mattox K. L. Prehospital care of the patient with an injured chest. Surg Clin North Am. 1989 Feb;69(1):21–29. doi: 10.1016/s0039-6109(16)44731-6. [DOI] [PubMed] [Google Scholar]
  40. Mattox K. L. Public entry into emergency medical services systems. JACEP. 1976 Feb;5(2):128–131. doi: 10.1016/s0361-1124(76)80193-1. [DOI] [PubMed] [Google Scholar]
  41. Milles G., Koucky C. J., Zacheis H. G. Experimental uncontrolled arterial hemorrhage. Surgery. 1966 Aug;60(2):434–442. [PubMed] [Google Scholar]
  42. Monafo W. W., Chuntrasakul C., Ayvazian V. H. Hypertonic sodium solutions in the treatment of burn shock. Am J Surg. 1973 Dec;126(6):778–783. doi: 10.1016/s0002-9610(73)80070-4. [DOI] [PubMed] [Google Scholar]
  43. Monafo W. W. The treatment of burn shock by the intravenous and oral administration of hypertonic lactated saline solution. J Trauma. 1970 Jul;10(7):575–586. doi: 10.1097/00005373-197007000-00006. [DOI] [PubMed] [Google Scholar]
  44. Moylan J. A., Jr, Reckler J. M., Mason A. D., Jr Resuscitation with hypertonic lactate saline in thermal injury. Am J Surg. 1973 May;125(5):580–584. doi: 10.1016/0002-9610(73)90141-4. [DOI] [PubMed] [Google Scholar]
  45. Nakayama S., Kramer G. C., Carlsen R. C., Holcroft J. W. Infusion of very hypertonic saline to bled rats: membrane potentials and fluid shifts. J Surg Res. 1985 Feb;38(2):180–186. doi: 10.1016/0022-4804(85)90025-3. [DOI] [PubMed] [Google Scholar]
  46. Nakayama S., Sibley L., Gunther R. A., Holcroft J. W., Kramer G. C. Small-volume resuscitation with hypertonic saline (2,400 mOsm/liter) during hemorrhagic shock. Circ Shock. 1984;13(2):149–159. [PubMed] [Google Scholar]
  47. Orlowski J. P., Abulleil M. M., Phillips J. M. The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med. 1989 Oct;18(10):1044–1049. doi: 10.1016/s0196-0644(89)80927-8. [DOI] [PubMed] [Google Scholar]
  48. Pepe P. E., Bass R. R., Mattox K. L. Clinical trials of the pneumatic antishock garment in the urban prehospital setting. Ann Emerg Med. 1986 Dec;15(12):1407–1410. doi: 10.1016/s0196-0644(86)80928-3. [DOI] [PubMed] [Google Scholar]
  49. Pepe P. E., Wyatt C. H., Bickell W. H., Bailey M. L., Mattox K. L. The relationship between total prehospital time and outcome in hypotensive victims of penetrating injuries. Ann Emerg Med. 1987 Mar;16(3):293–297. doi: 10.1016/s0196-0644(87)80174-9. [DOI] [PubMed] [Google Scholar]
  50. Pons P. T., Honigman B., Moore E. E., Rosen P., Antuna B., Dernocoeur J. Prehospital advanced trauma life support for critical penetrating wounds to the thorax and abdomen. J Trauma. 1985 Sep;25(9):828–832. doi: 10.1097/00005373-198509000-00003. [DOI] [PubMed] [Google Scholar]
  51. Prough D. S., Johnson J. C., Poole G. V., Jr, Stullken E. H., Johnston W. E., Jr, Royster R. Effects on intracranial pressure of resuscitation from hemorrhagic shock with hypertonic saline versus lactated Ringer's solution. Crit Care Med. 1985 May;13(5):407–411. doi: 10.1097/00003246-198505000-00008. [DOI] [PubMed] [Google Scholar]
  52. Rocha-e-Silva M., Negraes G. A., Soares A. M., Pontieri V., Loppnow L. Hypertonic resuscitation from severe hemorrhagic shock: patterns of regional circulation. Circ Shock. 1986;19(2):165–175. [PubMed] [Google Scholar]
  53. Rowe G. G., McKenna D. H., Corliss R. J., Sialer S. Hemodynamic effects of hypertonic sodium chloride. J Appl Physiol. 1972 Feb;32(2):182–184. doi: 10.1152/jappl.1972.32.2.182. [DOI] [PubMed] [Google Scholar]
  54. SHIRES T., COLN D., CARRICO J., LIGHTFOOT S. FLUID THERAPY IN HEMORRHAGIC SHOCK. Arch Surg. 1964 Apr;88:688–693. doi: 10.1001/archsurg.1964.01310220178027. [DOI] [PubMed] [Google Scholar]
