IV fluids given to trauma patients may do more harm than good. New research finds that severely injured patients given IV fluids by paramedics before transport to the nearest trauma center are more likely to die than patients with similar injuries not given IV fluids.
Researchers from Johns Hopkins University School of Medicine in Baltimore looked at data on nearly 770,000 trauma patients injured between 2001 and 2005. The patients were primarily male, white and under age 40. About half were given IV fluids at the scene.
Patients who were given prehospital fluids were 11 percent more likely to die than those who were not, the researchers found. Those at highest risk of death included patients who were shot or stabbed (25 percent more likely to die than those not given fluids), who had severe head injuries (35 percent more likely) or who needed emergency surgery once hospitalized (35 percent more likely).
Standard practice is to give trauma patients with dangerously low blood pressure due to blood loss IV fluids to boost blood pressure, says lead study author Elliott Haut, M.D., an associate professor of surgery, anesthesiology and critical care medicine. Many states, including Maryland, require paramedics to give IV fluids for all trauma patients, even though there is little evidence that all should receive fluids, according to a Johns Hopkins news release.
Not only does giving fluids take time and delay transport to the hospital, but some evidence suggests the fluid itself has the potential to cause harm, according to the study. Very low blood pressure can temporarily stop bleeding, while rapidly rising blood pressure can cause bleeding to start again before reaching the hospital, Haut says.
Researchers conclude that the routine use of IV fluids for trauma patients should be discouraged. “Our study suggests it may be better to get patients to the hospital faster,” Haut says. “Starting fluids takes time, and the IV fluids may cause harm on top of the timing issue.”
Still, Haut notes, IV fluids may be beneficial for some patients. Though patients with traumatic brain injury fared worse with IV fluids in this study, prior research has shown low blood pressure is very harmful for patients with brain injury. That group in particular merits more study, Haut says. ANNALS OF SURGERY, FEBRUARY 2011.
Few STEMI Patients Transferred by Air Medical Get Treated Quickly
Helicopters are fast, but not fast enough when it comes to transferring patients with ST-elevation myocardial infarction, a dangerous type of heart attack, from community hospitals to regional hospitals with catheterization labs.
A review of 179 patients flown in 2007 by Air Care, the air medical service for the University of Cincinnati’s University Hospital, from 16 community hospitals to six receiving hospitals found that only 3 percent of patients received percutaneous coronary intervention (PCI) within the 90 minutes recommended by the American Heart Association and the American College of Cardiologists. For more than half of patients, it took more than two hours to undergo PCI, in which a stent is inserted into a blocked artery. “The take-home point of our findings is certainly not that helicopter EMS doesn’t help STEMI heart attack patients; on the contrary, HEMS undoubtedly saves many lives in getting suburban and rural STEMI patients to cardiac catheterization labs for PCI as rapidly as possible,” says Air Care medical director and study co-author William Hinckley, M.D., in a University of Cincinnati news release. “Rather, the point is that calling the helicopter is not like saying, ‘Beam me up, Scotty’ on Star Trek. It’s fast, but it’s not instantaneous.”
A primary cause of the delays included emergency physicians needing to contact a cardiologist who would accept the patient, a step that had to be done prior to calling Air Care, according to the researchers. To reduce transfer time, researchers recommend streamlining the system by allowing physicians to simultaneously call for both helicopter transport and cardiologist approval; by allowing non-physician personnel to request a transfer; or enabling rural EMS to activate Air Care from the field.
Air Care is working with physicians at referring and receiving hospitals to revise the protocols, according to the researchers. ANNALS OF EMERGENCY MEDICINE, PUBLISHED ONLINE OCT. 18, 2010.
National Standard for Stroke, Chest Pain Centers Needed
Current programs to certify or accredit hospitals as stroke or chest pain centers of excellence are inadequate and should be revised, says an advisory from the American Heart Association (AHA) and the American Stroke Association (ASA).
Hospitals often refer to themselves as stroke or chest pain centers, which sends a message to patients that those hospitals are where they’ll get top-notch stroke and heart attack care. But these designations may be little more than good marketing, according to the advisory. A review of published studies found no clear connection between a hospital being accredited as a heart attack or stroke care center and patient mortality or medical errors.
While many recognition programs require hospitals to put certain protocols into place initially, the review found that those same programs do little ongoing monitoring to make sure hospitals are actually doing what they say they are doing. Since 2003, the Society of Chest Pain Centers has offered accreditation to hospitals that meet certain quality-of-care criteria for heart attack patients. But one study cited in the advisory found that on average, accredited hospitals are only adhering to evidence-based guidelines on two of five measures.
To give patients and providers more information about where to go for care, the AHA and the ASA are working on a new comprehensive stroke and cardiovascular care certification program that would serve as a national standard.
“Right now, it’s not always clear what is just a marketing term and what actually truly distinguishes the quality of a center,” says Gregg Fonarow, M.D., lead author of the advisory and an AHA spokesman. “There is a value to having a trusted source develop a certification program that clinicians, insurers and the public can use to understand which hospitals are providing exceptional cardiovascular and stroke care, including achieving high-quality outcomes.”
The certification program will take about two years to develop. Read the full advisory at circ.ahajournals.org/cgi/
content/full/122/23/2459. CIRCULATION, PUBLISHED ONLINE NOV. 12, 2010.
