Hypertonic saline (HTS), which is defined as any crystalloid solution containing more than 0.9% saline, has a potentially important role in the treatment of several life-threatening conditions seen in the emergency department (ED). With respect to the trauma patient, HTS has unique properties that may make it an ideal resuscitative fluid for the most common causes of traumatic death: central nervous system injury, exsanguination, and organ failure.1 (See Table 1.) It has been shown to reduce intracranial pressure (ICP) in patients with traumatic brain injury (TBI) and may have an immunomodulatory effect that further reduces neuronal damage and multiple-organ failure.2-7 HTS may also improve hemodynamics and microcirculation, resulting in improved resuscitation in hemorrhagic shock.8-10 Compared to traditional crystalloid solutions (normal saline or lactated Ringer’s solution), a smaller volume of HTS is required to improve hemodynamic stability in hypotensive patients.11 This has many practical advantages for the military and for other austere environments that preclude carrying a large volume of fluid for the purpose of resuscitation.12
HTS also has an important role in the treatment of severe hyponatremia. While hyponatremia in the ED is typically chronic and requires no immediate intervention, acute severe hyponatremia can cause significant morbidity and mortality. Appropriate recognition and treatment with HTS can help prevent devastating sequelae from both the hyponatremia itself and its overaggressive treatment.
This issue of EMCC examines the evidence supporting the use of HTS for the treatment of patients with TBI with elevated ICP, trauma patients in hemorrhagic shock, and patients with severe hyponatremia.
Jeffrey A. Holmes, MD
February 4, 2013