Fluid Therapy in the Hypotensive Trauma Patient

Hello! With regards to hypotension in a trauma patient secondary to blood loss. I recently reviewed in a text book that giving a hypotensive trauma patient a 0.9% normal saline fluid bolus can be detrimental to the patient due to its acidic properties as the patient is already going to be in metabolic acidosis due to the anaemia. With that being said and during a longer transport time where ORNGE is not available, can this be considered the benefit of fluid bolus would out weigh the negative impact on the patient as we should be trying to maintain perfusion to the vital organs until we arrive at the closest ED? Should a patch to a base hospital be considered?

Thank you for reaching out with your inquiry regarding fluid volumes in trauma management. You are correct in identifying the significant risks associated with aggressive crystalloid administration. High volumes of normal saline can indeed exacerbate the "Lethal Triad" by inducing hyperchloremic metabolic acidosis, causing dilutional coagulopathy, and increasing mean arterial pressure to a point that may disrupt existing micro-clots. In the prehospital setting, the goal of fluid administration in the trauma patient is to serve as a hemodynamic bridge to definitive care. Current directives prioritize maintaining critical organ perfusion just enough to facilitate safe transport to a Hospital or Trauma Center. Because crystalloids cannot carry oxygen or replace clotting factors, the objective is to minimize further physiological insult while ensuring the patient survives the transit to the operating room, where surgical intervention can achieve definitive hemostasis. If you encounter a clinical scenario where you believe following the medical directive would be detrimental to the patient, We encourage you to consult with a Base Hospital Physician (BHP) via OMC. This allows for real-time clinical advocacy and support through physician-orders based on the specific presentation.