Coma: hypertonic saline is no better than lactated Ringer's solution.

Clinical bottom line (level 1b-)

  1. Patients with a head injury who are given hypertonic saline, have no clear difference in Glasgow Outcome Score than those given lactated Ringer's solution.
Shackford et al: Journal of Trauma 1998; 44 (1): 50-57
Expires September 2003

The study

Double-blinded ?concealed randomised trial without intention-to-treat
Setting: 2 teaching hospitals, USA

41 patients (aged mean 32 years, 79% male) head injury

Excluded if
  • consent not given
  • <18 years old
  • not blunt mechanism of injury
  • injury not within 12 hours of admission
  • admission Glasgow Coma Score >13
  • negative computerised tomography score


    • Note:
  • 7 patients who died within 48 hours were not included in the analysis
  • The admission Glasgow Coma Score was lower in the hypertonic saline group (mean 4.7 versus mean 6.7).
  • Patients consisted of those with head injuries alone and those with multiple injuries.


    • Control Group: (n = 16, 16 analysed): Lactated Ringer's solution for haemodynamic instability during initial resuscitation, operative therapy or first 5 days of ICU care. Maintenance fluid was ½ NS given at a rate of 15 mL per kg per day.
    Experimental Group: (n = 18, 18 analysed): 1.6% hypertonic saline for haemodynamic instability during initial resuscitation, operative treatment or during first 5 days of ICU care. Maintenance fluid was NS given at a rate of 15 mL per kg per day.
    Fluid was given to return systolic blood pressure to >90 mmHg and to restore urine output to >0.5 mL per kg. Patients with a Glasgow Coma Score = 8 were intubated and sedated (providing haemodynamic stability). At the neurosurgeon's discretion and depending on initial examinations, a ventriculostomy or an ICP monitor was placed in the ER or ICU. Intracranial hypertension (intracranial pressure = 20 mmHg) was treated by hyperventilation, mannitol infusion, head elevation and ventricular drainage.
    83% followed for 120 hours

    The evidence

    Outcome Control Group
    (SD)    		 Experimental Group
    (SD)    		 Mean Difference
    (95% CI)
    Glasgow Outcome Score 2.50
    (0.20)     		2.70
    (0.20)     		0.20
    (0.06 to 0.34)

    Comments

    1. At the start of the study, seven patients died during the first 48 hours of treatment and were eliminated from the analysis.

    Citation

    1. Shackford SR, Bourguignon PR, Wald SL, et al: Hypertonic saline resuscitation of patients with head injury: a prospective, randomized clinical trial. The Journal of Trauma 1998; 44 (1): 50-57
    Contributor: Clare Wotton and Bob Phillips, September 1999
    Reviewer:

    Clinical Question.
    Patient head injury
    Intervention or Exposure hypertonic saline
    Comparison lactated Ringer's solution
    Outcome Glasgow Outcome Score