Letters to the Editor 131

1. H

ypotensive resuscitation presupposes measur-ing SBP and its use as a therapeutic objective.

2. S

BP is a poor indicator of perfusion and the stateof microcirculation.

3. T

he use of SBP as a therapeutic objective hasimportant limitations since its measurement var-ies considerably among observers,4 which may beaccentuated in states of shock making ausculta-tion of Korotkoff sounds more difficult.10

4. I

t is difficult to determine SBP by pulse palpation. 5. M easuring SBPmay constitute a distracting factor.

We understand permissive hypovolaemia asabstaining from fluid administration in traumapatients with clinical signs of haemorrhagic shock,palpable radial pulse and who respond to verbalinstructions,butdonotpresentsigns indicativeofTBI.

Given that there are expert opinions in support ofhypotensive resuscitation,7,8 that there are coher-ent physiopathological reasons behind non-normal-isation of BP in uncontrolled haemorrhage12 and thatthere are no clinical studies that define the quan-tities of fluid to be administered, it is imperativethat studies be performed in humans, designed toeffectively compare:

1. T

he concept of hypotensive resuscitation versusnormotensive resuscitation.

2. B

P versus indicators of perfusion such as sublin-gual CO2 level, as therapeutic objective.9

3. T

he concept of hypotensive resuscitation versusthat of permissive hypovolaemia.

As things stand at present we can only base ouropinions on personal experience and low levels ofevidence. Efforts must be made to design and per-form studies that provide the level of evidencenecessary to optimise the management of pre-hos-pital trauma and shock.2

DOI of original article: 10.1016/j.injury.2006.05.021.

References

1. Alexander D. New concepts in shock management. Air Med J1996;15:85—91.

2. Becker LB, Weisfeldt ML, Weil MH, Budinger T, Carrico J, KernK, et al. The PULSE initiative scientific priorities and strategicplanning for resuscitation research and life saving therapies.Circulation 2002;28(105):2562—70.

3. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitationduring active hemorrhage: impact on in-hospital mortality. JTrauma 2002;52:1141—6.

4. Edmonds ZV, Mower WR, Lovato LM, Lomeli R. Reliabilityof vital sign measurements. Ann Emerg Med 2002;39:233—7.

5. Ligtenberg J, van der Horst I, Zijlstra J. Fluid resuscitationduring active hemorrhage: need for a step forward. J Trauma2002;53:1196—7.

6. Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: asystematic review of animal trials. J Trauma 2003;55:571—89.

7. Mattox K. Permissve hypotension for trauma resuscitation 2002.(Consulted 11-11-2005). Available at: http://www.trauma.org/resus/permissivehypotension.html.

8. Pepe PE, Mosesso Jr VN, Falk JL. Prehospital fluid resuscitationof the patient with major trauma. Prehosp Emerg Care2002;6:81—91.

9. Pepe PE. Shock in polytrauma. B Med J 2003;327:1119—20.10. Sibbald WJ. Update on current treatment modalities in

shock. Medscape (Consulted 11-11-2005). Available at:http://www.medscape.com/ viewarticle/42036.

11. SøreideE,DeakinCD.Pre-hospitalfluid therapy in thecriticallyinjured patient–—a clinical update. Injury 2005;36:1001—10.

12. Stern SA. Low-volume fluid resuscitation for presumedhemorrhagic shock: helpful or harmful? Curr Opin Crit Care2001;7:422—30.

13. Tisherman SA. Regardless of origin, uncontrolled hemorrhageis uncontrolled hemorrhage. Crit Care Med 2000;28:892—4.

J. Suarez-Pelaez*Servicio de Urgencias Canarias, Tenerife, Spain

G. Burillo-PutzeEmergency Department,

Hospital Universitario de Canarias, Tenerife, Spain

S. Lubillo-MontenegroIntensive Care Unit,

Hospital Universitario Ntra. Sra. de La Candelaria,Spain

L. Ramos-GomezIntensive Care Unit,

Hospital General de La Palma, Spain

*Corresponding authorE-mail address: josuarez@teleline.es

(J. Suarez-Pelaez)

doi:10.1016/j.injury.2006.05.021

AUTHORS’ REPLY

Re: Pre-hospital fluid therapy in the criticallyinjured patient: need for clinical studies

To the Editor,

We appreciate the kind words and the positiveinterest in our clinical update on pre-hospital fluidtherapy in the critically injured patient.5

As pointed out, the topic remains controversial.Animal research strongly suggests that both toomuch and too little fluid is detrimental.4 Still, how

132 Letters to the Editor

to translate this into meaningful clinical practiceguidelines in the complex pre-hospital settingremains open for discussion. Perhaps using smalleraliquots of fluidwouldmake a difference, but are theuse of such small boluses with isotonic fluid feasible?We doubt it.Wouldmoving from protocol-fixed bloodpressure values to clinical signs as targets for volumetherapy change anything? Probably yes, but exactlywhat, and how, is not yet known. It is our distinctimpression that the whole international traumacommunity now has moved away from the previousover-reliance on rapid infusions of large volumes ofcrystalloids. That is probably a good start.

