Intravenous Fluid Therapy

Prove it: Trauma patients need two IV lines

Medic 16 responds to a motor-vehicle collision on a county road about thirty miles from the city center. A vehicle ran off the road, rolled twice, and came to rest on its roof. The rollover ejected the driver who sustained head injuries that were incompatible with life.

The restrained and non-ejected front seat passenger is conscious and alert and complaining of pain in the right lower leg. A quick visual exam reveals an obvious midshaft closed lower leg fracture that did not produce a disruption in distal blood flow. The remainder of the patient's physical exam is unremarkable for trauma. The patient's blood pressure is 128/86 mmHg, the heart rate is 96 bpm, the respiratory rate is 16 bpm, the room-air pulse oximetry reading is 96%, and the Glasgow Coma Scale (GCS) score is 13.

After taking spinal stabilization procedures, Medic 16 begins transport to the hospital. Local protocol requires the medics to transport all survivors from a passenger compartment involving a death to a Level 1 trauma center. On the way, the medic places the patient on an electrocardiogram (ECG) monitor and establishes one large-bore intravenous (IV) line with normal saline at a to keep open (TKO) rate. The transport interval is uneventful.

The medics roll the cot into the emergency department passed the waiting trauma team. A nurse asks why there is only one IV and the medic responds that because of the patient's stable condition, the second line (also required by local protocol) was unnecessary. The nurse accepts the explanation but seems perturbed.

After completing the paperwork, the medic asks the nurse to sign the chart accepting care for the patient. As she signs her name, she adds that if patients are bad enough for trauma team activation, they should probably have two large-bore IV lines to guard against the possibility of deterioration before arrival at the hospital.

On the way back to the station, the medic thinks about what the nurse said. Do trauma patients, even critical ones, really need a second IV line?

Review Researchers at the Robert Wood Johnson Medical School in New Jersey evaluated whether a second IV line provided any benefit for trauma patients (Merlin et al., 2011). Specifically, the researchers wanted to know if the second IV line influenced the patient's heart rate, blood pressure, total amount of fluid infused in the prehospital environment, rehospitalization rate, or 30-day mortality.

IV fluids may reduce severity of kidney failure in kids with<em> E ...

“HUS is like a heart attack to the kidneys,” says Christina Ahn Hickey, MD, a third-year pediatrics resident at Washington University School of Medicine in St. Louis and St. Louis Children’s Hospital and the first author on the study. “What we’re trying to do is make sure the kidneys get enough blood flow. By giving intravenous fluids, we try to keep those kidneys working and to keep these children urinating. We think this will have a substantial impact on reducing the severity of kidney failure in these kids.”

E. coli O157:H7 is the most common cause of acute kidney failure in otherwise healthy children in the developed world.

Hickey studied 50 children under 18 years old who were treated for diarrhea-associated HUS at 11 pediatric hospitals in the United States (St. Louis; Seattle; Sacramento, Calif.; Albuquerque, N.M.; Little Rock, Ark.; Milwaukee; Cincinnati and Columbus, Ohio; Indianapolis; and Memphis, Tenn.) and in Glasgow, Scotland. Her St. Louis collaborators were Robert J. Rothbaum, MD, the Centennial Professor of Pediatrics, and Anne M. Beck, MD, associate professor of pediatrics, both at Washington University School of Medicine.

In all, 68 percent of the children stopped urinating. Of the 25 patients who had received no intravenous fluids in the first four days of illness, 84 percent stopped urinating. But in the other 25 patients who were given IV fluids to keep their kidneys working, only 52 percent stopped urinating. Other factors did not seem to play a role, Hickey says.

“If a child is identified early as having an E. coli O157:H7 are vomiting and having frequent bouts of diarrhea, so they cannot stay hydrated.

“To ensure that the kidneys get enough blood flow, we need to have sodium-containing fluid go straight to the blood vessels, and it’s faster and more effective to use an IV,” Hickey says.

Hickey says any child with bloody diarrhea needs to be seen by a health-care provider immediately.

“ E. coli to infect someone else. When a child has diarrhea, there are 10 million to 100 million pathogens in each gram of stool. It is really important to get them away from other children immediately, and hospitalization can serve as effective infection control.”

Phillip I. Tarr, MD, the Melvin E. Carnahan Professor of Pediatrics and director of the Division of Pediatric Gastroenterology, supervised Hickey on the study and is senior author of the paper.