J Emerg Trauma Shock. 2011 Oct-Dec; 4(4): 465–471.

doi: 10.4103/0974-2700.86630
PMCID: PMC3214502

Influence of prehospital fluid resuscitation

on patients with multiple injuries in
hemorrhagic shock in patients from the
DGU trauma registry
Björn Huβmann, Rolf Lefering,1 Georg Taeger, Christian Waydhas, Steffen Ruchholtz,2 and
Sven Lendemans and the DGU Trauma Registry
Department of Trauma Surgery, University Hospital Essen, Germany
1
Institute for Research in Operative Medicine (IFOM), Faculty of Medicine, Witten/Herdecke
University GmbH (a non-profit, limited-liability company), Cologne Merheim Medical
Center, Germany
2
Department of Trauma, Hand and Reconstructive Surgery Unit, University Hospital
Marburg, Germany
Address for correspondence:Björn Huβmann, E-mail: ed.nesse-ku@nnamssuh.nreojb
Received 2010 Dec 15; Accepted 2011 Apr 20.
Copyright : © Journal of Emergencies, Trauma, and Shock
This is an open-access article distributed under the terms of the Creative Commons
Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract
Background:

Severe bleeding as a result of trauma frequently leads to poor outcome by means of direct or
delayed mechanisms. Prehospital fluid therapy is still regarded as the main option of primary
treatment in many rescue situations. Our study aimed to assess the influence of prehospital
fluid replacement on the posttraumatic course of severely injured patients in a retrospective
analysis of matched pairs.

Materials and Methods:

We reviewed data from 35,664 patients recorded in the Trauma Registry of the German
Society for Trauma Surgery (DGU). The following patients were selected: patients having an
Injury Severity Score >16 points, who were ≥16 years of age, with trauma, excluding those
with craniocerebral injuries, who were admitted directly to the participating hospitals from
the accident site. All patients had recorded values for replaced volume and blood pressure,
hemoglobin concentration, and units of packed red blood cells given. The patients were
matched based on similar blood pressure characteristics, age groups, and type of accident to
create pairs. Pairs were subdivided into two groups based on the volumes infused prior to
hospitalization: group 1: 0-1500 (low), group 2: ≥2000 mL (high) volume.

Results:

We identified 1351 pairs consistent with the inclusion criteria. Patients in group 2 received
significantly more packed red blood cells (group 1: 6.9 units, group 2: 9.2 units; P=0.001),
they had a significantly reduced capacity of blood coagulation (prothrombin ratio: group 1:
72%, group 2: 61.4%; P≤0.001), and a lower hemoglobin value on arrival at hospital (group
1: 10.6 mg/dL, group 2: 9.1 mg/dL; P≤0.001). The number of ICU-free days concerning the
first 30 days after trauma was significantly higher in group 1 (group 1: 11.5 d, group 2: 10.1
d; P≤0.001). By comparison, the rate of sepsis was significantly lower in the first group
(group 1: 13.8%, group 2: 18.6%; P=0.002); the same applies to organ failure (group 1:
36.0%, group 2: 39.2%; P≤0.001).

Conclusion:

The high amounts of intravenous fluid replacement was related to early traumatic
coagulopathy, organ failure, and sepsis rate.

Keywords: Hemorrhagic shock, mortality, prehospital volume replacement, rescue time,

trauma registry, trauma

INTRODUCTION
Bleeding, as a result of severe trauma, is correlated with high initial mortality and a high rate
of secondary complications.[1–4] Blunt trauma represents the most frequent form of severe
trauma in Europe (95% in Germany according to the Trauma Registry 2008 Annual Report).
Blunt trauma causing bleeding into the large body cavities (thoracic and abdominal) is
especially hard to access therapeutically. Furthermore, these injuries are related with an
increased mortality.[5–8]

At first glance, the reasonable course of action appears to be to replace the blood lost by fluid
as quickly as possible, that is, at the accident site.[9] However, this assumption has not yet
been confirmed in any study with sufficient patient numbers. In contrast to blunt trauma, the
influence of prehospital fluid replacement on penetrating injuries has been more thoroughly
investigated. Follow-up examinations of soldiers wounded in the Falklands war reported that
patients with hypotensive circulation and simultaneous hyperpyrexia prior to hospital
treatment had a better outcome.[10] Further studies involving patients who suffered
penetrating injuries showed that an excessive volume replacement (>2000 mL), which also
resulted in longer rescue times, correlated with increased mortality after trauma in most
cases.[11–13] Kreimeier et al. also showed an advantage for moderate fluid replacement and
permissive hypotension (90 mmHg) in patients with penetrating injuries. This strategy has
also the benefit that it reduces rescue time and is supported by several authors.[14–17]

