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Prehospital and ED Fluid Resuscitation in Trauma …to give or not to give… Corinne M. Hohl, MD, CCFP R5, Royal College Emergency Medicine Training Program April 2, 2003 Objectives • What are you going to learn? Cases: How would you manage these now? • Current guidelines and controversies. • EBEM review: – Assessment of vital signs as indicators of hypovolemia – Clinical evaluation of fluid loss. – Evidence for and against prehospital fluids. – Evidence for none vs. hypotensive vs normotensive resuscitation. – Penetrating trauma, head trauma. – Hypertonic saline, colloid resuscitation. • What have you learned? Cases: what would you do now? Case 1: Pedestrian versus car Case 1: Pedestrian versus Car • 60 yo, hit and run. • Brought in by EMS, you’re in the resus bay…he’s thrashing around… • GCS 14, HR 120, SBP 80, RR 24, T n. • O/E flail chest right, left chest sounds OK, abdomen nontender (…but GCS is 14), unstable pelvis. Case 1: Pedestrian versus Car • Chest tube R: 300 cc blood + air • Intubated with 20mg Etomidate and paralysis • Vitals after this: HR 120, SBP 95 • FAST negative • Pelvis bound • CXR: R CT good position, L lung OK. • The nurse asks you what fluids you want and at what rate? Do you want bld? How much? • Where will you go with this pt next? Case #2: Penetrating Torso Trauma Case #2: Penetrating Torso Trauma • 22 year old, GSW left torso, no exit. • EMS calls you: SBP of 80 en route, they cannot get an IV. What do you tell them? (They are 10min out.) • On arrival what is the first thing you are going to do, and how fast? • His BP recovers to 100 and hovers around there after this intervention – what are your fluid orders? What and how much? Case 3: Head Injury Case 3: Head Injury • 18 year old, MVA: driver - head vs. dashboard. • GCS 10 (withdraws to pain, inappropriate verbal, eye opening to command), HR 120, BP 100/70, normal temp, no toxidrome, Glu – the surgeons refuse to check!!! • Exam: pupils equal: withdraws to pain. • What fluid orders would you give? Case #4: Fall 36 ft Case #4: Fall • 11 year old boy, skied off the ski run and fell down into ravine 36ft below. • You are the doc in the ambulance – GCS 15, HR 125-130, radial pulse absent, good carotid pulse. Abdominal pain. Pt states he’s cold. • Two IV attempts unsuccessful. What do you do? Scoop and run or stay and play (i.e. try for IVs)? (25 min out) Who coined the term the “Golden Hour”, and why? Lockey, Resuscitation 2001 The concept of “the golden hour” was a marketing strategy by Dr. Cowley in 1963 in a letter to the Governor of Maryland, the purpose of which was to get ensure that police helicopters would over-fly local hospitals and bring severely injured pts to his Baltimore Shock Trauma Centre. …with no scientific evidence to support this statement at the time! Blunt trauma: Bimodal Distribution Meislin, J Trauma, 1997; 1999. • Retrospective review: 710 blunt & penetrating trauma deaths „91-93 in Arizona: 52% DOA (on EMS arrival) nonsalvagable 48% transported & died in hosp. (ISS 25) Did not describe whether these injuries Bimodal deaths: would have been survivable… Peak at 0-60min and 24-48hrs. Early deaths: 48% CNS, 31% circulatory. Are early deaths preventable? Wyatt Prospective n=331 • 75% dead instantaneously or had 1993 assessment of 93% unsurvivable injuries. (Scotland) trauma blunt • 25% died on transport or in the first dealths. 4hrs in hospital. • Did not analyze preventability. Papadopoulos Prospective n=82 • 47% potentially curable injuries. 