• Eileen M Bulger, Gregory J Jurkovich, Avery B Nathens, Michael K Copass, Sandy Hanson, Claudette Cooper, Ping-Yu Liu, Margaret Neff, Asaad B Awan, Keir Warner, and Ronald V Maier.
• Department of Surgery, Campus Box 359796, Harborview Medical Center, 325 Ninth Ave, Seattle, WA 98104, USA. ebulger@u.washington.edu
• Arch Surg. 2008 Feb 1;143(2):139-48; discussion 149.

BackgroundThe leading cause of late mortality after trauma is multiple organ failure syndrome, due to a dysfunctional inflammatory response early after injury. Preclinical studies demonstrate that hypertonicity alters the activation of inflammatory cells, leading to reduction in organ injury. The purpose of this study was to evaluate the effect of hypertonicity on organ injury after blunt trauma.DesignDouble-blind, randomized controlled trial from October 1, 2003, to August 31, 2005.SettingPrehospital enrollment at a single level I trauma center.PatientsPatients older than 17 years with blunt trauma and prehospital hypotension (systolic blood pressure, InterventionsTreatment with 250 mL of 7.5% hypertonic saline and 6% dextran 70 (HSD) vs lactated Ringer solution (LRS).Main Outcome MeasuresThe primary end point was survival without acute respiratory distress syndrome (ARDS) at 28 days. Cox proportional hazards regression was used to adjust for confounding factors. A preplanned subset analysis was performed for patients requiring 10 U or more of packed red blood cells in the first 24 hours.ResultsA total of 209 patients were enrolled (110 in the HSD group and 99 in the LRS group). The study was stopped for futility after the second interim analysis. Intent-to-treat analysis demonstrated no significant difference in ARDS-free survival (hazard ratio, 1.01; 95% confidence interval, 0.63-1.60). There was improved ARDS-free survival in the subset (19% of the population) requiring 10 U or more of packed red blood cells (hazard ratio, 2.18; 95% confidence interval, 1.09-4.36).ConclusionsAlthough no significant difference in ARDS-free survival was demonstrated overall, there was benefit in the subgroup of patients requiring 10 U or more of packed red blood cells in the first 24 hours. Massive transfusion may be a better predictor of ARDS than prehospital hypotension. The use of HSD may offer maximum benefit in patients at highest risk of ARDS.

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