To date definite evidence-based recommendations for the prehospital treatment of patients

with hemorrhage after blunt trauma do not exist. Anecdotal reports suggest that a short rescue
time and delivery directly to a level one trauma center is beneficial, as per the recommended
course of action for penetrating injuries, but no recommendations exist regarding how
aggressively the circulation should be supported by volume replacement. A recent study by
Geeraedts et al. recommended keeping treatment at the accident site as minimal as possible,
with the goal of maintaining vital signs and providing a rapid transport to a higher level
trauma center.[18] On the other hand, some reports continue to recommend extensive volume
replacement as the best treatment option.[19–21] Turner et al. identified no dependence of
mortality or outcome on the infused volume in patients with blunt trauma.[22] However, this
study focused on less severely injured patients (>75% had injury severity score (ISS) <16).

The following question arises after examination of the current literature: Does the quantity of
the volume replaced have consequences for hemorrhagic shock in the posttraumatic course,
including multiple organ failure (MOF), sepsis, and outcome? We addressed these questions
in a patient cohort selected from the DGU Trauma Registry, which had suffered severe
injuries (abbreviated injury scale >3) that resulted in hemorrhage.

MATERIALS AND METHODS

The Trauma Registry of the German Society for Trauma Surgery was started in 1993, which
contains prospectively collected data from 145 collaborating European trauma centers. Data
were entered manually from patient records until 2001, when data input was automated for
central submission via online data entry software (since 2002). About 100 data points per
patient are collected, including the coding of each injury according to the abbreviated injury
scale (AIS), revised version of 1998. Data are submitted to a central database that is hosted
by the Institute for Research in Operative Medicine at the University of Witten/Herdecke,
Cologne, Germany. Irreversible data anonymity is guaranteed for the patient and the
participating hospital. Only patients from Germany and Austria were included in this study to
minimize variation due to different rescue systems. All patients were attended by a physician
prehospitally. Records collected between 1993 and 2007 (total: 35,664 patients) were
considered for this study. The data of the Trauma Registry of the DGU has received the full
approval of the ethics committee of the University of Witten/Herdecke, Cologne, Germany.

Patients were selected for this study according to the following criteria:

1. Primary admission to the hospital (no transfers)

2. ISS ≥16
3. Age ≥16 years
4. Infusion of at least one unit of packed red blood cells (pRBC)
5. Data available for the prehospital administered fluid volume, Hb concentration on
hospital admission and blood pressure at accident site and on admission.

According to the amount of prehospitally administered volume (crystalloids plus colloids),

the patients were divided into a “low-volume” (≤1500 mL) and a “high-volume” (≥2000 mL)
group. This classification complies with the statistical mean value of all patients that were
recorded in the Trauma Registry of the DGU (MV, 1296±1137 mL; n=35,664 patients).
Values between 1501 and 1999 mL were hardly documented and excluded from this analysis,
because only a small number of patients were administered a volume between 1501 and 1999
mL. The decision for a higher volume replacement always seems to be reconciled with a
volume higher than 1999 mL. In order to evaluate the effect of prehospital volume
administration, patients with high and low volume were then matched according to the
following criteria:

 Pattern of injury for the following three body regions: head, torso (thorax and
abdomen), and extremities, where matching criteria were AIS severity ≥ or <3 points
 Date of accident had to be within ±1 year
 Systolic blood pressure at the accident site had to be at least 60 mmHg and was
subdivided into three groups which had to match exactly: (1) 60-89, (2) 90-99, and (3)
≥100 mmHg.
 Age categories with three subgroups had to match exactly: (1) 16-54, (2) 55-69, and
(3) ≥70 years of age.

