Pre-hospital Fluid Replacement - Essay Example

Pre-Hospital Fluid Replacement An Analytical Report Introduction: The Issue Fatal road accidents in UK are on an increase. The Official Department of Health, a government organization of UK, estimates that cost of accidental injury in England in 2000-01 was 2.2 billion. The cost of accidents was estimated at 25billion in 1996 (Dept. of Health (UK), 2007). These figures are on an increase. The research carried out recently by the Department of Transport of UK under the banner of 'ThinkRoadSafety', concluded that 3,201 people were killed in road accidents in 2005, nearly 28,954 were seriously injured and 238,862 were slightly injured (ThinkRoadSafety.gov, 10/06). Although road accidents form a major part of the accident pie chart, there are still other zones apart from roads where people are accident prone. Workers in factories, fire fighters, miners and virtually all blue collared working force in UK are under constant threat of accidents. Most of the deaths that result due to accidents have been identified to be due to excessive blood loss, a term, in medical terminology known as hemorrhage. Mainly two types of injuries are identified. In 'Penetrating Injuries', the skin is breached by sharp objects such as a knife and leads to potential internal bleeding. In 'Blunt Injuries', the skin is not deeply penetrated and generally remains unbroken. However the magnitude of the injury damages the internal organs. The bleeding that is caused by these injuries must be controlled. If the bleeding exceeds the normal bounds, it leads to the reduction in blood volume, technically known as 'hypovolaemia'. This may even lead to 'shock' which is a state of circulatory failure. In such a state the perfusion of necessary fluids and blood to vital internal organs is hampered. This consequently leads to multiple organ failure. The Traditional Solution: On - Site Fluid Replacement Generally the first crew to reach the scene of accident is the ambulance crew. Apart from the driver and attendant in most ambulances also have a paramedic. According to the JRCALC guidelines for pre hospital fluid replacement, only a paramedic can administer fluids on the site to the injured. In an email communication with the authors of 'Clinical Effectiveness and Cost Effectiveness of pre hospital intravenous fluids in trauma patients', trauma.org told that, "All patients would be considered for fluids. (Perhaps not all should receive but currently in the UK almost all will) [The] approximate percentage of trauma patients who receive fluids [is] currently 100%" (Dretzke et al, 2003). Administration of intravenous fluids on - site is a traditional approach to handle injuries. This method was supported by early animal studies. The theory behind fluid replacement methodology is that, fluid replacement therapy attempts to reverse the effects of excessive blood loss by increasing circulatory blood volume and blood pressure back to the normal levels and maintains the perfusion of vital organs thereby reducing the risk of death from multiple organ failure (NICE, 01/04). Methodology and Technology The physiological state of the victim of injury is analyzed by the paramedic to identify which pre - hospital fluids are needed. Certain factors are analyzed such as degree of blood loss and whether the hemorrhage is controlled or uncontrolled. The Technology Appraisal of NHS identifies the other indicators of hemorrhage in adults as tachycardia, peripheral vasoconstriction and reduced blood pressure (NHS, 01/04). The shock levels are categorized according to the severity. Intravenous fluids are considered on similar lines as medicines, and are broadly classified as crystalloids, colloids, or combination fluids. Combination fluids consist of hypertonic saline with starch or dextran. According to the JRCALC regulations only paramedics may administer crystalloid and colloid solutions. Crystalloids pass through cell membranes into different body fluid compartments, thereby making up for the fluids lost due to injury. Colloid solutions contain molecules such as albumin and polysaccharides that do not cross cell membranes. Smaller volumes of fluid infusions are required for fluid replacement with colloid fluids than with crystalloids (NICE Appraisal 74, 01/04). Timing of administration is very crucial for the success of the pre hospital Life Support System provided by intravenous fluids. This factor is also the bone of contention among various organizations and has split reactions to pre hospital fluid replacement methodology into two antithetical groups. Two approaches are under consideration to the timing of intravenous fluids. In the first approach, the paramedics or doctors trained in advanced life support system may start the intravenous fluid replacement in a pre - hospital setting. This is done either on spot or in an ambulance en route to the hospital. This methodology has the benefit of improved chances of survival. The other approach mandates the bringing of the bringing of the body to the hospital as soon as possible by avoiding any pre - hospital fluid replacements. At the hospital the patient is bound to receive definitive treatment for the injuries. The obvious advantage of delaying pre - hospital fluid replacement is that no time is lost on scene and the patient can be brought to the hospital as soon as possible. Pre - Hospital Fluid Replacement Versus Non/Delayed Pre Hospital Fluid Replacement Although pre - hospital fluid