Commonly used Crystalloids and Colloids in the pre-hospital environment
As detailed on the Mosby’s Paramedic textbook, the most common emergency requiring fluid replacement in the pre-hospital setting is loss of volume caused by haemorrhage or dehydration. But as to which type of intravenous fluid to be infused that depends upon the nature and extent of the volume loss (Sanders, 2012: 3800). And these fluid replacements are distinguished and put into two of categories, which are either crystalloids or colloids. And crystalloids in pre-hospital environment are usually limited to Ringer’s Lactate, Sodium Chloride (commonly known as Normal Saline), and Dextrose.
Where else colloids are your Whole blood, packed Red Blood Cells (RBCs), and Blood Plasma, and Plasma Substitutes (Sanders, 2012: 3802).
As much as Sodium chloride is the most commonly used isotonic intravenous fluid and has a strong ion difference equal to zero. According to a data took from British Journal of Anaesthesia: stated Normal saline (0.9%) contains supraphysiological concentrations of sodium (154 mmol/L) and chloride (154 mmol/L) Excessive and long-term administration of saline can, therefore, lead to hyperchloraemic metabolic acidosis when chloride concentrations exceed the serum concentration (100-110 mmol/lL.
In a systematic review and meta- analysis, it was shown that resuscitation with high-chloride fluids (chloride concentration >111 mmol/L) is associated with a higher risk of acute kidney injury and hyperchloraemia, whilst mortality was not affected. Patient with bleeding in the brain and post the surgery as compared to more healthy patients, showed a remarkable (3 x..) increase of Chloride concentration serum (Boer, et al.).
Preferably colloids are to be used in the hospital environment because it’s much more controlled than pre-hospital environment, due to the safety precautions that need to be established before administration.
But this is with an exception of Plasma substitutes, because they do not carry so mush risk that requires them to be screened for the Human Immunodeficiency Virus (HIV) or hepatitis viruses. However Plasma substitutes do have some detrimental results, which include increased bleeding tendencies and immune suppression. Even though Ambulance vehicles can carry Plasma substitutes, but the expenses and storage issues surrounding that makes them impractical to be used generally in the pre-hospital setting (Sanders, 2012: 3805).
Principal underpinning fluid resuscitation versus fluid maintenance Fluid resuscitation is one way that can be utilized to evaluate the patient response and also present indications of sufficient end-organ perfusion and oxygenation. But most importantly the key thing in managing trauma is to control bleeding. According to the international cross-section study, Hammond et al. conducted between year 2007 and 2014, they came to a conclusion that fluid resuscitation method have changed over that period. With remarkable growth in the use of Crystalloids and reduction in use of colloids. However as to what type of fluid to be administered for resuscitation, that was not determined. It depends upon which part of the world you from and its current clinical guidelines (Hammond, et al.).
Intravenous fluid therapy for routine maintenance refers to the provision of IV fluids and electrolytes for patients who cannot meet their needs by oral or enteral route. Fluid maintenance can be administered or rather beneficial in patients who have stroke (dysphagia), patients with gastrointestinal (GI) obstruction while waiting surgery, and other pre-operative patients who should not be eating. When giving fluids for maintenance purposes should be administered in small boluses of 500mL to a 1L. Routine of administering fluids for maintenance purposes should be a temporal thing in order to avoid fluid overload. Newly qualified doctors tend to commit a lot of clinical errors, by failing reverting to basics skills when treating patients in interhospital environment (NICE Clinical Guidelines. 2013).
Conclusion
What is the preferred fluid of choice would be required for a trauma case?The decision as to what fluid is best to be used or rather preferred for trauma cases is still debatable up until today. As years and years researchers have collected data and conducted studies to tried to prove otherwise. But it has become apparent that Sodium Chloride (Normal Saline), is probably should not be the best fluid of choice in trauma cases. According to study featured on the Journey of Emergency Medical Services (JEMS): Three Reasons Not to Use Normal Saline or Crystalloids in Trauma, concluded that as per their research that administration of crystalloid fluids could result to remarkably vasodilation effects.
However these results are worse when Sodium Chloride is used. Furthermore stated that only 20% of fluid administered remains in the vessels, the rest leak causing problems to cardiovascular system (Brandon, et al. 2018)An as well with more and more studies being conducted each and every year it is evident that intravenous fluid administration has no much effect in the survival of trauma patient. And that could actually result or rather cause some detrimental effect in other trauma cases. During intravenous fluid administration, as fluid are introduced into the system in order to raise systolic blood pressure, the down-side of this could potentially interfere with body clotting cascades and cause re-bleeding.
Thus, there is a strong argument that excessive fluid administration may aggravate any organ failure, and that additional fluid should not be administered except to correct hypotension. Most studies where fluid resuscitation was withheld where there was penetrating injuries, discovered that it was much easy to identify site if bleeding and manage it. But with blunt trauma involve where surgery intervention is might be required proved to be difficult to withheld fluids. In fact fluid resuscitation is the best bet to assess patient response while assessing vital signs and overall body respond. (Mizushima, et al. 2017)
Reference
- Sanders, M. J. 2012. Mosby’s Paramedic Textbook. 4th Edition. St. Louis, Mo, Elsevier/Mosby Jems
- Hammond, N.E. Taylor, C. Finfer, S. Machado, F.R. An, Y. Billot, L et al., 2017. Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study. PLoS ONE 12 (5): e0176292. pone.0176292
- Boer, C. Bossers, S. M. Koning, J. N. 2017. Choice of fluid type: physiological concepts and perioperative indications. British Journal of Anaesthesia. 120 (2): 384-396, December.
- Y. Shota, N. Koji, I. Tetsuya, M. The American Journal of Emergency Medicine, 35(6): 842-845.
- M. C. Andrew D. F. 2018. National Clinical Guideline Centre (UK). Intravenous Fluid Therapy: Intravenous Fluid Therapy in Adults in Hospital [Internet]. London: Royal College of Physicians (UK); 2013 Dec. (NICE Clinical Guidelines, No. 174.) 8, Intravenous fluid therapy for routine maintenance.
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