Sepsis was defined according to the criteria of bone which are close to the American College
of Chest Physicians/Society of Critical Care Medicine (ACCP-SCCM) consensus conference
definition.[23] Single organ failure was defined as a value ≥3, using the definition determined
by the Sequential Organ Failure Assessment (SOFA) Score.[24] This value is entered as the
total point value by individual hospitals. A posteriori, no conclusion about the individual
patient can be drawn. MOF is listed if simultaneous organ failure was recorded for at least 2
organs. Prehospital parameters, hospital stay, and coagulation were examined separately in
each group. Concerning the coagulation, the prothrombin ratio is the only value recorded in
the Trauma Registry. The fibrinogen levels, for instance, are not documented. To be able to
evaluate the ISS within the groups with sufficiently complete data, prognosis estimation by
means of the revised injury severity classification (RISC) was performed.[25] The prognosis
established in this way is contrasted with the observed mortality in the corresponding group.
Prognosis was also calculated according to the Trauma and Injury Severity Score (TRISS).

Statistics

Data were analyzed with the Statistical Package for the Social Sciences (SPSS; version 15,
Chicago, IL, USA). Incidences are represented as the number of cases and percentages, and
measured values as mean and standard deviation. Differences between the two groups with
low and high amount of prehospital volume were compared with the Chi-square test in case
of categorical variables, and t test in case of continuous variables. In case of obvious
deviation from normality continuous variables were tested with a nonparametric rank test
(Mann-Whitney). We applied a significance level α of 5% to all statistical tests.

RESULTS
From the DGU Trauma Registry, 1351 severely injured patients with a high amount of
prehospital volume could be matched with 1351 patients from the low-volume group. Patient
age in the total group averaged 40.2 years (±17.9), and 70.8% were male. There were
significantly more males in the high-volume than in the low-volume group (73.8% versus
67.7%, respectively; P≤0,001). The ISS was the same in both groups (low-volume:
35.4±13.6, high-volume: 35.2±13.9; P=0.71). There was a similar distribution for the cause
of accident in high- and low-volume groups. However, there were proportionally more
patients in the high-volume group that were injured in car accidents (high-volume: 48.7%,
low-volume: 35.9%; P≤0,001), and proportionally more accidents involving falls from a
height of ≥3 m in the low-volume group (low-volume: 19.8%, high-volume: 10.6%; P≤0,05).
All other accident causes were distributed homogenously without differences in frequency
[Table 1]. As expected, the majority of the injuries were blunt trauma (95.3%). The
subdivision of the injury severity in the corresponding body regions had nearly identical
distributions in the groups [Table 1], as was the Glasgow Coma Scale (GCS; low-volume:
10.4, high-volume: 10.3). The similarity of these general characteristics of the patients
involved in this study support that the groups receiving low- or high-volume replacement
therapy were similar, and are comparable.

Prehospital and emergency room treatment

Although significantly less fluid was infused prior to arrival at the hospital in the low-volume
group (on average, 1053 mL compared with 2793 mL in the high-volume group; P≤0.001),
there was no significant difference in the blood pressure measured at the accident site based
on the distribution of the blood pressure categories within the groups. As shown in Table 2,
the percentage of patients who had a blood pressure ≤90 mmHg was exactly the same in both
groups. It is a similar situation with the heart rate. As shown in Table 2, the groups are almost
the same here, too (low-volume group: 98.0 beats/min, high-volume group: 102.2 beats/min).
The heart rate as well as the blood pressure recovered at arrival in the emergency room.
However, fewer (24.8%) of the low-volume group patients had blood pressures ≤90 mmHg
as compared with the high-volume group (26.4%, Table 2). Taken together, the clinical
parameters for circulation are similar in the patient groups receiving either low- or high-
volume fluid replacement therapy.

Hemoglobin, base excess and coagulation values were measured during treatment in the
emergency room. Patients who received high fluid volumes showed significantly worse blood
values: The hemoglobin value was significantly lower in the high-volume group (low-
volume: 10.6±2.6 mg/dL, high-volume: 9.1±2.7 mg/dL; P≤0.001 [Table 2]. The same applies
to the prothrombin ratio (low-volume: 72.0% ± 22.1%, high-volume: 61.4% ± 23.3%;
P≤0.001). Patients in the high-volume group received more units of pRBC (low-volume: 6.9
units ±7.8 units, high-volume: 9.2 units ±9.6 units; P≤0.001). A higher percentage of patients
in the high-volume group received more than 10 units pRBC (low-volume: 21.5%, high-
volume: 32.5%; P≤0.001). The same holds true for the transfusion of fresh-frozen plasma
(low-volume: 3.3 units, high-volume: 4.6 units; P≤0.001, Table 2).

