1. Resuscitation Redefined
Kenneth L. Mattox, MD
Houston
Trauma

2. Resuscitation Redefined
Kenneth L. Mattox, MD
Baylor
College
Medicine
Ben Taub
Hospital

3. Purpose: to remove the word “RESUSCITATION” from your vocubulary
Purpose: to remove the word “RESUSCITATION” from your vocubulary. Or at least as you have used it in the past
Trauma 3

4. This talk for resuscitation in ACUTE surgical conditons
NOT Sepsis, Obstruction, etc
Trauma 4

5. “Why must we always have to relearn the lessons of the past?”
WWI
WWII
Korea
VietNam
Iraq-Afgh
1913
1938
1963
1988
2013
Dacron CT
Endo

6. Over
Under
Balanced
Benefit
Harm
Adjust

7. “Why must we always have to relearn the lessons of the past?”
WWI
WWII
Korea
VietNam
Iraq-Afgh
1913
1938
1963
1988
2013
Dacron CT
Endo

8. Historic 1960-1995 1995-2013 Current Changes
Outline - Objectives
Historic
Current Changes

9. Traditional

10. HISTORIC -misconceptions -over resuscitation
Legacy definitions faulted
Trauma 10

11. Many approaches & devices have come and gone
Trauma

12. Tabacco
Smoke
Resuscitator

13. Alexander Graham Bell Resuscitation Device

14. Alexander Graham Bell & his ventilator

15. “Over a barrel” - Needs resuscitation

19. RESUSCITATION Historic Concept
“Get the patient in shape so that surgery will be tolerated”
This is an URBAN LEGEND
(Abandon this concept)
Trauma

20. What is RESUSCITATION ? Historic Concept
Assure an airway
Control Bleeding
Raise the BP (? Towards normal or HIGHER)
Trauma 20

21. OVER

22. 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

23. Historic Approach 20th Century Algorithm
Replace blood with crystalloid in 3:1 ratio
No concern for impact on bleeding

24. Historic How Accomplished ?
RESUSCITATION ?
Historic How Accomplished ?
Position
Dressings & tourniquets
Medications (vasoactive)
Fluids, LOTS of fluids
Lots of Complications
Trauma 24

25. Fast FORWARD to the PAST
Trauma 25

26. Examine the PATIENT
Trauma 26

27. Recognize the patient in need of EMS or EC, or OR “Intervention”
…and who does NOT need it
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28. Less than 4% of ALL trauma patients actually need or benefit from “Resuscitation” (Whatever that is)
REALLY
Trauma 28

29. Problems

30. MEDICAL DISASTER RESPONSE
NEW Classification

31. More than 90% of ALL trauma patients need NO “Resuscitation”31

32. Some foundations for “resuscitation”
Trauma 32

33. William Shakespeare
Trauma

34. “ ..to stop his wounds, lest he do bleed to death.”
…..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

35. Stop the Bleeding

36. Walter Cannon
Trauma

38. 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.“

39. 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.”

40. WW II Office of the Surgeon General
Trauma

41. 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

42. 1954-1960 CPR External Cardiac Compression (Elan, Safar, Kouwenhoven)
Trauma

43. 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?

44. Not Really
Trauma 44

45. The Three to One Rule Original studies Described three isotope model
Shires, 1963
Described three isotope model
Showed extracellular repletion with crystalloid essential for survival

46. 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

47. NOW Call Surgeon RESUSCITATION ? Historic Assessment
A - ALL IVs FULL Flow
B – BP higher than normal
C – Chart Looks good
NOW Call Surgeon
Trauma 47

48. HISTORIC
AMAZING -Patient’s surgery DELAYED until “resuscitated” in EMS, EC, or ICU
This is a NO NO
Trauma 48

49. And NEW Problems happened
Vietnam experience
Approach to hypotension was 2 large caliber IVs
Give crystalloid as rapidly as possible.
And NEW Problems happened

50. Resuscitation Courses ATLS ACLS PALS (12 others)
Almost identical cirriculum
Teach ABCs
Encourage FLUID bolus
Lots of Urban Legends
Trauma

51. “Fill the tank” “Fluid Challenge”
Commonly quoted phrases
Trauma 51

52. Three Peaks in Mortality
Lethal
MOF
Early “resuscitation”
Pop the Clot
Early fluid type DOES effect Death & MOF

53. Residual, quiet continuing questions (Did not join bandwagon)
Trauma 53

54. 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:
Milles G, Koucky CJ, Zacheis HG. Experimental uncontrolled arterial hemorrhage. Surgery 1966; 60:

