Hypertonic saline as effective as normal saline for trauma patients (2024)

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Solutions more concentrated than normal, such as hypertonic saline, are as good as those more usually given to trauma patients with severe blood loss. Survival to hospital discharge was the same in patients treated before arrival at the hospital with either type of fluid.

There are around 20,000 cases of major trauma per year in England. Outcomes for patients have improved in the UK over the last 25 years, but as there is still room for improvement this review sought to find evidence that supported or challenged the convention that normal saline is always best.

Hypertonic solutions are given to patients in a lower volume, and so can be carried in more compact packaging. They could be preferred for transportation by emergency services if they are equally safe.

Why was this study needed?

Traumatic injury leads to more than 5.8 million deaths every year across the world. In 2010, it was estimated that there are at least 20,000 major trauma cases in England each year, of which around 5,400 result in death and several others in disability. Many of these are due to road traffic collisions.

Trauma patients with blood loss and low blood pressure need intervention by emergency staff before arrival at the hospital, and this may include fluid therapy. In the UK this is almost always with fluid which has a similar concentration to normal blood. Hypertonic saline is much more concentrated than normal human fluids and draws fluid into the bloodstream from the tissues, increasing the patient’s circulatory volume further.

Hypertonic fluids have been compared previously with isotonic fluids in various settings, but findings have been inconclusive. This study compares the two interventions in out-of-hospital care.

What did this study do?

This systematic review of five randomised control trials compared hypertonic 7.5% saline (about eight times the concentration of isotonic saline) with isotonic or near isotonic fluids in 1,162 trauma patients from North America, Australia or Finland. Patients were young adults aged 31 to 50 years.

The primary outcome was survival to hospital discharge, reported as in each study and assessed through a combined relative risk. Secondary outcomes were summarised as in the original studies, and they included longer-term survival, length of hospital stay and disability.

One study did not report enough data to assess bias. For the other studies, the risk of bias was low.

What did it find?

  • Survival to discharge did not vary with the type of fluid patients received (combined relative risk 1.02, 95% confidence interval 0.95 to 1.10).
  • Most data (58%) came from a single 2011 trial of 632 patients.
  • One trial showed a greater change in systolic blood pressure in patients treated with hypertonic saline, favouring this type of fluid.

What does current guidance say on this issue?

The NICE technology appraisal guidance on pre-hospital initiation of fluid replacement therapy in trauma recommends initiating fluid replacement in the ambulance en route to hospital in patients without a palpable pulse and when clinical judgement in the presence of severely reduced blood volume deems it necessary. It recommends using normal saline (isotonic fluids).

The guidance recommends assessing further different protocols for pre-hospital care of trauma patients.

What are the implications?

Hypertonic solutions seem to produce similar clinical outcomes in hypotensive trauma patients compared with isotonic solutions. These results are in line with previous findings.

Hypertonic solutions are given to patients in lower volumes, allowing for lighter and more compact packaging for the same clinical outcome when compared with isotonic solutions. This presents an advantage when space and weight are limited, as they are for helicopter rescues, for example.

The findings suggest that emergency teams may benefit from carrying hypertonic instead of isotonic solutions. Additional research is needed to validate these results and identify the optimal use of hypertonic solutions, particularly the optimal volume for hypotensive trauma patients.

Citation and Funding

Blanchard IE, Ahmad A, Tang KL, et al. The effectiveness of prehospital hypertonic saline for hypotensive trauma patients: a systematic review and meta-analysis. BMC Emerg Med. 2017;17(1):35.

This study was not funded.

Bibliography

Brake. Road collisions responsible for 1 in 5 trauma admissions to hospitals. London: Brake; 2017.

National Audit Office. Major trauma care in England. London: The Stationery Office; 2010.

NICE. Major trauma: assessment and initial management. NG39. London: National Institute for Health and Clinical Excellence; 2016.

NICE. Pre-hospital initiation of fluid replacement therapy in trauma. TA74. London: National Institute for Health and Clinical Excellence; 2004.

Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100.

Produced by the University of Southampton and Bazian on behalf of NIHR through the NIHR Dissemination Centre

Hypertonic saline as effective as normal saline for trauma patients (2024)

FAQs

Why is hypertonic saline used in trauma? ›

Both 3% hypertonic saline and mannitol can effectively reduce intracranial pressure, but 3% hypertonic saline has a more sustained effect on intracranial pressure and can effectively increase cerebral perfusion pressure.

Is hypertonic saline better than mannitol for traumatic brain injury? ›

Hypertonic saline is superior to mannitol for the combined effect on intracranial pressure and cerebral perfusion pressure burdens in patients with severe traumatic brain injury.

