Transcript Document

Resuscitation
Redefined
Kenneth L. Mattox, MD
Houston
Trauma
Resuscitation Redefined
Kenneth L. Mattox, MD
Baylor
College
Medicine
Ben Taub
Hospital
Purpose: to remove the
word
“RESUSCITATION”
from your vocubulary.
Or at least as you have
used it in the past
Trauma
This talk for
resuscitation in
ACUTE surgical
conditons
NOT Sepsis, Obstruction, etc
Trauma
“Why must we always have to relearn
the lessons of the past?”
WWI
1913
WWII Korea VietNam
1938
1963
Dacron
Iraq-Afgh
1988
CT
2013
Endo
•Over
•Under
•Balanced
• Benefit
• Harm
• Adjust
“Why must we always have to relearn
the lessons of the past?”
WWI
1913
WWII Korea VietNam
1938
1963
Dacron
Iraq-Afgh
1988
CT
2013
Endo
Outline - Objectives
•Historic
•1960-1995
•1995-2013
•Current Changes
Traditional
HISTORIC
-misconceptions
-over resuscitation
Legacy definitions faulted
Trauma
Many
approaches &
devices have
come and gone
Trauma
Tabacco
Smoke
Resuscitator
Alexander Graham Bell Resuscitation Device
Alexander Graham Bell & his ventilator
“Over a barrel” - Needs resuscitation
RESUSCITATION
Historic Concept
• “Get the patient in shape so
that surgery will be
tolerated”
• This is an URBAN LEGEND
(Abandon this concept)
Trauma
What is RESUSCITATION ?
Historic Concept
• Assure an airway
• Control Bleeding
• Raise the BP (? Towards
normal or HIGHER)
Trauma
OVER
Fluids
How Much (1963-1995)
•
•
•
•
•
•
2 LARGE BORE IVs
3 liter LR (or NS) in ambulance
3 liter LR (or NS) in ER
“If a little bit is good a lot is better”
Massive transfusion protocols
End Points vague
Trauma
Historic Approach
• 20th Century
Algorithm
– Replace blood with
crystalloid in 3:1
ratio
– No concern for
impact on bleeding
RESUSCITATION ?
Historic How Accomplished ?
• Position
• Dressings & tourniquets
• Medications (vasoactive)
• Fluids, LOTS of fluids
Lots of Complications
Trauma
Fast
FORWARD to
the PAST
Trauma
Examine the
PATIENT
Trauma
Recognize the
patient in need of
EMS or EC, or OR
“Intervention”
…and who does NOT need it
Trauma
Less than 4% of ALL
trauma patients
actually need or
benefit from
“Resuscitation”
(Whatever that is)
REALLY
Trauma
Problems
MEDICAL DISASTER
RESPONSE
NEW
Classification
More than 90% of
ALL
trauma patients need
NO
“Resuscitation”
Trauma
Some foundations
for “resuscitation”
Trauma
William
Shakespeare
Trauma
…..or not so new
“ ..to stop his wounds, lest
he do bleed to death.”
Shakespeare, The Merchant of Venice,
Act IV, Scene I
1597
Stop the Bleeding – Go to OR
Stop the Bleeding
Walter Cannon
Trauma
Cannon – World War I
"The injection of a fluid that
will increase blood
pressure has dangers in
itself. Hemorrhage may
not have occurred to a
marked degree because
the blood pressure has
been too low to overcome
the obstacle offered by a
clot.“
Less Resuscitation is Best
WWI lessons
• Cannon – JAMA
• “It is wasteful of time,
resources and people to give
fluid prior to operative
control of hemorrhage.”
WW II
Office of the
Surgeon
General
Trauma
Office of the Surgeon General,
U. S. Army
WWII lessons
• 2 reports
• “BP should not be elevated and
fluid not given till operative
control of bleeding”
• Do not pop the clot and loose
precious blood
1954-1960
CPR
External
Cardiac Compression
(Elan, Safar, Kouwenhoven)
Trauma
Fluid 3:1 Rule
• DALLAS
• Original studies
–Shires, 1963
• Described three isotope model
• Showed extracellular repletion with
crystalloid essential for survival
So? Does it work for trauma?