55. Permissive Hypotension
1980s and 1990s- rodent & swine models of hemorrhagic shock
Aggressive fluid resuscitation in uncontrolled hemorrhage resulted in increased mortality & morbidity
Control of bleeding is essential for a successful treatment of hemorrhagic shock with 7.5 per cent sodium chloride solution.
Rabinovici R, Krausz MM, Feuerstein G. Department of Surgery, Jefferson Medical College, Philadelphia, Pennsylvania
Surg Gynecol Obstet Aug;173(2):
Small volume hypertonic saline (HTS) solution resuscitation has been shown to restore hemodynamic derangements and to protect against mortality in "controlled" hemorrhagic shock (CHS), but it exacerbates the shock state in "uncontrolled" hemorrhagic shock (UCHS). To study the mechanisms associated with the divergent outcome of HTS treatment in CHS versus UCHS, HTS was administered to anesthetized rats (n = 7) subjected to 15 per cent resection of the tail followed by controlled or uncontrolled bleeding. HTS treatment of UCHS increased bleeding (13.3 +/- 1.6 milliliters, p less than 0.05), dropped mean arterial pressure (MAP) ( /- 8.9 millimeters of mercury, p less than 0.001), central venous pressure (zero millimeters of mercury, p less than 0.001) and cardiac index (CI) (41 per cent of basal value, p less than 0.001) and increased acidosis (pH /- 0.12, p less than 0.05) and mortality (mean survival time 75 +/- 15 minutes versus 122 +/- 23 minutes of untreated rats, p less than 0.05). In contrast, when administered after application of a ligature proximal to the resection site (at 15 minutes), HTS completely reversed the changes in MAP, CI and total peripheral resistance index (TPRI), and improved mean survival time (172 +/- 7 minutes, p less than 0.05). These data support the assumption that HTS should be used in the treatment of hemorrhagic shock only after bleeding was controlled.
The detrimental effects of intravenous crystalloid after aortotomy in swine.
Bickell, WH, Brutting SP, Millnamow GA, O?Benar J, Wade CE Division of Military Trauma Research, Letterman Army Institute of Research, Presidio of San Francisco, CA
Surgery 1991 Sep;110: Comment in: Surgery Sep;110(3):573-4
We tested the hypothesis that, after aortotomy, rapidly replacing three times the blood volume deficit with intravenous crystalloid will increase hemorrhage and decrease survival. Sixteen anesthetized Yorkshire swine underwent splenectomy and stainless steel wire placement in the infrarenal aorta and were instrumented with pulmonary artery and carotid artery catheters. The wire was pulled, producing a 5 mm aortotomy and spontaneous intraperitoneal hemorrhage. The animals had been alternately assigned to either an untreated control group (n = 8) or a treatment group (n = 8), which received 80 ml/kg lactated Ringer's solution intravenously. The volume of hemorrhage and the mortality rate were significantly increased (p less than 0.05) in the treatment group receiving lactated Ringer's solution relative to the control animals ( ml versus ml, and eight of eight animals versus zero of eight animals, respectively). From these data we conclude that, in this model of uncontrolled arterial hemorrhage resulting from abdominal aortotomy, rapidly administering lactated Ringer's solution intravenously significantly increases hemorrhage and death.
Effect of blood pressure on hemorrhage volume and survival in a near-fatal hemorrhage model incorporating a vascular injury. Stern, SA Dronen SL, Birrer P. et al. Department of Emergency Medicine, University of Cincinnati College of Medicine, Ohio. Ann Emerg Med 1993 Feb;22 :155. Comment in: Ann Emerg Med Feb;22(2):225-6 STUDY HYPOTHESIS: In a model of near-fatal hemorrhage that incorporates a vascular injury, stepwise increases in blood pressure associated with aggressive crystalloid resuscitation will result in increased hemorrhage volume and mortality. DESIGN: This study used a swine model of potentially lethal hemorrhage in the presence of a vascular lesion to compare the effects of resuscitation with mean arterial pressures of 40, 60, and 80 mm Hg. Twenty-seven fully instrumented immature swine (14.8 to 20 kg), each with a surgical-steel aortotomy wire in place, were bled continuously from a femoral artery catheter to a mean arterial pressure of 30 mm Hg. At that point the aortotomy wire was pulled, producing a 4-mm aortic tear and uncontrolled intraperitoneal hemorrhage. When the animal's pulse pressure reached 5 mm Hg, the femoral artery hemorrhage was discontinued and resuscitation was begun. INTERVENTIONS: Saline infusion was begun at 6 mL/kg/min and continued as needed to maintain the following desired endpoints: group 1 (nine) to a mean arterial pressure of 40 mm Hg, group 2 (nine) to a mean arterial pressure of 60 mm Hg, and group 3 (nine) to a mean arterial pressure of 80 mm Hg. After 30 minutes or a total saline infusion of 90 mL/kg, the resuscitation fluid was changed to shed blood infused at 2 mL/kg/min