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Prehospital endotracheal intubation:

Effects of prehospital endotracheal intubation depend on the experience of prehospital healthcare providers. Intubation by paramedics who are not well skilled to do so markedly increases mortality, suggesting that routine prehospital intubation of severe traumatic brain injury (TBI) patients should be abandoned in emergency medical services in which providers do not have ample training, skill and experience in performing this intervention.

For most trauma patients the initial life- and limb-saving care is achieved within the “golden hour”. Prehospital treatment occupies most of the golden hour. More prehospital interventions were performed with helicopter emergency medical services (HEMS) than with emergency medical services (EMS) only, but the higher number of interventions did not result in a longer on-scene time (OST) with HEMS. 

Prehospital Fluid administration:

The evolving evidence suggests that aggressive fluid resuscitation prior to hemostasis leads to additional bleeding through hydraulic acceleration of hemorrhage, soft clot dissolution, and dilution of clotting factors. Aggressive preoperative fluid infusion is still considered appropriate for unconscious patients without palpable blood pressure or for those with controllable hemorrhage (e.g. isolated extremity or head injury), However, the latest recommendations are to limit or delay intravenous fluid resuscitation preoperatively in those with uncontrollable haemorrhage (e.g. those with penetrating torso injuries), even if they are hypo-perfusing.

Early haemodynamic effects

The aim of administering fluids is to restore end-organ perfusion and therefore oxygen delivery. An increase in circulating volume will have a tendency to increase cardiac output and blood pressure. The speed with which a given fluid will produce its effect will largely be determined by its volume of distribution within the body and how quickly it equilibrates. A sudden increase in blood flow may not be beneficial because it has the potential to precipitate rebleeding from sites where physiological mechanisms have brought about cessation of haemorrhage.


In general, administration of fluid has a detrimental effect on haemostasis and a tendency to increase bleeding. To begin with, primary haemostatic thrombus may be dislodged from a vessel causing rebleeding, as outlined above. Most fluids will cause vasodilatation, at least as a result of reversing hypovolaemia, with similar risks. With the obvious exception of fresh frozen plasma, most will also reduce blood viscosity and dilute clotting factors to the detriment of haemostatic mechanisms. Direct interference with the clotting cascades is seen with some starches.Finally, hypothermia induced coagulopathy should be avoided, if possible, and the fluids should be warmed.

Oxygen carriage

High flow oxygen is administered routinely to trauma patients.The main thrust of fluid administration is directed towards reversing hypovolaemia. In the early stages, the relative anaemia caused by blood loss is compensated for by the decrease in blood viscosity, which permits improved peripheral oxygen delivery. Anaemia associated with haemorrhage is considered to be secondary in importance to hypovolaemia in the accumulation of oxygen debt. To date, no artificial oxygen carrying solutions have reached widespread use.

These guidelines provide one simple strategy applied to the use of fluids for trauma patients in the prehospital setting. There are three main areas that are attended to; cannulation, the choice of fluid, and the quantity of fluid given. It is intended that these issues should continue to be debated and, where ideas are put forward, it is expected that they will evolve or change as experience and evidence grow together.

Fluid administration for trauma in the prehospital environment is a challenging and controversial area. There is not yet any equivocal answer that can be supported by clear unanswerable evidence. Nevertheless, a careful reading of what evidence is available does permit some provisional conclusions to be drawn. I believe that the following represent the best possible current expert consensus on prehospital fluids in trauma. As future evidence brings clarity to this area, these guidelines can be modified, and further consensus statements will be issued taking into account such information.

Prehospital tranexamic acid (TXA):

Although we have made significant advances in the understanding of trauma-induced coagulopathy, there is still lack of clarity regarding links between diagnostic and laboratory coagulation testing and clinical bleeding risk.38 It is therefore evident that there is still significant controversy as to how best to manage trauma patients with severe injury and hemorrhage, including which patients would benefit most from TXA administration. At present, there is no definitive evidence to support efficacy of prehospital TXA administration in improving trauma outcomes. Data are lacking regarding which trauma patients might benefit, optimal dosing and timing and potential complications in the prehospital setting. Prehospital TXA protocols have not been adopted in most trauma centers. If prehospital TXA protocols are desired, issues to consider include time to definitive trauma care, feasibility of TXA intravenous administration, and how best to determine which patients would potentially benefit in the prehospital phase. The ongoing prehospital and in-hospital TXA randomized trials will provide additional high-quality evidence to support optimal clinical protocols for TXA use in the future. At present, the focus of prehospital care of the bleeding trauma victim should be hemorrhage control, hemostatic resuscitation and rapid transport to definitive hemorrhage control and definitive trauma care.

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