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Prehospital Hypertonic Saline Resuscitation of Patients With Hypotension and Severe Traumatic Brain Injury
A Randomized Controlled Trial
D. James Cooper, BMBS, MD;
Paul S. Myles, MBBS, MD;
Francis T. McDermott, MBBS, MD;
Lynette J. Murray, BAppSci;
John Laidlaw, MBBS;
Gregory Cooper;
Ann B. Tremayne;
Stephen S. Bernard, MBBS;
Jennie Ponsford, MA, PhD; for the HTS Study Investigators
JAMA. 2004;291:1350-1357.
Context Prehospital hypertonic saline (HTS) resuscitation of patients with traumatic brain injury (TBI) may increase survival but whether HTS improves neurological outcomes is unknown.
Objective To determine whether prehospital resuscitation with intravenous HTS improves long-term neurological outcome in patients with severe TBI compared with resuscitation with conventional fluids.
Design, Setting, and Patients Double-blind, randomized controlled trial of 229 patients with TBI who were comatose (Glasgow Coma Scale score, <9) and hypotensive (systolic blood pressure, <100 mm Hg). The patients were enrolled between December 14, 1998, and April 9, 2002, in Melbourne, Australia.
Interventions Patients were randomly assigned to receive a rapid intravenous infusion of either 250 mL of 7.5% saline (n = 114) or 250 mL of Ringer's lactate solution (n = 115; controls) in addition to conventional intravenous fluid and resuscitation protocols administered by paramedics. Treatment allocation was concealed.
Main Outcome Measure Neurological function at 6 months, measured by the extended Glasgow Outcome Score (GOSE).
Results Primary outcomes were obtained in 226 (99%) of 229 patients enrolled. Baseline characteristics of the groups were equivalent. At hospital admission, the mean serum sodium level was 149 mEq/L for HTS patients vs 141 mEq/L for controls (P<.001). The proportion of patients surviving to hospital discharge was similar in both groups (n = 63 [55%] for HTS group and n = 57 [50%] for controls; P = .32); at 6 months, survival rates were n = 62 (55%) in the HTS group and n = 53 (47%) in the control group (P = .23). At 6 months, the median (interquartile range) GOSE was 5 (3-6) in the HTS group vs 5 (5-6) in the control group (P = .45). There was no significant difference between the groups in favorable outcomes (moderate disability and good outcome survivors [GOSE of 5-8]) (risk ratio, 0.99; 95% confidence interval, 0.76-1.30; P = .96) or in any other measure of postinjury neurological function.
Conclusion In this study, patients with hypotension and severe TBI who received prehospital resuscitation with HTS had almost identical neurological function 6 months after injury as patients who received conventional fluid.
Author Affiliations: Departments of Intensive Care (Dr Cooper and Ms Murray) and Anaesthesia (Dr Myles), Alfred Hospital, Monash University; Neurosurgery Department, Royal Melbourne Hospital (Dr Laidlaw); Consultative Committee on Road Traffic Fatalities Victoria (Dr McDermott and Ms Tremayne); Metropolitan Ambulance Service (Mr Cooper and Dr Bernard); and Department of Psychology, Monash University (Dr Ponsford), Melbourne, Victoria, Australia.
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