As shown in Table 2, patients receiving high-volume replacement also required further

prehospital therapeutic measures, such as catecholamine supplementation, intubation, and
chest tube at the accident site. Rescue time, defined as the time until arrival in the emergency
room, for the high-volume group was significantly higher than for the low-volume group,
79.4 min versus 68.0 min (P≤0.001), respectively [Table 2].

Clinical course and outcome

The number of patients treated with an operative therapy was significantly higher in the low-
volume group (low-volume: 95.8%, high-volume: 94%; P≤0.036, Table 3). The days spent in
the intensive care unit (ICU), the total hospital length of stay, and the total days of intubation
were also similar in both groups [Table 3]. Some parameters differed significantly between
low- and high-volume groups: the ventilator-free days with reference to the first 30 days
(low-volume: 15.6 d, high-volume: 13.9 d; P≤0,001) and the ICU-free days with reference to
the first 30 days (low-volume: 11.5 d, high-volume: 10.1 d; P≤0.001) [Table 2]. The
occurrence of sepsis and organ failure was significantly higher in patients receiving high-
volume replacement [Table 3]. The occurrence of multiple organ failure was not significantly
different in the groups; however, there was a trend toward lower occurrence of multiple organ
failure in the low-volume group [Table 3].

Although the TRISS prognosis showed no significant difference between low- and high-
volume groups, the RISC prognosis showed a higher probability of dying for patients in the
high-volume group, 25.4% compared with 21.5% in the low-volume group (P≤0.001; Table
3). In this context, it has to be pointed out that for the calculation of the TRISS prognosis, the
respiratory rate has to be documented at the accident site. In the Trauma Registry of the DGU
(Effective 2009), this is the case in only 60% of the documented patients. Therefore, the
validity of the TRISS prognosis, in contrast to the RISC prognosis, is restricted because of
the small number of cases. The percentage of mortalities was similar between low- and high-
volume groups, with 22.0% versus 23.5% (P≥0.62), respectively. The percentage of patients
that died within the first 6 h was also not significantly different; however, the percentage in
the low-volume group was lower with 7.8% versus 9.3% in the high-volume group (P=0.15;
Table 3). Treatment cost was higher for the high-volume group with treatment costing €2500
more per 1.5 days per patient [Table 3].

DISCUSSION
The aim of this study was to statistically examine relevant differences in organ failure, sepsis,
clinical course, and outcome in patients receiving either low or high volumes of prehospital
fluid replacement during rescue after trauma with severe hemorrhage. The study was limited
to patients for whom it was possible to show an advantage or disadvantage of a fluid
replacement therapy based on the severity of their injuries with related blood loss and similar
regions of injury. Matched-pairs analysis was performed to distinguish between two groups
having the same initial conditions but receiving different volumes of replacement therapy,
thus allowing the assessment of the patient benefit from different volumes of prehospital fluid
replacement. It has to be pointed out that a matched-pairs analysis based in a retrospective
analysis of a trauma registry can only give clues to particular connections.

Compared to penetrating trauma, definite recommendations concerning the quantity of

prehospital fluid replacement therapy after blunt trauma did not previously exist in the
literature. The data records for blood pressure-related penetrating trauma are well
documented, and recommend, in addition to fast transport to a level one trauma center, a
permissive hypotension and only moderate fluid replacement.[15–17]

Our study shows that rescue time has an influence on the hemorrhage volume prior to
hospitalization, and thus, must be regarded as a factor in future studies making
recommendations for prehospital therapy. The question regarding the appropriate volume for
prehospital therapy cannot be answered without also considering the rescue time. Our results
show a possible connection between a long rescue time, a related increased volume
replacement and, as a consequence, an impairment of the coagulation system and the
hemoglobin values upon arrival at the hospital. This is also illustrated by the number of units
of transfused pRBC necessary in patients receiving either low or high volumes of prehospital
replacement therapy, and is especially apparent in those patients who received more than 10
units of pRBC. A connection supported in studies assessing blunt trauma patients in England
by Turner et al., Trunkey, and a current study by Geeraedts et al.[18,22,26] In addition, our
study shows an association between a high number of therapeutic activities during rescue,
such as intubation and chest tube, and a longer rescue time as well as a higher volume of fluid
replacement in case of similar injury severity of the pairs. The decision of extending therapy
conducted at the accident site must be made individually on a case-by-case basis. A
comprehensive set protocol can certainly not be established for this situation. However, this
study supports that recommendations for the prehospital treatment of patients with
penetrating trauma also apply to patient with blunt traumas. That is, to limit prehospital
therapy to only the bare necessities of stabilizing the cardiovascular and pulmonary systems,
and make rapid transport to a level one trauma center the priority.[18]