1991 assessment of 90% • 70% of preventable deaths were CNS (Greece) all prehospital blunt related. Of all non-CNS injured DOAs: deaths, DO hemorrhage & A/B were the most (ED)A. common causes deaths. Maio Prospective n=155 • 58% DO(EMS)A nonsalvagable 1996 study of all 85% • 42% were transported and died in ED/ in (Michigan) trauma deaths blunt hosp 28% of these preventable in 1 year in a rural area in (i.e. 12% of all trauma deaths) Michigan. • Hemorrhage (55%) & CNS injury (25%) (by ISS score) most frequent causes of preventable deaths. Are early deaths preventable? Hussain Retrospective n=409 • 39% of all trauma deaths 1994 review of all 89% happened in the field/on transport. (Scotland) prehospital blunt trauma deaths 11% pen. 40% of these prehospital deaths preventable (i.e. 16% of all trauma deaths preventable by optimal prehospital care!) 70% of preventable prehospital deaths occurred from airway obstruction. Ottoson Retrospective n=158 • 2% “potentially salvagable”. 1984 review of all All blunt (Sweden) MVA fatalities (prehospital and in hospital). Paradox • ALS procedures = BLS + intubation, IV fluids and medications (+ application of PASG/MAST suits). • ALS procedures are expected to reduce mortality by restoring physiologic hemodynamic parameters and delaying hemodynamic compromise in the prehospital phase. • However, they may increase risk of death by significantly delaying time to definitive care, impairing physiologic responses to hemorrhage and inducing coagulopathy and hypothermia. ( Sampalis et al. J Trauma 1997) Rosen’s 5th ed. 2002 p.2622 • “..interventions for traumatic injuries should be performed en route to hospital, and all efforts should be extended to reduce on-scene time.” • “Controversy surrounds the issue of IV fluid administration. High volume IV fluid for hemodynamic instability ... has …been the accepted standard in most prehospital care systems. Some data, however, support a paradigm shift to restrictive or hypotensive resuscitation for penetrating traumatic injuries. Restoration of hemodynamic stability with aggressive fluid resuscitation before definitive surgical hemostasis may lead to increased morbidity.” Tintinalli 5th ed. 2000 p.223 “ The concept of field stabilization of trauma victims has been discredited for those with hemorrhagic shock. The prehospital interventions that improve survival include attention to the airway, ventilation, immobilization, and rapid transport; not fluid resuscitation. Standard prehospital interventions directed at restoring blood pressure, such as application of PASG and infusion of intravenous fluids, have not been shown to improve survival.” ATLS, 6th ed. 1997 Prehospital Phase: • “Every effort should be made to minimize scene time.” • No comment on fluids. ED Phase: • “Fluid resuscitation must be initiated when early signs and symptoms of blood loss are apparent or suspected, not when the blood pressure is falling or absent.” • 2 lg bore IVs, initial bolus of 1-2L, 20cc/kg for a child. • Ongoing replacement of 3:1 with Ringer’s. Fluid Resuscitation in Pre-Hospital Trauma Care: a Consensus View. (Greaves et al. J Royal College of Surgeons of Edinborough. 2002) Consensus guidelines: methods not explicit. • When treating trauma victims in the prehospital arena cannulation should take place en route. • Only 2 attempts at cannulation ... • Transfer should not be delayed by attempts to obtain IVs. • Entrapped patients require cannulation at the scene. • NS may be titrated in boluses of 250cc against presence or absence of a radial pulse (caveats: penetrating torso injury, head injury, infants.) What does the absence or presence of a radial pulse mean? Accuracy of the ACLS guidelines for predicting systolic blood pressure using carotid, femoral and radial pulses: observational study. (Deakin & Low, BMJ 2000) Intro: • ACLS: presence of carotid pulse SBP 60-70mm Hg presence of carotid & fem pulse SBP 70-80mm Hg presence of radial pulses SBP > 80mm Hg Methods: • Studied sequential pts with hypovolemic shock who had invasive BP monitoring. • Observer blinded to BP reading established the absence or presence of pulses. Conclusions: • ACLS guidelines overestimate the actual BP of pts with hypovolemic shock by palpation of pulses. • Not reported how pts were resuscitated prior to study, also some were under GA influence on pulses? Accuracy of the ACLS guidelines for predicting systolic blood pressure using carotid, femoral and radial pulses: observational study. (Deakin & Low, BMJ 2000) 3 pulses carotid carotid No pulses present & femoral pulse palpable pulses only present Using 250cc boluses… • In normotensive individuals: Initially: NS will expand intravascular volume by 30%. 