Would changing from a mental framework of‘‘hypotensive resuscitation’’ to ‘‘permissive hypo-volemia’’ improve anything? We are not sure, as wethink this is more a question of semantics ratherthan differences in approach. We agree that thefocus should be on clinical signs of ‘‘acceptabletissue perfusion’’. In some patients this will meanthat no fluid is needed at all, while in others, largervolumes will be needed to achieve the same target.Hence, the two concepts bear within them the sameclinical approach of reducing fluid volumes whileaiming at specific targets. Importantly, the use ofanalgesia and the individual response to injury, painand bleeding may be as important as the use of fluidboluses in determining the individual patient’s bloodpressure responses and thereby the risk of re-bleed-ing. This was clearly pointed out by Dutton et al.1

Given that expert opinions are prominent andcontrolled studies few, asking for more controlledclinical studies seem the right thing to do. However,based on previous power analysis, we know that hugenumbers of trauma patients with uncontrolled hae-morrhage must be included to produce meaningfulcomparisons.1 The pre-hospital diagnosis of patientswith uncontrolled internal haemorrhage based onvital parameters is not as easy as it may seem.2

Therefore, including the appropriate patients in sucha trial may not be easy. Further, choosing betweenmerely bringing the patient as rapid as possible to thewaiting, knife-holding surgeon, or over-infusing thepatient while spending more time on scene, is anoversimplification of the issues at stake.We sincerelydoubt that a well-controlled randomised controlledtrial with adequate number of patients to clarify allthese issues will ever be performed.

While for a patient with stab or gun shot wounds,rapid pre-hospital transport is the key issue, this isnot necessarily so in blunt trauma. In the very fewpatients with blunt trauma that need immediatehaemostatic surgery, rapid diagnosis and treatmentof the bleeding source without any undue delay iscrucial. In the large majority of blunt traumapatients, however, we think a combination of cri-

tical care team work following the ABCDE principlesand initial diagnostic work-up in the ED beforedefinitive treatment is a better description of themost effective process of care.

So, what can we do to define ‘‘best practice’’ inthis context? A good start would be to document ourown practice and outcomes in an internationallyaccepted way for comparison3. For decades we havelooked across the Atlantic for new studies that couldanswer all these questions. What about taking thechallenge in Europe? Non-randomised studies are farbetter than no studies when it comes to comparingdifferent approaches. Instead of just comparing onesmall fraction of the process of care (e.g. pre-hospital fluids), we should try to address the wholechain of survival, look for the weak links and addressthem accordingly. Then we may see actual improve-ments in survival.

References

1. Dutton RP, Mackenzie CF, Scalea TM. Hypotensive resuscitationduring active hemorrhage: impact on in-hospital mortality. JTrauma 2002;52:1141—6.

2. Lechleuthner A, Lefering R, Bouillon B, et al. Prehospitaldetection of uncontrolled haemorrhage in blunt trauma. EurJ Emerg Med 1994;1:13—8.

3. Lossius HM, Langhelle A, Soreide E, et al. Reporting datafollowing major trauma and analysing factors associated withoutcome using the new Utstein style recommendations. Resus-citation 2001;50:263—72.

4. Mapstone J, Roberts I, Evans P. Fluid resuscitation strategies: asystematic review of animal trials. J Trauma 2003;55:571—89.

5. Pelaez, JS. Pre-hospital fluid therapy in the critically injuredpatient: need for clinical studies, Injury, this issue.

Eldar Søreidea,b,*aDivision of Acute Care Medicine,

Stavanger University Hospital,Stavanger, Norway

bDepartment of Anaesthesiology andEmergency Medicine,

University of Bergen, Norway

Charles D. Deakina,b,caHampshire Ambulance Service NHS Trust,

Winchester, UK

bHelicopter Emergency Medical Service,Royal London Hospital, London, UK

cSouthampton University Hospital,Southampton, UK

*Corresponding authorE-mail address: soed@SIR.NO (E. Søreide)

doi:10.1016/j.injury.2006.05.023