Not
Really
Trauma
The Three to One Rule
• Original studies
– Shires, 1963
• Described three
isotope model
• Showed
extracellular
repletion with
crystalloid essential
for survival
Fluid 3:1 Rule
• Developed in “controlled
hemorrhage” model
• NEVER tested in people
• Pre-dated EMS and Trauma
Systems
• Became “doctrine” without any
class I, II, or III data
RESUSCITATION ?
Historic Assessment
A - ALL IVs FULL Flow
B – BP higher than normal
C – Chart Looks good
NOW Call Surgeon
Trauma
HISTORIC
AMAZING
-Patient’s surgery
DELAYED until
“resuscitated” in EMS,
EC, or ICU
This is a NO NO
Trauma
• Vietnam experience
• Approach to
hypotension was 2
large caliber IVs
• Give crystalloid as
rapidly as possible.
And NEW Problems happened
Resuscitation Courses
ATLS
ACLS
PALS
(12 others)
Almost identical cirriculum
Teach ABCs
Encourage FLUID bolus
Lots of Urban Legends
Trauma
“Fill the tank”
“Fluid Challenge”
Commonly quoted phrases
Trauma
Three Peaks in Mortality
Lethal
Early
“resuscitation”
Pop the Clot
MOF
Early fluid type DOES effect Death & MOF
Residual, quiet
continuing
questions
(Did not join bandwagon)
Trauma
 1960s “aggressive fluid
administration in uncontrolled
hemorrhage resulted in increased
mortality”
 Shaftan GW, Chiu CJ, Dennis C, Harris B. Fundamentals of

physiologic control of arterial hemorrhage. Surgery 1965;
58: 851-856.
Milles G, Koucky CJ, Zacheis HG. Experimental uncontrolled
arterial hemorrhage. Surgery 1966; 60: 434-442.
Permissive Hypotension
• 1980s and 1990srodent & swine models
of hemorrhagic shock
• Aggressive fluid
resuscitation in
uncontrolled
hemorrhage resulted
in increased mortality
& morbidity
1994
BIG BOMB
Trauma
Mattox
Trauma
Keeping the BP
low saves lives
– Do NOT POP
the CLOT
Permissive Hypotension
• 1994 – 1st clinical
evaluation of
fluid restriction in
uncontrolled
hemorrhage
Mattox: Immediate versus delayed fluid
resuscitation for hypotensive patients with
penetrating torso injuries. N Eng J Med.
1994;331:1105-9
Permissive Hypotension
(Bickel et al)
 598 patients with penetrating
torso injury & systolic BP ≤
90 mmHg in prehospital
setting
 Patients randomized to
receive high-volume fluids,
or fluids delayed until patient
in OR
Permissive Hypotension
• Results:
– Group Divisions
• Delayed: n=289
• Standard fluids: n=309
– Survival:
• Delayed: 70%
• Standard fluids: 62%
– Complications:
• Delayed: 23%
• Standard fluids: 30%
Statistical
Significance
Other studies
supportive
In-Theater Combat Mortality*
Mortality after Entering
Echelon Hospital Chain
No demonstrable
decrease in combat
zone mortality
Crimean War
WWII
1970
1955
1940
1925
1910
Russian-Japanese
War
WWI
American Civil War
*Slide from Dr. Jane Alexander, DARPA
1895
1880
1865
Combat Zone Mortality Prior to First MTF
1850
45
40
35
Combat
30
Casualty
25
Mortality
(Cumulative 20
15
% of All
Wounded) 10
5
0
Vietnam War
Korean War
In-Theater Combat Mortality*
Killed in Action (KIA) in Iraq
12.2%
(Averaged 20% for all wars since
Crimean War)
WHAT WAS DIFFERENT IN IRAQ?
*Source – USUHS Symposium March 26, 2004
UNDER
Redefine
RESUSCITATION
Trauma
Abandon use of
Sphygmomanometer
Trauma
Mental Status
Presence of a pulse
Trauma
“NOVEL” NEW
HEMORRHAGE
CONTROL
Trauma
EVOLVING
Minimal (to NO)
“resuscitation” in
the field, ambulance,
or Emergency Room
Keep the BP low
Trauma
Hypotensive Resuscitation
What BP PEAK is
BEST?
