8th ed of ATLS -? Lactated Ringer?

[Timothy Craig Hardcastle]

Guys

It is all about risk versus benefit. The saline versus ringers debate was settled years ago.

Saline causes hyperchloraemic metabolic alkalosis, with long term acid-base issues. In patients with trauma most of whom do not have hyperkalaemia there is also the issue of hypokalaemia which is of importance in the context of muscle function and other metabolic processes. Longer term hypernatraemia is also not really helpful.

RL on the other hand may cause a transient worsening of the acidosis as it is pH 6,4 in the bag. If there is hepatic failure the lactate clearance may be lessened also.

Both of the fluids cause a prolonged and more severe inflammatory response than hypertonic saline, but neither has a distinct effect on coagulopathy other than dilutional as I understand the current literature.

So, if you are going to use a crystalloid, in hospital (hypertonic saline is a PRE hospital fluid in my book, given its dose limitation of 4ml/kg), my choice would still be RL over saline, given that it is more physiological compared to serum electrolyte values than Normal saline.

Volume limitation will most likely decrease the inflammatory effects anyhow, so use as little as required in the patient with ongoing bleeding.

Remember too that most of the discussion on this list over the years has related to the UNSTABLE hypotensive patient, which is only around 10% of all trauma patients anyhow - the rest can safely get RL or saline. It has been in this unstable group that permissive hypotension and HT have been recommended; also only for pre-haemorrhage control. After that most people still recommend current standard of care as being only what the patient needs and then of a physiological type fluid, with early enteral intake and IV fluid reduction.

Regards
Tim
Dr Timothy C Hardcastle
M.B., Ch.B. (Stell); M. Med (Chir) (Stell); FCS (SA)
Principal Surgeon-Lecturer / Sub-specialist: Trauma and Critical Care
Deputy director: Trauma Unit and Trauma ICU
Inkosi Albert Luthuli Central Hospital / UKZN
800 Bellair Road
Mayville, Durban
 
Postal: PostNet Suite 27
Private Bag X05
Malvern, 4055
KwaZulu Natal
 
timothyhar at ialch.co.za 
 

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Nicholas Macartney
Sent: 17 June 2008 13:34
To: Trauma & Critical Care mailing list
Subject: Re: 8th ed of ATLS -? Lactated Ringer?

On the other hand, can someone give me a valid reason why I would ever  
want to use 0.9% Saline. I last used it several years ago ( apart from  
flushing arterial lines). Lactated Ringer's ( Hartmann's ) is my fluid  
of choice.
Nick Macartney
On 17 Jun 2008, at 11:06, Lorick Fox, MPAS, PA-C wrote:

>
> I thought there was good evidence that using LR for volume was
> contraindicated in shock and that IF any crystalloid was to be used,  
> it
> should be isotonic or hypertonic saline.  I see ATLS still includes  
> LR as an
> acceptable isotonic crystalloid.  As I just got through recommending  
> that we
> remove LR from our supplies, I would appreciate being educated.
>
> Lorick
>
>
> Lorick Fox, MPAS, PA-C
> Gianaclis Support Complex
> 03-448-2335
> Fax 03-448-2339
> Mobile 018-230-4448
>
>> -----Original Message-----
>> From: trauma-list-bounces at trauma.org [mailto:trauma-list-
>> bounces at trauma.org] On Behalf Of Frank Østergaard Hansen
>> Sent: Tuesday, June 17, 2008 12:45 PM
>> To: trauma-list at trauma.org
>> Subject: 8th ed of ATLS
>>
>>
>>
>>
>>
>> Fra: Frank Østergaard Hansen [mailto:drfrank.hansen at gmail.com]
>> Sendt: 17. juni 2008 11:39
>> Til: 'trauma-list at trauma.org'
>> Emne: 8th ed of ATLS
>>
>>
>>
>> See this paper, on new ATLS, it looks like a good step towards many  
>> of the
>> point the list had
>>
>>
>>
>>> From my points, as army doctor is good to see, tourniquet and  
>>> permissive
>> hypotension there, too bad they don't take as far as PHTLS do, in  
>> their
>> 2006
>> update, it looks to be a small talk.
>>
>>
>>
>> Frank Hansen
>>
>>
>
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