replacement methodologies have been followed and in many cases have helped in ensuring the survival of the patient, still, in UK, there does yet not exist a common consensus on the usage of the method. During 1980s it was suggested that delaying definitive treatment would be harmful for the life of the victim (Dretzke, 2003). Infact, newer models researched by various health care organizations suggested that introduction of intravenous fluids in the body itself had several harmful effects. Observations against Pre - Hospital fluid replacement Firstly the opponents of Advanced Life Support (ALS) Systems argued that the methodology of pre - hospital fluid replacement would lead to the loss of valuable and critical time. They believe that the time spent on trying to provide ALS to the patient is not worth the time it consumes and it is much more important to bring the patient to the hospital as soon as possible by avoiding pre - hospital fluid replacement on - scene. Proponents of Basic Life Support (BLS) also believe that definitive treatment has a higher success rate than ALS. Several guidelines have come into existence which stresses that pre - hospital fluid replacement should not be at the expense of delaying time to definitive hospital treatment. It was published in the Journal of the Royal College of Surgeons at Edinburgh that, "Transfer should not be delayed by attempts to obtain intravenous access" (Greaves et al, 2002). Apart from the concern that pre - hospital fluid replacement would delay the bringing of patient to the hospital, in the1980s people began to feel that intravenous fluid replacement might actually be harmful to humans. Through research it was found out that intravenous fluids resulted in increased blood loss because of the dilution of clotting factors. It was also suggested that these fluids may lead to mechanical rupture of blood clots because of increased blood pressure. These situations if happened would exacerbate the shock rather than alleviating it. The relevance of the early animal studies, based on which the pre - hospital fluid replacement methodology was adopted was questioned. Newer research was carried on which later proved that fluid resuscitation might indeed be harmful (Krausz et al, 1992). Finally, the study by Demetriades et al (1996) also suggested that immediately bringing the patient to hospital was beneficial, as the result of his research enumerates that the rate of mortality is higher in patients brought to hospital by paramedics when compared to those brought in by bystanders, relatives or the police (Demetriades et al, 1996). Conclusive Comparison Between On - Site Pre - Hospital Fluid Replacement and Delayed Pre - Hospital Fluid Replacement Although several papers have been published and many guidelines written, still, UK faces the problem of not having a uniform opinion on the pre - hospital fluid replacement methodology. However, by analysis the various papers previously published and guidelines written by health care related organizations such as NICE, NHS and JRCALC, we can conclusively enumerate the features of both the methodologies. Pre - Hospital Fluid Replacement Delayed Fluid Replacement Legally qualified paramedics administer intravenous fluids on the site before taking the victim to hospital. Victims are immediately taken to hospital without spending any time on fluid replacement. Fluids can be administered either on - spot or in an ambulance en route to the hospital. No fluids are administered on - spot. Patients are carried immediately to the hospital. Traditionally tested method that aims to reverse the effects of excessive blood loss due to injuries. A new proposal that aims to ensure as little time lost as possible in bringing the patient to the hospital. Proponents believe this method to a commendable extent reverses the impacts of hemorrhage and increases chances of survival. Proponents believe this method to be more effective because definitive hospital care is better than advanced life support systems provided by paramedics. Pre - Hospital Fluid Replacement Guidelines In order to achieve a unison regarding the administration of fluids on - site several organizations have regulated guidelines that need to be followed by paramedics while handling injured victims. Organizations like NICE and JRCALC have formulated conditions which must be satisfied in order to go ahead with pre - hospital fluid replacement. The guidelines also mention various other factors such as what type of fluid has to be administered and in how much quantity. National Institute of Clinical Excellence is a major health organization working in the UK. It is an independent organization that aims at promoting good health. As a part of its endeavors, NICE provides several guidelines on various health related fields to ward off health problems. As a part of its latest guidelines on pre - hospital fluid replacement methodology, edited in January 2007, NICE suggests the following guidelines. Firstly, NICE suggests that a person who has been injured should not be given intravenous fluids on the site if a pulse can be felt at his or her wrist. This pulse is referred to as a radial pulse in medical terminology. However, if the bleeding is caused at the stomach or back because of a knife or glass, the paramedic should check the pulse at the neck. This is referred to as the central pulse. After checking for the pulses, fluid should be administered only if the pulse cannot be felt. The person should