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Prehospital and ED Fluid Resuscitation in Trauma � by jbYvQr49

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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. Immediate versus Delayed Fluid Resuscitation for Hypotensive Patients with Penetrating To rso Injuries. NEJM
       1994;331:1105-1109.
Bruscagin V, di Figueirido P, Rasslan S et al. Fluid Resuscitation Improved Hemodynamics without Increased Bleeding in a Mode l of Uncontrolled Hemorrhage
       Induced by an Iliac Artery Tear in Dogs. J Trauma 2002; 52:1147-1152.
Cayton CG, Longmore W, Kuehl A. BLS vs. ALS for Urban Trauma. J Trauma 1984;24,7: 651.
Corey MS, Herr EW, Londorf D et al. Success Rates for Initiation of Intravenous Therapy en Route by Prehospital Care Provider s. Am J Emerg Med
      1990;8:305-307.
Cwinn AA, Pons PT, Moore EE et al. Prehospital ATLS for Critical Blunt Trauma Victims. Ann Emerg Med; 16, 4:399 -403.
Deakin CD & JL Low. Accuracy of the advanced trauma life support guidelines for predicting systolic blood pressure using car otid, femoral and radial
      pulses:observational study. BMJ 2000: 673-674.
Dutton RP, Mackenzie CF & TM Scalea. Hypotensive Resuscitation during Active Hemorrhage: Impact on In -Hospital Mortality. J Trauma 2002; 52(6):1141-
      1146.
Fortner GS, Oreskovich MR, COpass MK. The Effects o fPrehospital Trauma Care on Survival from a 50 ft fall. J Trauma 1983; 23 :11:976-981.
Gervin AS & RP Fischer. The Importance of Prompt Transport in Salvage of Patients with Penetrating Heart Wounds. J Trauma, 22 ,6:443-448.
Greaves I, Porter KM & MP Revell. Fluid Resuscitation in Pre-Hospital Trauma Care: a Consensus View. J Royal College of Surgeons of Edinb orough 2002;
      47(2): 451-457.
Hamilton-Davies C, Mythen MG, Salmon JB. Comparison of commonly used clinical indicators of hypovolemia with gastrointestinal to nometry. Int Care Med
      1997; 23:276-281.
Hedges JR, Sacco WJ, Champion HR et al. An analysis of Prehospital Care of Blunt Trauma. J Trauma 1982; 22,12:989 -993.
Holcoft JW, Vassar MJ, Turner JE et al. 3%NaCl and 7.5%NaCl/Dextran 70 in the Resuscitation of Severely Injured Patients. Ann Surg 1987;
      260,3:279-287.
Jacobs LM, Sinclair A, Beiser A et al. Prehospital ALS: Benefits of Trauma. J Trauma 1984; 24,1:8 -13.
Maio RF, Burney RE, Gregor MA. A Study of Preventable Trauma Mortality in Rural Michigan. J Trauma 1996; 41,1: 83-90.
Marshall HP, Capone A, Courcoulas A. Effects of Hemodilution on Long -Term Survival in an Uncontrolled Hemorrhagic Shock Model in Rats. J Trauma 1997;
       43,4:673-679.
Marx JA, Hockberger RS & RM Walls. Mosby. Rosen’s Emergency Medicine; 5th ed. 2002.
Meislin H, Criss E, Judkins D et al. Fatal Trauma: The Modal Distribution of Time to Death Is a Function of Patient Demograph ics and Regional Resources. J
       Trauma 1997; 43,3:433-440.
Meislin H, Conroy C, Conn K et al. Fatal Injury: Characteristics and Prevention of Deaths at the Scene. J Trauma 1999; 46, 3:457-461.
Nolan J. Fluid Resuscitation for the trauma patient. Resuscitation 2001; 48: 57 -69.
Messick J, Rutledge R & A. Meyer. ALS Training is Associated with Decreased Trauma Death Rates: an Analysis of 12‟417 Trauma Deaths. J Trauma 1990;
       30,12:1621.
Novak L, Shackford S, Bourguignon P et al. Comparison of Standard and Alternative Prehospital Resuscitation in Uncontrolled H emorrhagic Shock and Head
       Injury. J Trauma 1999; 47, 5:834.
References
O‟Gorman M, Trabulsy P & DB Pilcher. Zero-time Prehospital IV. J Trauma 1989; 29,1:84-85
Ottosson A & P Krantz. Traffic fatalities in a system with decentralized trauma care. A study with special reference to poten tially salvagable
      casualities. JAMA 1984; 251, 20.
Owens TM, Watson WC, Prough DS et al. Limiting Initial Resuscitation of Uncontrolled Hemorrhage Reduces Internal Bleeding and Subsequent
      Volume Requirements. J Trauma 1995; 39,2:200-209.