as needed to maintain the desired mean arterial pressure or to a maximum volume of 24 mL/kg. Animals were observed for 60 minutes or until death. MEASUREMENTS AND MAIN RESULTS: Data were compared using repeated-measures analysis of variance with a post hoc Tukey-Kramer, Fisher's exact test, and Kruskal-Wallis. Mortality was significantly greater in group 3 (78%) compared with either group 1 (11%; P = .008) or group 2 (22%; P = .028). Mean survival times were significantly shorter in group 3 (44 +/- 12 minutes) compared with either group 1 (58 +/- 6 minutes; P = .007) or group 2 (59 +/- 3 minutes; P = .006). The average intraperitoneal hemorrhage volumes were 13 +/- 14 mL/kg, 20 +/- 25 mL/kg, and 46 +/- 11 mL/kg for groups 1, 2, and 3, respectively (group 1 versus 2, P = .425; group 1 versus 3, P < .001; group 2 versus 3, P = .014). Group 2 animals demonstrated significantly greater oxygen deliveries compared with groups 1 and 3. CONCLUSION: In a model of near-fatal hemorrhage with a vascular injury, attempts to restore blood pressure with crystalloid result in increased hemorrhage volume and markedly higher mortality.  Prospective evaluation of preoperative fluid resuscitation in hypotensive patients with penetrating truncal injury: a preliminary report. Martin RR. Bickell WH. Pepe PE. Burch JM. Mattox KL. Cora & Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas Journal of Trauma Sep;33(3):354-61; discussion 361-2, Although intravenous (IV) fluid therapy is routinely prescribed for hypotensive injury victims, there are concerns that elevating the blood pressure before hemorrhage is controlled may be detrimental. This is a preliminary report of an ongoing randomized study designed to evaluate the effect fluid resuscitation, delayed until surgical intervention, has on the outcome for hypotensive victims of penetrating truncal injury. In the first year, 300 consecutive patients with gunshot or stab wounds to the trunk who had a systolic blood pressure of 90 mm Hg or less were entered into the study. Patients were excluded from the outcome analysis because of death at the scene or minor injury not requiring surgical intervention. The remaining study patients were randomized into (1) an immediate resuscitation group (n = 96) for whom IV fluid resuscitation was initiated in the ambulance and in the emergency center before surgical intervention, or (2) a delayed resuscitation group (n = 81) for whom IV fluid resuscitation was delayed until the time of surgical intervention. The two study groups were found to be well balanced with respect to anatomic injury severity, pretreatment vital signs, survival probability, and preoperative treatment times. There were no significant differences in the rate of survival to hospital discharge (immediate resuscitation group, 56%; delayed resuscitation group, 69%). There were no significant differences in the rate of postoperative complications. Further study is necessary to determine if it is advantageous to delay fluid resuscitation until surgical intervention.  Improved Outcome With Hypotensive Resuscitation of Uncontrolled Hemorrhagic Shock in a Swine Model Kowalenko T, Stern S, Dronen S, Wang X Department of Emergency Medicine, University of Cincinnati College of Medicine, Ohio. Journal of Trauma 1992 Sep;33(3):349,1992:349-53; discussion Recent animal studies have shown that aggressive saline infusion may produce significant mortality in models of moderately severe (20-30 mL/kg) uncontrolled hemorrhage. The postulated mechanism is an increase in hemorrhage that accompanies restoration of normal blood pressure. Although aggressive saline infusion and restoration of blood pressure appear indicated when hemorrhage is potentially lethal (40-45 mL/kg), we hypothesized that the attempt to restore blood pressure with aggressive saline infusion would not improve survival. This study used a swine model of severe uncontrolled hemorrhagic shock to compare the effects of resuscitation to mean pressures of 40 and 80 mm Hg. Twenty-four immature swine, each with a surgical steel aortotomy wire in place, were bled rapidly from a femoral artery catheter to a mean arterial pressure (MAP) of 30 mm Hg. The aortotomy wire was then pulled, producing a 4-mm aortic tear and free intraperitoneal hemorrhage. When the pulse pressure decreased to 5 mm Hg, saline infusion was begun at 6 mL/kg/minute and continued as needed to maintain the following endpoints: group I (MAP = 40 mm Hg), group II (MAP = 80 mm Hg), and group III (no resuscitation). After a maximum saline infusion of 90 mL/kg, the infusate was changed to shed blood at 2 mL/kg/minute. Data were compared using analysis of variance and Fisher's exact test. One-hour survival was 87.5%, 37.5%, and 12.5% for groups I, II, and III, respectively. Intraperitoneal hemorrhage for the three groups was 8.2 mL/kg, 39.9 mL/kg, and 6.7 mL/kg. The amount of saline infused was 55.8 mL/kg in group I and 90 mL/kg in group II.