30min: 16% of NS remains intravascular. • In hypovolemia: Decreased rate of elimination of RL from plasma. • Necessary replacement volume of crystalloid should be 3-4 times the blood volume lost: i.e. 250cc of saline would replace 70cc of blood… Fluid Resuscitation for the trauma pt. (Nolan J. Resuscitation 2001) • Vital signs may not be reflective of degree of shock: – Pure hemorrhage relative bradycardia. – Response to injury tachycardia and elevated BP. • Philosophy of immediate fluid resuscitation to normotension was based on animal models of controlled hemorrhage philosophy of permissive hypotension based on animal studies of uncontrolled hemorrhage as well as some human studies. • Suggests the following resuscitation endpoints: BP >80 U/O >0.5cc/kg/hr HR < 120 GCS 15 O2 sat >96% lactate <1.6 base def > -5 Hb >90 Vagal slowing of the heart during hemorrhage: observations from 20 consecutive hypotensive patients. (Sander-Jensen et al. BMJ, 1986) Methods: • Observation of 20 consecutive adults (btw 19-91 yrs) in hemorrhagic shock. • Mean blood loss 2.3L (+ 0.3L). • Treated with 2.0L blood and albumin, and 3.3L crystalloid. • BP was measured by sphygmanometry, HR by monitor. Results: • Both medical (PUD, aneurysms, extrauterine pregnancies) and traumatic hypovolemia. • Mean BP prior resuscitation: 81/55 • Mean HR prior resuscitation: 73 + 3 bpm • With fluid resuscitation the HR increased to 100 and the BP to 111/72 within 30 minutes of resuscitation Vagal slowing of the heart during hemorrhage: observations from 20 consecutive hypotensive patients. (Sander-Jensen et al. BMJ, 1986) Prior fluid resuscitation Prehospital Time – Stay & Play or Load & go? Pro ALS Author Study type n Blunt/ Contro Rando %ALS Outcomes Results yr Penetr l m measured %BLS group Assign. Hedges Retrospective 163 Blunt No No ALS Change in Trend towards 1982 Descriptive only only TS during improved TS en transport. route. Jacob Prospective 272 Blunt & Yes No 80 ALS Change in Trend in 1984 All severly Penetr. 98 BLS TS during improvement in TS injured trauma transport. w/ ALS. victims. Reines Retrospective 538 Blunt Yes No 435 ALS Change in Increase in BP 1988 Blunt trauma MVA‟s 102 BLS BP during during transport in pts in shock. transport, ALS group. panel opinion. Messick Retrospective 12‟417 ? Yes No ? Death rates Higher death rate in 1990 review of in BLS vs. BLS counties. 12‟417 trauma ALS deaths counties. statewide. No baseline characterist ics. Against ALS/Equivocal Author, yr Study type n Blunt/P Compa Rando %ALS Outcomes Results enetr rison m measured %BLS group Assign. Gervin Retrospective 13 All Yes No 6 BLS Prehosp BLS: 9min to hosp. 1982 review- all pts penetr. 7 ALS time. 5/6 survived w/ penetrating Survival. ALS:25 min to hosp wounds to the heart 0/7 survived. (Baseline similar) Cayten ? 102 ? Yes No 37 ALS Actual vs. No change in TS w/ 1984 65 BLS predicted ALS vs. BLS. survival. Higher mortality than Change in predicted w/ ALS. TS. (ALS: sicker pts) Smith Retrospective 52 65% No No All ALS Delay in Delays of 15min for IVs. 1985 review of all penetr. transport. 5 deaths possibly hypotensive 35% Survival. amenable to surgery if trauma victims blunt less delay. Ivatury Retrospective 100 All Yes No 51 ALS Prehosp ALS: TS and PI 1987 review of all penetr. 