Papadopoulos IN, Bukis K, Karalas E et al. Preventable Prehospital Trauma Deaths in a Hellenic Urban Health Region: An Audit of Prehospital
       Trauma Care. J Trauma 1996; 41,5:864-869.
Pepe P, Wyatt C, Bickell W et al. The Relationship Between Total Prehospital Time and Outcome in Hypotensive Victims of Penet rating Injuries.
       Ann Emerg Med 1987;16,3:293-297.
Pons PT, Moore EE & JM Cusick. Prehospital Venous Access in an Urban Paramedic System – Prospective On-scene Analysis. J Trauma
       1988; 28 (10):1460-1463.
Pons P, Honigman B, Moore EE. Prehospital Advanced Life Support for Critical Penetrating Wounds to the Thorax and Abdomen. J Trauma
       1985; 25,9:828-832
Potter D, Goldstein G, Selig M et al. A Controlled Trial of Prehospital ALS in Trauma. Ann Emerg Med 1988; 17,6:582 -588.
Reines HD, Barlett RL, Chudy NE et al. Is ALS Appropriate for Victims of Motor Vehicle Accidents: The South Carolina Highway Trauma
       Project. J Trauma 1988; 28,5:563-570.
Riddez L, Hahn R, Brismar B. Central and regional hemodynamics during acute hypvolemia and volume substitution in volunteers. Critical Care
       Medicine 1997; 25, 4:635-640.
Rosemurgy AS, Norris PA, Olson SM et al. Prehospital Traumatic Cardiac Arrest: The Cost of Futility. J Trauma 1993; 35, 3: 468-474.
Sampalis JS, Tamim H, Denis R et al. Ineffectiveness of On-Site Intravenous Lines: Is Prehospital Time the Culprit? J Trauma 1997; 43,4:608-
       617.
Smith JP, Balazs IB, Hill AS. Prehospital Stabilization of Critically Injured Patients: A Failed Concept. J Trauma 1985; 25,1 : 65-70.
Spaite DW, Criss EA, Valenzuela TD et al. Prehospital Advanced Life Support for Major Trauma: Critical Need for Clinical Trials. Ann Emerg
       Med 1998; 32,4:480-489.
Spaite DW, Valenzuela TD, Criss EA et al. A Prospective In-Field Comparison of Intravenous Line Placement by Urban and Nonurban
       Emergency Medical Services Personnel. Ann Emerg Med 1994;24,2:209-214.
Stern SA, Dronen SC, Birrer P. Effect of Blood Pressure on Hemorrhage Volume and Survival in a Near-Fatal Hemorrhage Model Incorporating
       Vascular Injury. Ann Emerg Med 1993; 22,3:155-163.
Tintinalli JE, Kelen GD & JS Stapczynski. McGraw Hill. Emergency Medicine a Comprehensive Study Guide; 5th ed. 2000.
Wade CE, Kramer GC, Grady JJ et al. Efficacy of hypertonic 7.5% saline and 6% dextran-70 in treating trauma: A meta-analysis of controlled
       clinical studies. Surgery 1997; 122:609-616.
Wears RL & Winton CN. Load and Go Versus Stay and Play: Analysis of Prehospital IV Fluid Therapy by Computer Simulation.
Wilmink AB, Samra GS, Watson LM et al. Vehicle entrapment rescue and pre-hospital trauma care. Injury 1996; 27, 1:21-25.

								
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