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Are IV fluids helpful or harmful in trauma?

It has been argued that modern medicine is practical and evidence based. However, this is not always the case. Some medical ideas are slow to die, even when they are poorly supported by evidence.

Here is one example: It is common practice in my emergency department, and every other emergency department in the country, to provide IV fluids to bleeding patients.  Sometimes this is life saving.  But do we give fluids too much and too often?

The infusion of electrolyte (crystalloid) solution, for bleeding patients is routine both in the pre-hospital setting and emergency department. Emergency health care workers are reassured by the increase in blood pressure and decrease in pulse that happens as IV fluids expand the blood volume in trauma patients. An assumption underlying this practice is that replacement of blood loss with IV fluid improves oxygen delivery to tissues and decreases the likelihood of shock. It is further argued that so-called “fluid resuscitation” prevents decompensation, exsanguination, and death.

This thinking has been challenged by a century of experimental data, clinical experience, and battlefield medical experience.

The vast majority of studies of prehospital fluid and emergency department fluid resuscitation in trauma support the notion that fluid resuscitation can be harmful. In aggregate, the data suggests that less is more when it comes to IV fluids.

Here it may be useful to consider an evolutionary approach to the question of IV fluids.  First, trauma has been and continues to be a major source of mortality for humans. Second, the mechanisms involved in hemostasis have been subjected to natural selection, ever since the ancient circulatory system first emerged. As a result, blood clotting during trauma is a tightly regulated process. This process involves a highly complex network of altered gene expression, platelet activity, clotting factor and fibrinogen activation, and immune activation. It should come as no surprise that IV fluids have the capacity to disturb some of these processes. Thus, while IV fluids can improve blood pressure and decrease the heart rate, making a patient appear more stable, fluids may worsen hemostasis. Uncontrolled bleeding, of course is ultimately deadly.

I explored this issue in a recent piece that will be published this month in The Sharp End, an emergency medicine publication edited by my colleague Andy Brainard MD.

For the complete article and some very thought provoking articles about other well-intentioned but ill-advised medical interventions :Read More Here: The Sharp End

Joe Alcock MD

Categories: Uncategorized

Joe Alcock

Emergency Physician, Educator, Researcher, interested in the microbiome, evolution, and medicine

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