• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: fluid resuscitation. New York (NY): Brain Trauma Foundation; 2005. 12 p. [31 references]

This is the current release of the guideline.

"Degrees of Certainty" (Standards, Guideline, Options) and "Classification of Evidence" (Class I to III) and the correlation between the two are defined at the end of the "Major Recommendations" field.

Recommendations

1. Standards

   Data are insufficient to support a treatment standard for fluid resuscitation in the patient with severe traumatic brain injury (TBI).

2. Guidelines

   It is customary to treat hypotension with fluids in patients with TBI. Inadequate data exist to support a specific target blood pressure. Inadequate clinical outcome data exist to prefer one resuscitation fluid choice over another; however, hypertonic saline and colloids offer clear logistical advantages over isotonic crystalloids in a combat environment. Hypertonic saline in the prehospital phase is safe in doses <500 mL and can be used for hypovolemia.

3. Options

   Hypotension (systolic blood pressure <90 mm Hg) in patients with TBI has an association with poor outcome. Fluid therapy can be used to maintain adequate cerebral perfusion pressure and limit secondary brain injury. Inadequate fluid resuscitation with aggressive diuresis can precipitate hypotension and should be avoided in the field setting. Hypertonic saline resuscitation, with or without dextran, has been used with some encouraging results compared to isotonic fluids. If a casualty requires additional fluids after the administration of 500 ml of hypertonic saline, isotonic fluids or colloids can be used.

Summary

The deleterious association of hypotension in patients with TBI has been documented in the literature. While permissive hypotension is practiced in the field for penetrating torso trauma, it is not advisable to recommend this for patients with TBI at this point. Because the underlying cause of hypotension in TBI patients is almost always secondary to bleeding or other fluid losses, intravascular volume resuscitation seems to be the most efficacious way of restoring blood pressure. Isotonic crystalloid solution is the fluid most often used in the prehospital resuscitation of head injury patients.

There is Class I evidence that demonstrates that the use of hypertonic saline is a safe alternative method of treating hypotensive TBI without worsening outcome and there is lesser quality data to show it may have survival advantages in patients with TBI. Because hypertonic saline offers logistic advantage in terms of weight and cube in the field, it can be used in patients with TBI as it can reduce intracranial pressure (ICP) while restoring intravascular volume. Two 250 mL bolus of 5% hypertonic saline or two 500 mL boluses of 3% hypertonic saline can be used as the initial resuscitation fluid. Colloids such as Hextend also offer weight and volume advantage compared to other fluids so it is also an alternative that can be used in the field setting. In patients with TBI that have no evidence of significant blood loss and have normal pulse character or blood pressure, there is no evidence to show that any fluid resuscitation is necessary. Mannitol in the prehospital/field setting has not yet been shown to improve outcome.

Definitions:

Classes of Evidence

Class I: Evidence from good quality randomized controlled trials (RCT)

Class II: Evidence from moderate or poor quality RCT, good quality cohort, or good quality case-control studies

Class III: Evidence from moderate or poor quality cohort; or moderate or poor quality case-control; or case series, databases, or registries

Degrees of Certainty

Standards: Reflect a high degree of clinical certainty as indicated by the scientific evidence available (supported by Class I evidence).

Guidelines: Reflect a moderate degree of clinical certainty as indicated by the scientific evidence available (supported by Class II evidence).

Options: Reflect unclear clinical certainty as indicated by the scientific evidence available (supported by Class III evidence).

A clinical algorithm for "Field Management of Combat-Related Head Trauma" is provided in the original guideline document.

An evidentiary table appears at the end of each major section of the guideline document, which classifies each citation based on the quality of the evidence (Class I-III; see "Major Recommendations" for definitions). The recommendations in this summary are supported by six Class II studies and two Class III studies.

• Knuth T, Letarte PB, Ling G, Moores LE, Rhee P, Tauber D, Trask A. Guidelines for the field management of combat-related head trauma. Treatment: fluid resuscitation. New York (NY): Brain Trauma Foundation; 2005. 12 p. [31 references]

Not applicable: The guideline was not adapted from another source.

2005

Brain Trauma Foundation - Disease Specific Society

Brain Trauma Foundation

Uniformed Services University of the Health Sciences

Not stated

Authors: Tom Knuth, MD, MPH, FACS, COL, Medical Corps, US Army, Chief, Combat Casualty Care Integrated Concepts Team, Directorate of Combat Doctrine and Development, Army Medical Department Center and School, Fort Sam Houston, Texas; Peter B. Letarte, MD, FACS, Neurosurgeon, Hines VA Medical Center, Loyola University Medical Center; Geoffrey Ling, MD, PhD, LTC, Medical Corps, US Army, Professor and Vice-Chair of Neurology, Director of Critical Care Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; Leon E. Moores, MD, FACS, LTC, Medical Corps, US Army, Assistant Professor of Surgery and Pediatrics, Uniformed Services University of the Health Sciences, Chief of Neurosurgery, Director of Pediatric Neurological Surgery, Walter Reed Army Medical Center; Peter Rhee, MD, MPH, FACS, FCCM, CAPT, Medical Corps, US Navy, Professor of Surgery/Molecular Cellular Biology, Director, Navy Trauma Training Center, Los Angeles County Medical Center, University of Southern California; David Tauber, CCEMT-P, NREMT-P, I\C, Executive Director, Advanced Life Support Institute (New Hampshire) Medical Specialist/Hazardous Materials Technician, FEMA USAR Team MA1; Art Trask, MD, FACS, INOVA Regional Trauma Center, INOVA Fairfax Hospital

Not stated

This is the current release of the guideline.

None available

None available

This NGC summary was completed by ECRI Institute on August 24, 2007. The information was verified by the guideline developer on January 28, 2008.

This is a limited license granted to NGC, AHRQ and its agent only. It may not be assigned, sold, or otherwise transferred. BTF owns the copyright. For any other permission regarding the use of these guidelines, please contact the Brain Trauma Foundation.