receive not more than 250 ml of fluid at a time. Secondly NICE suggests that, if the paramedics decide to administer the fluids, they should consider starting replacement en route to hospital rather than on the spot. The idea behind this is that fluid replacement should not cause delays in getting the person to hospital. Similar guidelines as the first two hold even in case of children. NICE stresses on the need to avoid delays and administer fluids in such a way that the time needed to bring the child to the hospital is not procrastinated. Finally, NICE also mentions in its guidelines that only paramedics with skills in advanced life support systems must detect the need to administer fluids; and upon finding it necessary administer the fluids. Another organization, in the UK that has constantly strived to provide efficient ambulance related health care is Joint Royal Colleges Ambulance Service Liaison Committee (JRCALC). JRCALC was set up in 1989 to provide a national forum to support the UK Ambulance Service with a particular focus on its interactions with other professional healthcare groups (JRCALC, 2003). The JRCALC guidelines state that: 'As a rule, intravenous infusions should be commenced en route to hospital, and only sufficient fluid given to maintain a systolic BP of 80-90 mmHg. 500 ml IV of crystalloid solution should be given and the effects on the circulatory system assessed, before further fluids are given. (JRCALC, 2003)' An Analytical Conclusion A major issue facing the administration of pre - hospital fluid replacement is the lack of consensus among people and organizations related. However there are several reasons to believe that pre - hospital fluid replacement had definite advantages. Absolutely delaying the administration of fluids until the patient is brought to the hospital may have some fatal implications especially in cases where the loss of blood is heavy. Qualified paramedics who have a thorough understanding about the guidelines, various fluids and the timing of administration, must administer the necessary fluids if they find it necessary. Based on a survey conducted by a group of researchers at the University of Birmingham, it can be proved that not using certain fluids in a pre - hospital setting would not obviate the need to carry the fluids in ambulances. This is primarily because the costs of the fluids that are generally administered are not exorbitantly high (Dretzke et al, 2003). Although there is some evidence that administering intravenous fluids is harmful, they are not conclusive enough to contradict the consensus agreement formulated by the JRCALC to administer the fluids. There is no conclusive evidence to support that administration of fluids lead to increased chance of death. Even if, intravenous fluids may increase the chance of death in immediate situations, on a long run, it may infact save the life of the patient by avoiding multiple organ failure. The consensus statement as well as guidelines by NICE and JRCALC suggest cautious approaches to fluid replacement and therefore there is a strong sense in adapting these guidelines. The consensus statement that was adopted in 2000, is definitely the largest consensus ever obtained on this methodology. The consensus involved all major related organizations such as the JRCALC, Ambulance Service Association (ASA), BASICS and UK Military and Defense Forces. As a conclusion the consensus suggested the continuation of cautious administration of intravenous fluids in a pre - hospital setting. Finally, there is a strong motive behind the pre - hospital fluid replacement methodology. It aims at reversing the fatal effects of hemorrhage and saving the life of the patient. Until further strong research proves that this methodology is indeed very harmful, paramedics must continue to administer fluids within the guidelines imposed by JRCALC, NICE and similar organizations. The studies that exist currently are based on research that was carried out a long time ago. Thus there is a compelling need to conduct further research under controlled environments to reach to strong conclusive conclusions about pre - hospital fluid replacement methodology. References ThinkRoadSafety.com, http://www.thinkroadsafety.gov.uk/statistics.htm, 2006 Dept. of Health, United Kingdom, http://www.dh.gov.uk/PolicyAndGuidance/HealthAndSocialCareTopics/Accidents/fs/en, 2007 Dretzke J, Sandercock J, Bayliss S, Burls A. The clinical effectiveness and cost-effectiveness of pre-hospital intravenous fluids in trauma patients. Birmingham: West Midlands Health Technology Assessment Collaboration, University of Birmingham, July 2003. National Institute of Clinical Effectiveness, www.nice.org.uk/TA074guidance, 2004 Greaves I, Porter KM, Revell MP. Fluid Resuscitation in Pre-Hospital Trauma Care: a consensus view, Journal of the Royal College of Surgeons Edinburgh 2002 Chudnofsky CR, Dronen SC, Syverud SA, Hedges JR, Zink BJ. Early versus later fluid resuscitation: lack of effect in porcine hemorrhagic shock. Annals of Emergency Medicine 1989 Krausz MM, Landau EH, Klin B, Gross D. Hypertonic saline treatment of uncontrolled hemorrhagic shock at different periods from bleeding. Archives of Surgery 1992 Demetriades D, Chan L, Cornwell E, Belzberg H, Berne TV, Asensio J, et al. Paramedic vs private transportation of trauma patients: Effect on outcome, Archives of Surgery 1996 Joint Royal Colleges Ambulance Service Liaison Committee, http://www.asancep.org.uk/JRCALC/, 2003 Read More