Management of trauma has changed over many years. This is because of more evidence-based research on the major causes of mortality and morbidity in the acute management of trauma patients. Currently, a significant proportion of world morbidity and mortality is attributed to trauma. Hemorrhage accounts for 40% of the deaths related to trauma (Nicola et al., 2011). This is because of blood volume loss that results in shock. Poor tissue perfusion due to inadequate blood flow results in end-organ damage. Strategies have been put in place to control bleeding and coagulopathy resulting from the injury. Fluid resuscitation is a major intervention in trauma management. This involves the use of crystalloids, colloids, blood, and its components for volume replacement. Clinicians have a wide range of choices between which fluid is best for their patients. This has led to controversies on which particular one is the most reliable and cost-effective in the management of trauma. Several studies have been carried out to try to answer this question. This literature tries to look at the merits and demerits of each one of them in practical use.
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Use of Crystalloids
Crystalloids are resuscitation fluids that are aqueous solutions with soluble molecules. They are classified as being hypertonic, isotonic, or hypotonic depending on their concentration. Isotonic solutions include normal saline and Ringer’s lactate. High concentrations of normal saline are the main hypertonic fluids and are useful in the management of head trauma. These include 3%, 6%, and 7.5% concentrations of normal saline. 5% dextrose solution and 0.45% normal saline are the hypotonic solutions. After infusion, they are redistributed to extravascular sites hence they are poor in volume replacement during resuscitation and may lead to dilutional hyponatremia and edema. For instance, infusion of 5% dextrose solution results in <10% of the volume being intravascular whereas two-thirds redistributes to intracellular space.
In an international survey carried out in 2004, crystalloids are the most used resuscitation fluid in clinical practice. The major reasons cited were the brief time needed for correction of volume loss, the effect duration, affordability, and fewer adverse drug reactions (Schortgen, Deye, & Brochard, 2004). Crystalloids are quite affordable and readily available. During infusion, they immediately replace both intravascular and interstitial volumes and replenish the renal output to normal. The popular use of Ringer’s Lactate could be attributed to its reduced elimination rate in hypovolemic patients. In a study in 1999, volunteer patients were used where stable normal volume patients were found to have an elimination rate of 133mL per min. The marked volume of blood was then withdrawn from the patients. Elimination rates of 100mL per min were found in patients who had lost 450mL of blood whereas those who had lost 900mL had a rate of 34mL per min. this showed that the elimination rate decreased as the volunteers became hypovolemic. This shows how useful ringers lactate would be too acutely hypovolemic patients (Drobin & Hahn 1999).
One of the demerits of fluid resuscitation using crystalloids is edema especially in patients having increased capillary permeability. Patients tend to develop interstitial and intracellular edema. In a study carried out in hemorrhagic rats, resuscitation with normal saline stabilized their homeostatic volume but caused extracellular volume expansion with gut edema and cellular edema on the heart tissues (Moon, Hollyfield-Gilbert, Myers, & Kramer, 1994). It has also been demonstrated that crystalloid use in the resuscitation of head injury in rats made worse the already present cerebral edema. Mesenteric edema was also recorded in the same study. This was however of little significance when it was substituted with blood (Drummond, Patel, Cole, & Kelly, 1998). In resuscitation of post-trauma patients, overzealous administration of ringer’s lactate was reported to cause mesenteric edema leading to the development of abdominal compartment syndrome.
This had high morbidity and mortality (Balogh, McKinley, & Cocanour, 2003). In fact, the volume of crystalloids used is one of the key risk factors for developing the syndrome in patients with multiple injury patients. This is associated with significant morbidity and mortality. The implementation of crystalloid restriction preoperatively has been shown to lower the morbidity associated with nausea and vomiting. It hastens the healing process and recovery of bowel motions. All this helps shorten the number of admission days postoperatively (Nisanevich, Felsenstein, & Almogy, 2005). Compared to colloids, crystalloids need higher volumes to achieve an equivalent volume replacement during resuscitation. High dose infusions of >30ml/kg of normal saline cause hyperchloremic metabolic acidosis that could be detrimental in patients with shock. This is however not observed in Ringers Lactate (Scheingraber, Rehm, & Finsterer, 1999). This is probably because its chloride levels are almost equivalent to plasma levels. Lactate ions too help, and those large volumes may be a risk of alkalosis.
Ringer’s lactate is not indicated in patients with hyperkalemia. This is because of potassium levels in its concentration. Studies have also shown the presence of hyperkalemia in more patients under normal saline infusion than those under Ringer’s Lactate. This was in a study done to compare Ringers Lactate and normal saline (O’Malley, Frumento, & Hardy, 2005). Ringers Lactate has been shown to cause hyponatremia and a low osmolarity, which is harmful to patients with head injury patients.
