Which crystalloid solution is most appropriate for the resuscitation of a patient with traumatic brain injury (TBI) and hypotension, given both haemodynamic and neurological considerations?

• A Hypotonic saline (0.45% NaCl)
• B 5% dextrose in water
• C Normal saline (0.9% NaCl) or hypertonic saline (3% NaCl) ✓
• D Ringer's lactate as the preferred crystalloid due to its balanced composition

Explanation

In TBI, cerebral oedema is worsened by hypotonic fluids that shift water into brain tissue. Normal saline (osmolality ~308 mOsm/kg) is iso-osmotic and preferred over Ringer's lactate (osmolality ~273 mOsm/kg, slightly hypotonic) for TBI resuscitation. Hypertonic saline (3% NaCl) is the agent of choice when ICP elevation is suspected — it reduces cerebral oedema via osmotic mechanism and simultaneously restores intravascular volume. Hypotonic saline and 5% dextrose are absolutely contraindicated as they lower serum osmolality and dramatically worsen cerebral oedema.

Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.

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Written and medically reviewed by the StethoPrep medical team.