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<< Therapeutic Uses Of Hypertonic Saline In The Critically Ill Emergency Department Patient (Trauma CME)

Critical Appraisal Of The Literature

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Critical Appraisal Of The Literature

Critical Appraisal Of The Literature

A literature search was performed using Ovid MEDLINE®, PubMed, and EMBASE from 1990 to the present. The area of focus was the use of HTS in the treatment of TBI, hypovolemic shock, and severe hyponatremia. Search terms included hypertonic saline, traumatic brain injury, intracranial hypertension, shock, hypovolemic shock, hemorrhagic shock, and hyponatremia. Over 300 articles were retrieved and provided background for further literature review. The Cochrane Database of Systematic Reviews, Eastern Association for the Surgery of Trauma (EAST) Guidelines, Western Trauma Association (WEST) Guidelines, American College of Emergency Physicians Clinical Policies, National Neurotrauma Society, National Brain Trauma Foundation, Neurosurgical Society of America, Annals of Emergency Medicine’s Evidence-Based Emergency Medicine reviews, and National Guideline Clearinghouse (www.guideline.gov) were also searched. All HTS solutions were incorporated, with solutions ranging from 1.6% to 30%, including those mixed with colloids.

The literature on the use of HTS for resuscitation of trauma patients is difficult to interpret due to several confounding variables. For instance, studies have used varied concentrations of HTS (from 2% to 7.5%), have used varied methods of HTS administration (bolus as well as maintenance drips), and have included nontrauma patients in their study groups. In addition, the results from some clinical trials comparing HTS to mannitol can be deceiving, as they do not use equiosmolar doses of HTS. This difference may make HTS appear more effective than mannitol, where the primary effect could arguably be attributed to the higher osmotic load. Lastly, most studies only demonstrate significance in surrogate physiologic markers rather than meaningful clinical outcomes. For these reasons, current treatment guidelines for the use of HTS in trauma resuscitation are based largely upon expert opinion.

The literature on the use of HTS to treat patients with severe hyponatremia is weak and mostly comprised of retrospective studies. Few prospective studies have been done, and treatment guidelines are based mostly upon expert consensus.

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