Early crystalloid resuscitation in Trauma: How much is too much? Insights from a National Trauma Registry

Crystalloid administration during early resuscitation of bleeding trauma patients is recommended by current guidelines, yet evidence supporting this practice is limited. We aimed to evaluate the trends in the utilization of crystalloids during the last decade and to determine the threshold crystalloid volume independently associated with mortality risk in trauma patients at risk of or experiencing shock.

A retrospective cohort study using data from the Israel National Trauma Registry (January 2013 to December 2022) was conducted. We included patients ≥16-years-old transported by emergency medical services from the injury scene and subsequently hospitalized. Inclusion criteria included systolic blood pressure < 90 mmHg and/or shock index >1 in the field or emergency department (ED). Patients transferred between facilities, those who received prehospital blood products, or those who suffered burns were excluded. The primary outcome was all-cause in-hospital mortality. Multivariable logistic regression was performed to investigate the association between the total volume of crystalloid administered during prehospital and ED treatment and the primary outcome, adjusting for clinical variables.

Among 10,707 eligible patients, the median age was 39.0 years (IQR 25.0-65.0), 63.5 % were male, and 81.4 % suffered from blunt trauma, mainly caused by motor vehicle collisions. There was a trend toward reduced crystalloid use over the study period both prehospital and in the ED. Crystalloid volumes ≥2 liters were independently associated with increased mortality with an aOR of 1.47 (95 % CI 1.09-1.96, p = 0.01) for 2000-2499 ml and an aOR of 1.49 (95 % CI 1.08-2.04, p = 0.01) for ≥2500 ml. Older age, male gender, lower blood pressure, and severe injury (ISS >15) were also independently associated with higher mortality.

The administration of ≥2 liters of crystalloids during the initial phase of care was independently associated with increased mortality in hemodynamically compromised trauma patients. These findings support the judicious and goal-directed use of crystalloids in the resuscitation of trauma patients.