Several studies have been done in trying to compare the use of colloids and crystalloids as fluids of resuscitation. In a study conducted in 1989, differences were observed in trauma and septic randomly sampled patients. Amongst trauma patients, there was a 12.3% mortality difference that favored the use of crystalloids as a reliable means of resuscitation. This demonstrated that crystalloids were better in hypovolemic patients. However, in septic patients, the mortality difference was 7.8% favoring the use of colloids as a better resuscitative fluid in septic patients. This was explained by the presence of an increased capillary permeability that leads to the leakage of crystalloids (Velanovich, 1989). In another study in 1998 in trauma, burns, and septic patents, colloids were found to have higher mortality over 4% (Schierhout & Roberts, 1998).
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Use of Colloids
There is wide use of colloids in trauma resuscitation they are recommended in several guidelines and algorithms that are still in use (Armstrong, 1994). Colloids are classified as either protein or non-protein colloids. Albumin and gelatin solutions are the protein colloids whereas dextran and starches are non-protein. They can also be classified as synthetic and non-synthetic. Gelatins, starches, and dextran are synthetic whereas albumin is processed from plasma. In a study trying to find the possible causes of hemorrhage in cardiothoracic operations, it was concluded that among other risk factors, the use of Hetastarch was a risk factor for the bleeding observed postoperatively.
This has led to the concern that synthetic colloids are associated with hemorrhage hence their use in trauma is now being limited (Herwaldt et al., 1998). Colloids are also more expensive than crystalloids and the use of blood makes their use more controversial. They however remain intravascular for a longer duration than crystalloids. They are therefore less likely to cause edema after infusion. A lesser infusion volume is needed to achieve a similar volume of expansion. Cases of anaphylaxis have been reported with their use. This has particularly been observed with Pentastar in asthmatic patients. A dose-related coagulopathy has been reported with the use of Hetastarch. Some studies have also associated starches with end-organ damage. For instance, starch molecules have been reported to be a cause of renal tubular injury leading to acute renal failure.
In 2004 and 2007, studies by the Cochrane group in 8000 patients in trauma, surgery, and burns put up a different argument. Colloids had no superiority to crystalloids in those patients. They had no particular improvement in the mortality and morbidity of patients despite being expensive (Roberts, Alderson, & Bunn, 2004). A similar conclusion was made by the SAFE study in 2004 where 7000 patients were used in a randomized study. This was a comparison between isotonic saline and albumin (Finfer, Bellomo, & Boyce 2004). These more current demonstrated no difference between the two fluids apart from the fact that crystalloids were more affordable.
Colloids have a more rapid and higher volume expansion property than crystalloids. In a study in 2003, differences between the rate and volume of expansion were established when a crystalloid (Ringer’s lactate) and a Colloid (Hetastarch) were infused in 8 healthy subjects. 900mL of blood was withdrawn from them before the infusion to achieve moderate hypovolemia. An intravascular volume of 1000mL with each of the solutions was achieved through infusion over 5-7 minutes.
Peak expansion volumes were then obtained by hematocrit after 5 minutes. Ringer’s lactate had 630 ± 127 mL volume expansion compared to Hetastarch 1123 ± 116 mL after 5 minutes. This was suggestive of a rapid increase in volume in the colloids after a short time compared to crystalloids even when rapidly administered (McIlroy & Kharasch, 2003). This makes colloids more reliable in the resuscitation of severely hypovolemic post-trauma patients than crystalloids. Other studies have also demonstrated that colloids are at least two times more effective in plasma expansion than crystalloids (Wills, Nguyen, & Ha 2005). According to the current guidelines, the severity of hypovolemia is used as a basis for deciding on the choice between crystalloids and colloids as a resuscitation agent in trauma. Colloids are used in severe cases whereas crystalloids are in mild and severe cases.
Studies have demonstrated both anti-inflammatory and antioxidant characteristics in albumin. This is because of its inherent ability to increase the level of thiols in plasma after an infusion. It also increases the levels of glutathione in the lung. These multiple physiological properties help in reducing inflammation that usually follows tissue injury after trauma. This property gives it an advantage over the use of crystalloids (Quinlan et al., 2004).