Trauma
What BP Target is BEST?
<80/Higher POPS the CLOT
Trauma
New ARMY
field
Tourniquet
Trauma
Intravenous
Hemostatic
Drugs ?
Did not work out
Trauma
? Topical
Hemostatic
Agents ?
Trauma
“new” topical
hemostatic agents
still not proven
Trauma
NOVEL NEW
UNDERSTANDING
of EMS & ER
Trauma
For the patient needing
“resuscitation,” the purpose
of the ER is to WAVE to the
patient going from
Ambulance dock to the OR
or ICU
Trauma
NOVEL NEW
CONCEPT
RAPID OPERATION
Trauma
EARLY (immediate)
aggressive operative
(or critical care)
intervention
Trauma
NOVEL NEW
FLUID POLICY
Trauma
Fluid ISSUES
Trauma
Fluid Conference Proceedings 2003
Restricted Fluid Resuscitation
Restricted Fluid Resuscitation
Restricted Fluid Resuscitation
Restricted Fluid Resuscitation
Fluids
WHAT KIND?
•
•
•
•
•
•
•
Ringer’s Lactate
Normal Saline
Dextrans, Starches, Gelatin, Albumin
Hypertonic solutions
Designer fluids
Blood & blood products
Hemoglobin substitutes
Trauma
Crystaloids
•
•
•
•
Advantage
Disadvantage
Readily available
• Does not stay
Inexpensive
in vasculature
Repleats
• Need LARGER
intravascular &
interstitial volume
volumes
Encourages
• Edema
Urinary flow
• Inflammation
Trauma
Non-Protein Colloids
Advantage
• Readily available
• Equal to protein
colloids (?)
•
•
•
•
•
•
•
Disadvantage
Expensive
Coagulopathy
Long half life
RES activation
Short dwell time
Anaphalaxis
Cross Match
problems
Trauma
Protein Colloids
 Albumins
5% human serum albumin
25% human serum albumin
 Gelatins – Not available in US
Plasmagel
Haemacell
Gellifundol
}
•
•
•
•
Fluids
How Much (2012)
Check for pulse & CNS
If absent- give fluid bolus (25
ml) until pulse (or CNS) returns
Use Blood & Plasma (1:1)
Have defined end points
-? NIR, Base Deficit, Lactate, (NOT BP)
• Markedly limit (or NO) LR & NS
Trauma
Permissive Hypotension
Systolic BP <80 mm Hg
 “Pop the Clot” @ 80/-
 Low MAP is tolerated compensatory flow and
metabolism
 Fluid infusion rate not to
exceed 45 ml/min (no benefit
to faster rates - even if
systolic BP is ~ 40 mm Hg)
Permissive Hypotension
• Elevation of BP to pre-injury levels (absent
definitive hemostasis) is
associated with:
– Progressive and repeated
re-bleeding
– Hypoxemia from excessive
hemodilution
BALANCED
Major NEW Lesson
• Replace blood loss with
(FRESH) blood
• Match blood with FFP (1:1)
• For each unit of blood – give
1 unit of platlets (1:1:1)
• RESTRICT crystalloid
Trauma
Summary
• Novel “New” Concepts WORK
• Abandon the word Resuscitate
• Keep treatment
–Functional
–Simple
–Effective
• Stop hemorrhage
Hurdsfield, ND
January 15, 1992
Both arms severed in farm
accident
Trauma
“He did not bleed
to death…because
he was in shock.”
--Sister of boy with two
severed arms
Machiavellia
“The Prince”
“There is nothing more difficult
to take in hand, nor perilous
to conduct, nor more
uncertain in its success than
to take the lead in
introduction in a new order of
things….
Machiavellia
“The Prince”
…for the innovator has for
enemies, all those who
have done well under the
old and lukewarm
defenders those who
might do well under the
new.”
Redefine
Resuscitation
Concepts
Kenneth L. Mattox, MD
Houston
Trauma