49 BLS time. deteriorated en route; pts with Survival TS, 22min prehosp time. penetrating PI. Survival 1/51. thoracic BLS: greater number trauma arriving to ED w/ VS; requiring RT. prehosp time 8min. Survival 9/49. Against ALS/Equivocal Author, yr Study type n Blunt/P Compa Rando %ALS Outcomes Results enetr rison m measured %BLS group Assign. Potter Prospective 1061 Not Yes. No 472 ALS Survival. Case fatality rate similar comparison of reported in BLS and ALS; BLS 1988 589 BLS trauma pts died sooner. transported by ALS: higher ISS. ALS (Sydney) vs. BLS (Brisbane) Clevenger Retrospective 72 57% Yes No 62 ALS Mortality. 3/62 ALS survived 1988 reviews of all blunt (prior 10 BLS 2/10 BLS survived resuscitative institutio 43% 3% vs. 20% . thoracotomies. n of penetr scoop Prehosp time and run 50 vs. 22min. policy) (Did criteria to do RT change during study period?) Conclusions (with a grain of salt): Long prehospital times are probably bad. Pro ALS studies measured physiologic indices, no hard outcomes. Mortality outcome studies favor BLS. …puzzling – in the urban setting… The Relationship Between Total Prehospital Time and Outcome in Hypotensive Victims of Penetrating Injuries (Pepe et al. Ann Emerg Med 1987.) Objective: • Survival of pts w/ hemorrhagic shock from pen. trauma vs. prehosp time Methods: • Prospective: hypotensive trauma pts transported to a trauma center. • Outcome: prehospital time vs. survival. • Standard care: Ett prn, IVs en route, immobilization, MAST prn. Results: • n=498 victims with penetrating trauma and SBP<90 in the field. • Average prehospital time 30min. • Survival was related to TS and not to prehospital time. Comments: • In an urban model time to definitive therapy in hypotensive victims of penetrating trauma did not influence survival in pts 40min or less away from trauma center consider bypassing smaller centers • Did not report prehospital interventions! IV access – Feasibility? Stay and play … or Load and get a bumpy IV? Prehospital Venous Access in an Urban Paramedic System – Prospective On-scene Analysis (Pons et al. J Trauma, 1988) Objectives: • Measure time to establish IV in prehosp pts & document on-scene times. Methods: • Prospective observational study with convenience sample of pts. Nonblinded. Controls were patients that paramedics judged did not need an IV. • Observers timed paramedics. • On site IVs only, did not assess time in moving ambulance. Results: • n = 125 pts in whom IV access was attempted. • First attempt success rate 90% in trauma pts, 83% in medical pts. • Time required to start first IV and obtain bld sample 2 min 20 sec. On- scene times for trauma pts with IVs: 11.0 min vs. 9.4 min w/o IV. Commentary: • Observer not blinded, paramedics chose who they put IV on and who not. Does not report the usefulness of these IVs. Zero-time Prehospital IV (O‟Gorman et al, J Trauma 1989) Methods: • n=350 (86 trauma) pts, prospective recording of time from tourniquet placement to IV fluids infusing. • Data self-reported by paramedics. Results: • On scene IV attempts successful: 70/90 (77%) average time 3.8min. • En route IV attempts successful: 213/260 (81%) average time 4.1min. • Lower rates of successful IVs for hypotensive pts. Conclusions: • Huge potential biases: self-reporting and only started calculating time once turniquet applied. • Small study. • Utility of IV. • ISS or TS? IV Fluids: …to give or not to give - allcomers Early models of controlled hemorrhagic insults to animals indicated that volume resuscitation was beneficial. Animal Models of Uncontrolled Hemorrhage Author Animal Model of Comparison Outcome Interpretation s hemorrhage - no benefit + benefit resusc + benefit nor resus/ hypotensive resus Stern Swine Controlled then Hypotensive resuscitation Less bleeding in hypotensive gp. 1993 (27) uncontrolled vs normotensive resus Lower mortality and bleeding in hypotensive gp. + Owens Swine Controlled then No resuscitation vs. Less operative blood loss, less 1995 (20) uncontrolled limited (60% CI) vs