Use of Blood Replacement
Blood transfusion is trauma is lifesaving when all the safety measures are observed to the later. Whole blood or its specific components can also be transfused to address specific deficiencies and to avoid wastage. Fractionated components include platelet concentrates, which addresses platelet dysfunction and deficiencies. Fresh frozen plasma helps replace coagulation factors. Cryoprecipitate is also another component that is important in fibrinogen deficiency. Packed red blood cells are used in patients whose hemoglobin levels have fallen below 6g/dl. Indications of whole blood transfusion include active bleeding leading to shock and at times clinical evidence of hypoxia in critical care. It is also indicated in several forms of anemia.
Most severe traumatic incidences are accompanied by a “lethal triad.” This is descriptive of acutely developed coagulopathy that leads to bleeding, low body temperatures (hypothermia), and metabolic acidosis. Bleeding during trauma leads to hypoperfusion due to blood volume loss. This results in reduced oxygen delivery to tissues leading to anaerobic respiration due to tissue hypoxia. This presents lactic acidosis with increased lactic acid production. Hypothermia develops due to the administration of cold resuscitation fluids and anaerobic respiration that limits heat production. In a study, temperatures less than 35oC was found to be a risk factor to mortality in patients (Martin et al., 2005). An acute coagulopathy also develops immediately due to procoagulant protease loss due to consumption and bleeding (Brohi, Singh, Heron, & Coats, 2003). All these factors in the lethal tried if not addressed well in the management of trauma patients have a poor prognostic index (Moore & Thomas, 1996).
Blood transfusion reactions do occur and carry a high risk of morbidity and mortality if safety measures are not observed. These range from febrile reactions that are self-limited to life-threatening hemolytic reactions. Statistics from the Centre for Disease Control (CDC) in the U.S.A indicate that hemolytic reactions have been recorded at a rate of 1 case of reaction in 40,000 units of packed red blood cells transfused. Febrile reactions have been noted as being the most occurring reaction together with minor allergic reactions. They do occur in up to 3-4% of recorded blood transfusions. Anaphylaxis too has been recorded at a rate of 1 case in 20,000 transfusions. Graft vs. Host disease is relatively well controlled with recorded cases being < 0.15%. Acute lung injury has been diagnosed in only 0.1-0.2% transfusions. The majority of the transfusion-related infections are hepatitis B and C. The risk attached to HIV infection is 1 in every 150,000 transfused units of blood. These statistics show how significant blood reactions occur during a blood transfusion. Safe transfusion practices, therefore, need to be practiced to the latter to avoid them.
|Blood Transfusion Reactions|
|Immediate ||Delayed and Long Term |
Table 1: Transfusion Reactions. Source: (Kirkman, et al., 2008).
Several strategies have been put in place to counter the lethal triad. It has been established that rapid management and control of coagulopathy carries a far much better prognosis in trauma patients (Kirkman et al., 2008). Immediate and steadfast use of blood and its products after trauma has been noted as an important step in the management of trauma to replace lost coagulant factors. Fluid resuscitation alters the clotting process by diluting the coagulation factors. This may aggravate the bleeding process. These fluids should therefore be restricted until bleeding is controlled. The coagulopathy may also be controlled using blood components like FFP, cryoprecipitate, and platelets. All these strategies should however proceed simultaneously with damage control surgery (Jansen et al., 2009). This is a major reason advocating for the use of blood transfusion in preference to crystalloids in post-trauma resuscitation.
The optimum use of blood in resuscitation has no edematous effects like the ones recorded in the use of crystalloids. However, overzealous transfusion can lead to heart failure leading to generalized body edema. In a study, the use of crystalloids during emergency resuscitation of head injury in rats made worse the already present cerebral edema. Mesenteric edema was also recorded in the same study. This was however of little significance when it was substituted with blood (Drummond, Patel, Cole, & Kelly, 1998).
Hemorrhage has been acknowledged as the leading cause of mortality and morbidity in trauma patients. Proper management of trauma with particular emphasis on blood volume replacement is therefore essential. The choice between the use of blood, colloids, and crystalloids has raised a raging debate. The use of blood has been encouraged because of its ability to manage the lethal triad noted immediately after trauma. It controls the acute coagulopathy and restores perfusion to help acutely reduce metabolic acidosis. Blood transfusion can however be accompanied by adverse effects if safe practices are not followed to the later. The use of colloids has its positives in quick and constant volume expansion. Albumin too has an inherent anti-inflammatory ability. Colloids are however expensive rendering them unaffordable and having no effect on mortality and morbidity when compared to crystalloids. Crystalloids are cheaper but need to be given in more volumes to achieve volume expansion. They are also associated with edematous states especially on the gastrointestinal system.
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