56. 1994 BIG BOMB
Trauma

57. Mattox
Trauma

58. Keeping the BP low saves lives – Do NOT POP the CLOT

59. 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

60. 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

61. 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

62. In-Theater Combat Mortality*
Combat Casualty
Mortality
(Cumulative % of All Wounded)
Mortality after Entering Echelon Hospital Chain
No demonstrable decrease in combat zone mortality
Combat Zone Mortality Prior to First MTF
Crimean War
Russian-Japanese
War
WWI
WWII
Vietnam War
American Civil War
Korean War
*Slide from Dr. Jane Alexander, DARPA

63. 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

64. UNDER

65. Redefine RESUSCITATION
Trauma 65

66. Abandon use of Sphygmomanometer
Trauma 66

67. Mental Status Presence of a pulse
Trauma 67

68. “NOVEL” NEW HEMORRHAGE CONTROL
Trauma 68

69. EVOLVING
Minimal (to NO) “resuscitation” in the field, ambulance, or Emergency Room
Keep the BP low
Trauma 69

70. Hypotensive Resuscitation What BP PEAK is BEST?
Trauma

71. What BP Target is BEST? <80/-
Higher POPS the CLOT
Trauma

72. New ARMY field Tourniquet
Trauma 72

73. Intravenous Hemostatic Drugs ?
Did not work out
Trauma 73

74. ? Topical Hemostatic Agents ?
Trauma 74

76. “new” topical hemostatic agents still not proven
Trauma 76

77. NOVEL NEW UNDERSTANDING of EMS & ER
Trauma 77

78. 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 78

79. NOVEL NEW CONCEPT RAPID OPERATION
Trauma 79

80. EARLY (immediate) aggressive operative (or critical care) intervention
Trauma 80

81. NOVEL NEW FLUID POLICY
Trauma 81

82. Fluid ISSUES
Trauma 82

83. Fluid Conference Proceedings 2003

84. Restricted Fluid Resuscitation

85. Restricted Fluid Resuscitation

86. Restricted Fluid Resuscitation

87. Restricted Fluid Resuscitation

88. Fluids WHAT KIND? Ringer’s Lactate Normal Saline
Dextrans, Starches, Gelatin, Albumin
Hypertonic solutions
Designer fluids
Blood & blood products
Hemoglobin substitutes
Trauma

89. Crystaloids Disadvantage Does not stay in vasculature
Readily available
Inexpensive
Repleats intravascular & interstitial volume
Encourages Urinary flow
Disadvantage
Does not stay in vasculature
Need LARGER volumes
Edema
Inflammation
Trauma

90. 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

91. } Protein Colloids Albumins 5% human serum albumin
Gelatins – Not available in US
Plasmagel
Haemacell
Gellifundol }

92. If absent- give fluid bolus (25 ml) until pulse (or CNS) returns
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

93. Permissive Hypotension
Systolic BP <80 mm Hg
“Pop the 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)

94. Permissive Hypotension
Elevation of BP to pre-injury levels (absent definitive hemostasis) is
associated with:
Progressive and repeated
re-bleeding
Hypoxemia from excessive
hemodilution

95. BALANCED

96. Replace blood loss with (FRESH) blood Match blood with FFP (1:1)
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 96

97. Summary Novel “New” Concepts WORK Abandon the word Resuscitate
Keep treatment
Functional
Simple
Effective
Stop hemorrhage

99. Hurdsfield, ND January 15, 1992 Both arms severed in farm accident
Trauma

101. “He did not bleed to death…because he was in shock.”
--Sister of boy with two severed arms

102. 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….

103. 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.”

104. Redefine Resuscitation Concepts
Kenneth L. Mattox, MD
Houston
Trauma
104