standard (100%CI) resuscitation. intraop. blood and crystalloid requirements. + Greater O2 delivery in SR gp. Sakles Sheep Uncontrolled. Immediate fluids to Sheep resuscitated to normal BP 1997 (16) normotension vs. no fluids. bled twice as much and twice as long. + Marshall Rats Controlled then Hypotensive vs. Poorer survival in rats 1997 (32) uncontrolled (tail amputat‟n) normotensive resus w/ RL & blood prior hemorrhage control resuscitated with RL to normotension; equal survival in - others. Burris Rats Uncontrolled Hypotensive bs. Hypotensively resuscitated rats 1999 (86) Normotensive resuscitation with RL or HS vs. no resuscitation with RL and HS survived the longest. + Bruscagin Dogs Uncontrolled No resuscitation vs. lg No difference in blood loss, 2002 (20) volume RL vs. small volume HS. mild rise in BP with resuscitation - Preventable Death Evaluation of the Appropriateness of the On-Site Trauma Care Provided by Urgences-Sante Physicians (Sampalis et al. J Trauma, 1995) Methods: • Analyzed the 73 deaths on the 1987 cohort by expert panel review. • Expert committee: 3 surgeons, 3 EPs, 3 anesthesiologists were blinded to pt outcome. • Classified injuries as survivable, potentially survivable and nonsurvivable. Results: • 44/73 (62%) of injuries were classified as potentially survivable. • Mean ISS 28; 68% had injuries to the H&N, 64% injuries to chest and 32% to the abdomen. 64% of these pts were in MVAs. • Mean prehosp time: 40min maximal allowable time: 23 min. • Expert committee classified IV fluids as harmful for 16 (42%), as neutral for 19 (50%), and beneficial for 3 (8%). Commentary: • Retrospective; based on expert opinion. • Estimate that IV placement took 5min took valuable time on scene when pt should have been transported already Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) • IV fluid replacement on scene is associated with increased mortality even with short prehospital times. Methods: • Observational “quasi-experimental” design:2 cohorts, one from 1987 (n=360), second from 1993-94 in Mtl: all pts transported by US. • Included: pts with on-site PHI >3 who were transported alive to hospital. • Pts tx‟ed w/ fluids matched to controls not tx‟ed w/ IV fluids (matched PHI; adjusted for age, gender, mech of injury, body region injured, ISS). Results: • n=217 pairs; 164 exact matches for PHI scores. Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) Baseline characteristics: • IV treated group had higher ISS score (14.7 vs 9.7), had higher incidence of head & neck, abdominal and chest trauma, higher incidence of MVAs, GSWs and SWs. • Non-IV tx‟ed group: older pts, higher proportion of males, more falls. • Physician on-scene in 100% of pts treated w/ IV‟s, 65% of pts w/o IV‟s. Prehospital times: • Overall the group without IV‟s got to hospital later: Mean prehospital time; 42min in the IV group vs. 47min in the no IV group. Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) Prehos Total IV No IV Crude OR pital Fatalities (n=217) (n=217) (of mortality with IV time (n=434) fluids vs. no fluids) All 62/434 50/217 12/217 5.1 (14%) (23%) (6%) (2.6-9.9) 0-30min 15/112 10/45 5/67 3.5 (13.4%) (22.2%) (7.5%) (1.1-11.2) 36/240 33/151 3/89 8.0 31- (15%) (22%) (3.4%) (2.4-27) 60min 11/82 7/21 4/61 7.1 >60min (13.4%) (33%) (6.6% (1.8-28) Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) Prehos Total IV No IV Crude OR pital Fatalities (n=217) (n=217) (of mortality with IV time (n=434) fluids vs. no fluids) All 62/434 50/217 12/217 5.1 (14%) (23%) (6%) (2.6-9.9) 0-30min 15/112 10/45 5/67 3.5 (13.4%) (22.2%) (7.5%) (1.1-11.2) 36/240 33/151 3/89 8.0 31- (15%) (22%) (3.4%) (2.4-27) 60min 11/82 7/21 4/61 7.1 >60min (13.4%) (33%) (6.6%) (1.8-28) Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) Prehos Total IV No IV Crude OR pital Fatalities (n=217) (n=217) (of mortality with IV time (n=434) fluids vs. no fluids) All 