The question why the patients of the high-volume group on average received so much more
volume (~1500 mL) remains speculative. The classification was made in a way that not only
the hemodynamic initial conditions were approximately identical, but also the injury severity
per body region (AIS). Apart from the thoracic injuries, of which 3.2% more were found in
the high-volume group, the remaining injuries of the body regions were almost exactly the
same. A possible bias by means of the distribution of dissimilar severity injuries was thus
minimized. In addition, the difference of the mean ISS between both the groups is not
significant. As already mentioned at the outset, the individual decision on the volume to be
administered rests with the attending personnel. However, it has to be emphasized that in a
retrospective statistical analysis, no conclusions about the individual decisions can be drawn.
Therefore, it is only to be assumed, and this is supported by the present data, that once a team
opts for an extended therapy, this is related to an elevated volume replacement. The injury
severity does not always seem to be determining in this context. The significant higher
number of chest tubes can certainly not be explained by the slightly higher number of
thoracic injuries in the high-volume group. It may be that here rather the standard of
education and the experience of the medical personnel matter. This assumption is supported
by a review from Oestern concerning the medical assistance of severely injured patients in
the emergency trauma room.[27] On the other hand, it has to be considered that an extended
rescue time and the related increased volume replacement can be induced by the fact that
during an extended rescue time (eg, due to a patient stuck in a car), more volume is given. In
this context, it has to be pointed out that an average difference of 11.4 min between the two
groups does not explain an elevated volume replacement of 1740 mL on average. But in
individual cases, this may be of importance. Unfortunately, this connection cannot be
discussed due to missing studies in the literature. However, this should be considered in
future studies.

One remarkable finding of this study is that higher replacement volumes were related to a
significantly more frequent occurrence of organ failure and sepsis. However, mortality during
the entire period of care was not significantly different in the low- and high-volume
replacement groups. We assume that better treatment possibilities in the hospital can
potentially compensate for worse condition prior to hospitalization if the patient survives the
first posttraumatic stage and an early intensive medical care was given. Based on the results
of the study presented here, the patient group receiving high-volume replacement therapy
required more extensive therapeutic care (more units of pRBC, longer intubation per first 30
ICU days, and so on) for equivalent occurrence of mortality as the low-volume patient group.
To reduce the cost of patient care, the recommendations concerning a moderate volume
replacement with the least possible additional impairment of the coagulation, the dilution of
oxygen carriers and a fast transport in a level one trauma center for a definitive surgical and
intensive medical therapy appear to be the best course of action. As already mentioned above,
Geeraedts et al. and Turner et al. drew similar conclusions.[18,22] This assumption is
furthermore supported by the fact that the total days spent in ICU or days of intubation do not
differ significantly in patients who received either low- or high-replacement volumes, but the
ICU-free days and the ventilator-free days concerning the first 30 days differed significantly.
It is presumable that especially the direct therapy time after trauma was of essential
importance. However, it has to be pointed out again that the mortality within the first 6 h and
the total mortality did not differ significantly between the two groups, but both mortality
values were elevated in the high-volume group. A reference to a maybe higher total severity
of the injuries cannot be reconstructed. The study was designed in a way that the injury
severity per body region (AIS) was approximately the same and the total ISS was the same in
all groups. Also the elevated RISC score that the high-volume group had received does not
serve as a clue to a more severely injured group, because it has to be considered that the data
(eg, prothrombin ratio) included in the calculation of the RISC score had already been
influenced prehospital by the volume replacement. In total, our study does not fully support
the conclusion drawn by Turner et al. that the volume replacement does not influence
mortality.[22]

The study presented here does not support an aggressive volume replacement after blunt
trauma and bleeding. Some authors have recommended this in past studies to improve the
tissue perfusion pressure.[19–21] These recommendations were mostly made for injuries of
the extremities. Interestingly, patients with blood pressure less than 90 mmHg at the accident
site, recovered better after a low-volume replacement than after a high-volume replacement.
The same held true for the heart rates at the accident site and in the emergency room. Similar
results for penetrating and blunt trauma in America were shown by Dutton et al.[28] Based
on these results, low-volume replacement also appears to achieve the required perfusion
pressure. Permissive hypotension could represent the better therapeutic option as has been
shown for penetrating trauma patients. Geeraedts et al. drew a similar conclusion in their
review.[18] Catecholamines should not substitute a volume therapy in the treatment of a
hemorrhagic shock. A catecholamine therapy to maintain the mean arterial pressure is only
recommended as a last-chance scenario.[19]