  55. Shackford S. R., Fortlage D. A., Peters R. M., Hollingsworth-Fridlund P., Sise M. J. Serum osmolar and electrolyte changes associated with large infusions of hypertonic sodium lactate for intravascular volume expansion of patients undergoing aortic reconstruction. Surg Gynecol Obstet. 1987 Feb;164(2):127–136. [PubMed] [Google Scholar]
  56. Shackford S. R., Sise M. J., Fridlund P. H., Rowley W. R., Peters R. M., Virgilio R. W., Brimm J. E. Hypertonic sodium lactate versus lactated ringer's solution for intravenous fluid therapy in operations on the abdominal aorta. Surgery. 1983 Jul;94(1):41–51. [PubMed] [Google Scholar]
  57. Siritongtaworn P., Moore E. E., Marx J. A., Van Lighten P., Ammons L. A., Bar-Or D. The benefits of 7.5% NaCl/6% dextran 70 (HSD) for prehospital resuscitation of hemorrhagic shock: improved oxygen transport. Braz J Med Biol Res. 1989;22(2):275–278. [PubMed] [Google Scholar]
  58. Smith G. J., Kramer G. C., Perron P., Nakayama S., Gunther R. A., Holcroft J. W. A comparison of several hypertonic solutions for resuscitation of bled sheep. J Surg Res. 1985 Dec;39(6):517–528. doi: 10.1016/0022-4804(85)90120-9. [DOI] [PubMed] [Google Scholar]
  59. Smith J. P., Bodai B. I., Hill A. S., Frey C. F. Prehospital stabilization of critically injured patients: a failed concept. J Trauma. 1985 Jan;25(1):65–70. doi: 10.1097/00005373-198501000-00011. [DOI] [PubMed] [Google Scholar]
  60. Stanford G. G., Patterson C. R., Payne L., Fabian T. C. Hypertonic saline resuscitation in a porcine model of severe hemorrhagic shock. Arch Surg. 1989 Jun;124(6):733–736. doi: 10.1001/archsurg.1989.01410060105022. [DOI] [PubMed] [Google Scholar]
  61. Todd M. M., Tommasino C., Moore S. Cerebral effects of isovolemic hemodilution with a hypertonic saline solution. J Neurosurg. 1985 Dec;63(6):944–948. doi: 10.3171/jns.1985.63.6.0944. [DOI] [PubMed] [Google Scholar]
  62. Traverso L. W., Bellamy R. F., Hollenbach S. J., Witcher L. D. Hypertonic sodium chloride solutions: effect on hemodynamics and survival after hemorrhage in swine. J Trauma. 1987 Jan;27(1):32–39. [PubMed] [Google Scholar]
  63. Vassar M. J., Perry C. A., Holcroft J. W. Analysis of potential risks associated with 7.5% sodium chloride resuscitation of traumatic shock. Arch Surg. 1990 Oct;125(10):1309–1315. doi: 10.1001/archsurg.1990.01410220093013. [DOI] [PubMed] [Google Scholar]
  64. Velasco I. T., Pontieri V., Rocha e Silva M., Jr, Lopes O. U. Hyperosmotic NaCl and severe hemorrhagic shock. Am J Physiol. 1980 Nov;239(5):H664–H673. doi: 10.1152/ajpheart.1980.239.5.H664. [DOI] [PubMed] [Google Scholar]
  65. Wangensteen S. L., Ludewig R. M. Bleeding and blood pressure. Am J Surg. 1969 Sep;118(3):413–414. doi: 10.1016/0002-9610(69)90146-9. [DOI] [PubMed] [Google Scholar]
  66. Wildenthal K., Mierzwiak D. S., Mitchell J. H. Acute effects of increased serum osmolality on left ventricular performance. Am J Physiol. 1969 Apr;216(4):898–904. doi: 10.1152/ajplegacy.1969.216.4.898. [DOI] [PubMed] [Google Scholar]
  67. Wisner D. H., Schuster L., Quinn C. Hypertonic saline resuscitation of head injury: effects on cerebral water content. J Trauma. 1990 Jan;30(1):75–78. doi: 10.1097/00005373-199001000-00011. [DOI] [PubMed] [Google Scholar]
  68. de Felippe J., Jr, Timoner J., Velasco I. T., Lopes O. U., Rocha-e-Silva M., Jr Treatment of refractory hypovolaemic shock by 7.5% sodium chloride injections. Lancet. 1980 Nov 8;2(8202):1002–1004. doi: 10.1016/s0140-6736(80)92157-1. [DOI] [PubMed] [Google Scholar]

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