62/434 50/217 12/217 5.1 (14%) (23%) (6%) (2.6-9.9) 0-30min 15/112 10/45 5/67 3.5 (13.4%) (22.2%) (7.5%) (1.1-11.2) 36/240 33/151 3/89 8.0 31- (15%) (22%) (3.4%) (2.4-27) 60min 11/82 7/21 4/61 7.1 >60min (13.4%) (33%) (6.6%) (1.8-28) Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? (Sampalis et al. J Trauma, 1997) • After adjusting for ISS, patient age, GSW, MVA and prehosp time odds of dying with prehosp fluids was still 2.3 (95% CI 1.0-5.3). Commentary: • Selection bias: significant differences in baseline characteristics – sicker pts probably got an IV. • Adequate adjustment for differences in baseline characteristics? • More no-IV gp pts from 1993 cohort & matched them w/ 1987 pts: Does this reflect a change in physician paradigm about IV fluids? Or could this have favored the no-IV cohort unfairly because of improvements in surgical technique, standard of care… • No-IV group: 65% had physician on-scene: does the fact that he/she chose not to put in a line reflect the fact that pts were less sick? • Validity of PHI (i.e. VS) in gaging injury severity? Penetrating Torso Trauma Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries (Bickell et al. NEJM, 1994) Methods: Prospective controlled study, quasi random assignment. • Prospective trial: Immmediate vs. delayed (IV but no fluids till OR) fluid resuscitation in adults (>16 yrs) with GWS or SW to the torso with SBP <90 mm Hg. • Urban, single EMS and receiving facility (Houston), data collection 1989-1992. • Alternate day assignment (not randomized). • Early resuscitation group received fluids as per paramedic judgment in field, and to BP of 100 mm Hg in trauma center. • In the OR, both groups were resuscitated to BP 100 mmHg, Hct 25% and u/o 50cc/hr. Results: • n= 598 (309 immediated resuscitation, 289 delayed resuscitation) adults with penetrating torso injuries with a prehospital BP <90. • Simillar in baseline characteristics. • Average SBP on scene was 58 (immediate) vs. 59 mmHg (delayed). Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries (Bickell et al. NEJM, 1994) Baseline characteristics: Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries (Bickell et al. NEJM, 1994) On arrival in trauma center: Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries (Bickell et al. NEJM, 1994) At initial operative intervention: Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating Torso Injuries (Bickell et al. NEJM, 1994) • Volume infused in prehospital phase: 870 cc vs. 90cc • Volumes administered in the trauma center: 1600cc vs. 280cc 2470cc vs. 370cc • Intraoperative volume infusion Ringer‟s 6.7L vs. 6.5L starch 0.5L vs. 0.54L PRBP 1.9 vs. 1.7L FFP 0.35 vs 0.3L immediate versus delayed • Estimated intraoperative blood loss: 3.1L 2.5L (p=NS) • Length of hospital stay: 14d 11days (p=0.006) • Survival to hospital discharge: 62% (CI 65-75%) 70% (CI 57-68%)(p=0.04) • Length of ICU stay: 8d 7d (p=0.3) • Complications: 30% 23% (sepsis, ADRS, ARF, coagulopathy, infection, pneumonia): Survival advantage maintained after adjustment for prehospital and trauma-center intervals. In response to letters to the editor (Bickell et al. NEJM, 1995) Commentary: • Interestingly, the BP in the OR was the same in both groups even though by that point both groups had received significantly different volumes of resuscitation physiologic mechanisms kicking in in the delayed group? • Lack of standardized protocol for fluid administration in prehospital setting: what were the paramedics titrating fluids to? • Did not report final diagnoses in both groups – were they similar? • Pt assignment not random alternate day assignment. • Longer intraoperative period delay in the delayed resuscitation group does this indicate greater need for initial intraop resuscitation in the delayed resuscitation gp? • Need for large RTC‟s to confirm these findings. In response to letters to the editor questioning the severity of injuries: • Posthoc analysis excluding all minor injuries by analyzing only data from pts with ISS >25 showed survival rate of 48% vs. 61% (p=0.02) favoring the delayed resuscitation group confirming that baseline differences in severity of injury is unlikely to account for the difference in outcome. Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality (Dutton RP et al. J Trauma 2002) Methods: • RTC: hypotensive (SBP 70) vs. normotensive (SBP 100) resusc • Included: trauma pts with SBP <90mm Hg documented once in the first hour after injury and “evidence of ongoing hemorrhage”. • Fluid resusc: fluid boluses of 200-500cc‟s until target BP reached, if over target BP analgesia/sedation was administered “if indicated.” • Enrolled & randomized patients on arrival to trauma center. • Fluids to SBP of 70 vs. 100 while maintaining Hct of >25%. Results: • n= 110 pts, 55 in each group; 80% male, 50% penetrating. • Baseline characteristics: higher rate of blunt trauma in hypotensive resusc gp, higher rate of pen. trauma in normotensive resusc gp, ISS higher in hypotensive resusc gp (19.5 vs. 24) Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality (Dutton RP et al. J Trauma 2002) Hypotensive Resuscitation during Active Hemorrhage: Impact on In-Hospital Mortality (Dutton RP et al. J Trauma 2002) Commentary: • Did not reach goal of hypotensive resusc – the hypotensive gp was normotensive on arrival to trauma center this alone could explain lack of positive result. • Small study, limited power. • Analgesics & sedatives given to “hypertensive pts”. • How much fluids in prehospital? How much fluids in the trauma center? • Lower mortality than in the Houston trial: does hypotensive resusc only make a difference in sick pts? • Treating physicians NOT BLINDED. • Lower mortality may require larger studies in future to detect significant differences in survival. Head Injury Comparison of Standard and Alternative Prehospital Resuscitation in Uncontrolled Hemorrhagic Shock and Head Injury (Novak et al. J Trauma, 1999) Methods: • 24 anesthetized swine, intubated, hemodynamically monitored. • Arterial phlebotomy w/ ongoing hemorrhage during resuscitation and cryogenic brain injury. • Randomizated to no resuscitation vs. 1000cc RL and 3cc/kg of 10% DCLHb • DCLHb = diaspirin cross-linked hemoglobin: hemoglobin tetramer which has been shown to elevate MAP after hemorrhage, contract cerebral arteries & reduce ischemic changes caused by hypotension to the brain. Results: • Bld loss greatest in resusc gp, least in the delayed resuscitation gp. • ICP increased slightly in the RL resuscitation gp, cerebral perfusion pressure dropped more in the delayed resuscitation gp (- 45mm Hg) than in the DLCHb gp (-25mm Hg) and the RL gp (-40mm Hg). Commentary: • Small animal study. Physiologic endpoints. Prehospital Resuscitation w/ Phenylephrine in Uncontrolled Hemorrhagic Shock & Brain Injury (Alspaugh, J Trauma 2000) Methods: • Anesthetized swine – inflicted cryogenic brain injury & splenic lac. (uncontrolled hemorrhage model) • Delayed RL resuscitation vs. standard RL resuscitation vs. phenylephrine to maintain MAP at baseline. • Animals sacrificed and brain biopsies evaluated for ischemic damage. Results: • Hemorrhage volumes similar. • Mortality at 8 hrs: 11% in Phenylephrine gp vs. 40% in the delayed resuscitation grp vs. 33% in the standard RL grp. • CPP was not significantly different in the different groups. • In the RL group trend towards smaller ischemic penumbra once animals were sacrificed. Conclusions: • Small animal study. • May indicate a role for phenylephrine larger human studies. Colloids, HS Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: A meta-analysis of controlled clinical studies. (Wade et al. Surgery 1997) • Is isotonic fluid resuscitation in the prehospital setting ineffective because too little volume can