Another interesting aspect influenced by the choice of volume in prehospital replacement

therapy became apparent when the cost of patient care was examined. In the study presented
here, additional expenses amounting to €2,500 per 1.5 days per patient was concurred in the
high-volume replacement therapy group. This reflects the intensified therapeutic effort in the
high-volume group. In the health system with limited resources, this is a factor that should
not be ignored.

There are several limitations to our retrospective study:

 TRISS calculation could be performed only in 46% of the participating trauma

centers, whereas RISC methodology was available in 88% of the cases. Thus, the data
might be biased as TRISS could not be calculated for the majority of the trauma cases.
But this also indicates that RISC is much easier to maintain than TRISS, which might
be because RISC does not compute the respiratory rate prehospitally. The respiratory
rate is documented by the physicians on site only in 60% of the cases
 Regarding the coagulation analysis, in the Trauma Registry of the DGU, only the
prothrombin ratio is documented, and therefore available for analysis. Other
laboratory values, which might be of interest with respect to coagulation (eg,
fibrinogen, protein C), are not documented at all in the Trauma Registry.
 All the patients were treated by a physician at the accident site. However, it remains
unclear which specialty (eg, trauma surgeon, anesthetist) the physician practicing at
the accident site represents and which education is underlying here. In German-
speaking countries, for example, a certificate in “emergency medicine” is required for
 working as an emergency doctor at the accident site. This certificate is independent of
being a medical specialist (surgeon, anesthetist, or others).

Finally, we conducted a retrospective analysis and only associations but no causalities can be
ascribed to the given data. In the future, a prospective randomized study is indispensable to
clarify the advantage or disadvantage of a volume therapy in the bleeding, most severely
injured patient at the accident site.

CONCLUSION
Moderate prehospital volume replacement therapy after severe trauma was related with a
better clinical course in the patient content to a high amount of fluid replacement. Aggressive
volume therapy is related with early traumatic coagulopathy and increased rescue time. From
these analyses, rapid transport to a hospital appears to be the more important factor. The
results of this study suggest recommending permissive hypotension and a restrained volume
replacement during rescue of patients suffering from trauma and severe bleeding.

ACKNOWLEDGMENTS
Special thanks go to the IFOM Institute under the direction of Prof. Neugebauer and his
associate PD Dr. Rolf Lefering for their outstanding support. Great thanks go to Kathy
Astrahantseff for critical reading. The authors also thank the members of the emergency care,
intensive care, and treatment teams of severely injured patients of the DGU for their long-
standing intense involvement in the Trauma Registry. The following members have
decisively contributed to the success of the Trauma Registry of the DGU: F. Barth, A. Bonk,
B. Bouillon, K. Grimme, S. Grote, M. Grotz, M. Hering, S. Huber-Wagner, U. Krehmeier, G.
Kanz, M. Kleiner, C. Krettek, C. Kühne, L. Kumpf, K. Ledendecker, I. Marzi, H. Meyer, S.
Müller, W. Mutschler, C. Lackner, R. Lefering, D. Nast-Kolb, E. Neugebauer, U. Obertacke,
H.J. Oestern, H.-C. Pape, T. Paffrath, Ch. Probst, M. Qvick, M. Raum, D. Rixen, S.
Ruchholtz, S. Sauerland, U. Schweigkofler, A. Seekamp, R. Simon, O. Steitz, B. Strohecker,
T. Tjardes, F. Walcher, C. Waydhas, M. Wittke, J. Westhoff.

Footnotes
Source of Support: Nil.

Conflict of Interest: None declared.

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Figures and Tables

Table 1

Demographical and clinical data for bleeding, severely injured patients treated prior to
hospitalization with low- and high-volume fluid replacement therapy (1351 patients per
group)
Table 2

Patient data from treatment at the accident site, in the emergency room and during initial
surgical treatment, group-specific

Table 3
Clinical course and outcome of patients receiving either low- or high-volume prehospital
replacement therapy after trauma and bleeding

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