What is the difference between hypertonic saline and normal saline? ›

Hypertonic saline is much more concentrated than normal human fluids and draws fluid into the bloodstream from the tissues, increasing the patient's circulatory volume further. Hypertonic fluids have been compared previously with isotonic fluids in various settings, but findings have been inconclusive.

Why is normal saline solution contraindicated in a bleeding trauma patient? ›

The use of NS in trauma resuscitation has been shown to exacerbate the first two aspects of this triad, metabolic acidosis and coagulopathy, as well as effect blood concentration and induce blood vessel dilation, all of which have the potential to worsen patient outcomes.

Why is 3 saline used in neuro trauma? ›

Hypertonic saline has clinically desirable physiological effects on cerebral blood flow, intracranial pressure and inflammatory responses in models of neurotrauma. Animal studies support its use, but definitive human trials using mortality end-points in brain trauma are lacking.

What is hypertonic solution for trauma? ›

Hypertonic saline is a hyperosmolar therapy that is used in traumatic brain injury to reduce intracranial pressure.

Why use hypertonic saline over mannitol? ›

Hypertonic saline had significantly lower treatment failure, lower intracranial pressure 30–60 mins after infusion termination, and higher cerebral perfusion pressure 30–60 mins after infusion termination compared to mannitol in subjects with traumatic brain injury.

What is the fluid of choice for head trauma patients? ›

Mannitol, a hypertonic crystalloid solution, is commonly used to decrease brain water content and reduce intracranial pressure (ICP). Hypertonic saline solutions also decrease brain water and ICP while temporarily increasing systolic blood pressure and cardiac output.

What IV fluid is used for traumatic brain injury? ›

Replacing fluid or blood loss due to wounds is an especially essential benefit of IV therapy for traumatic brain injury patients, who may have an imbalance of fluids or electrolytes and considerable blood loss.

What are the disadvantages of hypertonic saline? ›

Common side effects of hypertonic saline include:
  • Increased cough.
  • Sore throat.
  • Chest tightness.

When to use hypertonic saline? ›

Sodium is the most abundant extracellular ion. Historically, therapy with hypertonic saline was widely used for a variety of conditions. Currently, there are 3 primary indications for its use in critical care: hyponatremia, volume resuscitation, and brain injury.

What are the guidelines for hypertonic saline? ›

The initial rate of hypertonic saline administration is not to exceed 50 ml per hour. Serum sodium and serum osmolality levels should be monitored at least every 6 hours (more frequently at first, but never less frequently) while hypertonic saline is administered. References: New England Journal of Medicine.

Which is better for trauma lactated Ringers or normal saline? ›

Lactated ringers are more similar to your blood plasma than saline. Lactated ringers are used for: Burn and trauma patients who need fluids. Acute blood loss.

Why is too much IV fluid a bad thing in trauma? ›

Intensive fluid resuscitation is a crucial element of early resuscitation in trauma; however, excessive fluid infusion may lead to fluid accumulation and consequent complications such as pulmonary edema, cardiac failure, impaired bowel function, and delayed wound healing.

What is the 3 to 1 rule for fluid replacement? ›

ATLS continues to support the use of a 3-for-1 rule (3 mL of crystalloid should be used as replacement for every 1 mL of blood loss), but also encourages frequent reassessments if large amounts of crystalloid are not providing adequate resuscitation. ATLS also dictates treatment based on the class of hypovolemic shock.

What are the reasons for giving hypertonic solution? ›

Historically, therapy with hypertonic saline was widely used for a variety of conditions. Currently, there are 3 primary indications for its use in critical care: hyponatremia, volume resuscitation, and brain injury.

How does hypertonic saline reduce brain swelling? ›

HTS acts via multiple purported mechanisms to decrease cerebral edema. HTS improves regional cerebral blood flow and lowers ICP via osmotic effects and dehydration of erythrocytes, increasing their ability to navigate small capillaries (rheologic effects) and increasing vascular diameter.

Why are IV fluids given to trauma patients? ›

Therefore, if a decrease in intravascular volume is left uncorrected, it may result in irreversible shock and mortality. Fluid resuscitation primarily aims to attain adequate cardiac output to ensure acceptable oxygen delivery and tissue perfusion until the hemorrhage can be controlled.

What is the purpose of administering mannitol or hypertonic saline in acute brain injuries? ›

Management guidelines from the Brain Trauma Foundation recommend measuring ICP to guide therapy. In particular, hyperosmolar therapy, which includes mannitol or hypertonic saline (HTS), is frequently administered to reduce ICP.

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