be infused in a short time? Methods: • Metaanlysis of RTCs comparing 250cc HS (7.5%) w/ NS/RL in trauma pts with SBP <100mm Hg. • Endpoint: survival to hospital D/C or 30days. Results • No complications of HS were reported in 11 studies (n=1798). • No difference in survival rate between HS and RL/NS. • Trend towards better survival in pts with HSD vs. RL/NS (NS). Comments: • Elusive methodology. Heterogeneity of studies not assessed. • Individual studies did not have the same 30-day mortality endpoint. • One of 11 studies showed greater survival for head injuries with HSD. Fluid resuscitation with colloid or crystalloid solutions in critically ill patients: a systematic review of randomised trials (Schierhout & Roberts, BMJ 1998) Methods: • Systematic review of RTCs comparing colloids (albumin, pentastarch, dextran, HS, Ringer‟s acetate, plama, Haemacell) with crystalloid in critically ill pts (trauma, burns, surgery and sepsis) • Outcome: all-cause mortality. Results: • 37 trials, 26 unconfounded, 19 reported mortality n = 1315 pts. • Absolute risk increase of mortality: 4% for colloid (CI 0-8%), trend similar with trials with adequate concealment of allocation. • Trials not heterogeneous. Comments: • Different colloids used, different resusc protocols in different studies. • Colloids remain the resuscitation fluid of choice Human albumin administration in critically ill patients: systematic review of randomised controlled trials (Cochrane Injuries Group Reviewers, BMJ 1998) Methods: • Identified 32 RTC on albumin or plasma protein fraction supplementation vs crystalloid resuscitation in hypovolemic (surgery, trauma, burns) or hypoalbuminemic pts. • Endpoint: mortality at end of follow-up - not specified how long this was… Results: • Significant increased RR of mortality w/ albumin overall and in all subgroups (RR 1.68 CI 1.26-2.23) pooled increase in risk of death 6% (3-9%) • No significant heterogeneity reported. Comments: • Mortality not reported at specific time cut-off (were later deaths missed?) • Small studies, small amount of deaths, not all properly concealed. Case 1: Pedestrian versus car • Blunt trauma: permissive hypotension vs. normotensive resuscitation – debate not resolved, but he may also have a head injury and is unstable... • Isotonic resuscitation, consider HS. • STAT angio (during which dropped BP) surgically uncontrollable bleed: needs to tamponade retroperitoneum. will need blood (and lots of it!) • Massive resuscitation in ICU. Case 1: Pedestrian versus car Case 1: Pedestrian versus car Case #2: Penetrating Torso Trauma Case #2: Penetrating Torso Trauma • Left chest tube STAT!! • STAT OR if he drains more than …cc immediately or ….cc/hr. • If BP recovers – permissive hypotension. Get 2 lines and have fluids and blood ready to go if needed. • If unstable right chest tube and volume OR if does not stabilize, CT scan if stabilizes. Case #2: Penetrating Torso Trauma Case 3: Head Injury • HS 250cc of 7.5% Saline with Dextran. • No mannitol unless HD stable! Isotonic Fluid resuscitation to maintain good cerebral perfusion pressure. • CT head if HD stable, otherwise OR. Case #4: Fall • Scoop and run with further attempts in the ambulance, continue secondary survey for potentially reversible causes (i.e. pneumothorax). • Unfortunately, coded en route. • Autopsy: ruptured liver, retroperitoneal bleed. Questions? References American College of Surgeons. ATLS Manual, 6 th Ed. Chicago. 1997. Alspaugh D, Sartorelli K, Shackford SR. Prehospital Resuscitation with Phenylephrine in Uncontrolled Hemorrhagic Shock and Br ain Injury. J Trauma 2000; 48,5:851-864. Aprahamian et al. Traumatic Cardiac Arrest: Scope of Paramedic Services. Ann Emerg Med 1985; 14,6: 583 -586. BIckell WH. Response, letter to the editor. NEJM 1995; 332:681-683. Bickell WH, Wall MJ, Pepe PE et al. 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