Bickell et al 1994 - Fluids in penetrating trauma

Question 1

Summarise Bickell et al 1994

Answer 1

Published in NEJM

Prospective none randomised cohort study
America

Aim to assess whether withholding volume resuscitation until theatre was superior to immediate

Methods:
- Adults with central penetrating trauma and systolic <90
- Minor injury, head gunshot, trauma score 0 excluded
- Even numbered days got fluid, odd numbered waited until theatre

598 patients in the study, 528 made it to theatre

Fluid:
- more fluid in pre-hospital group
- higher rate of infusion

Outcome:
- significantly higher rate of survival (70 vs 62%) in delayed group
- 870ml and 1608ml to pre-hospital group
- lower Hb and lower platelets
- longer PT

Fluids given before surgical control of bleeding lead to either accentuation of ongoing haemorrhage or hydraulic disruption of an effective thrombus, followed by a fatal secondary haemorrhage

Take home: careful, restrictive use of fluids while awaiting definitive control

Question 2

What do the tablets in Bickell et al 1994 show?

Answer 2

Table 1 - Patient characteristics
Table 2 - Arrival BP and lab results
Table 3 - BP and lab results once in theatre
Table 4 - Total volumes of fluids
Table 5 - Outcomes
Table 6 - Post-op complications