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Resuscitation Redefined Kenneth L. Mattox, MD Houston Trauma.

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Presentation on theme: "Resuscitation Redefined Kenneth L. Mattox, MD Houston Trauma."— Presentation transcript:

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. Or at least as you have used it in the past Trauma

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

5 WWI WWIIKorea VietNam Iraq-Afgh DacronCTEndo “Why must we always have to relearn the lessons of the past?”

6 Over Under Balanced Benefit Harm Adjust

7 WWI WWIIKorea VietNam Iraq-Afgh DacronCTEndo “Why must we always have to relearn the lessons of the past?”

8 Historic Current Changes Outline - Objectives

9 Traditional

10 HISTORIC -misconceptions -over resuscitation Legacy definitions faulted Trauma

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

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

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

21 OVER

22 Fluids How Much ( ) 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 20 th Century Algorithm –Replace blood with crystalloid in 3:1 ratio –No concern for impact on bleeding

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

25 Fast FORWARD to the PAST Trauma

26 Examine the PATIENT Trauma

27 Recognize the patient in need of EMS or EC, or OR “Intervention” …and who does NOT need it Trauma

28 Less than 4% of ALL trauma patients actually need or benefit from “Resuscitation” (Whatever that is) REALLY Trauma

29 Problems

30 NEW Classification MEDICAL DISASTER RESPONSE

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

32 Some foundations for “resuscitation” Trauma

33 William Shakespeare Trauma

34 …..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

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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 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

45 The Three to One Rule Original studies –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 RESUSCITATION ? Historic Assessment A - ALL IVs FULL Flow B – BP higher than normal C – Chart Looks good Trauma NOW Call Surgeon

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

49 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

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

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

56 1994 BIG BOMB Trauma

57 Mattox Trauma

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

59 Permissive Hypotension 1994 – 1 st 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) Crimean War American Civil War Russian-Japanese War WWI WWII Korean War Vietnam War Combat Zone Mortality Prior to First MTF Mortality after Entering Echelon Hospital Chain No demonstrable decrease in combat zone mortality *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

66 Abandon use of Sphygmomanometer Trauma

67 Mental Status Presence of a pulse Trauma

68 “NOVEL” NEW HEMORRHAGE CONTROL Trauma

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

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

73 Intravenous Hemostatic Drugs ? Did not work out Trauma

74 ? Topical Hemostatic Agents ? Trauma

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76 “new” topical hemostatic agents still not proven Trauma

77 NOVEL NEW UNDERSTANDING of EMS & ER Trauma

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

79 NOVEL NEW CONCEPT RAPID OPERATION Trauma

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

81 NOVEL NEW FLUID POLICY Trauma

82 Fluid ISSUES Trauma

83 Fluid Conference Proceedings 2003

84 Restricted Fluid Resuscitation

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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 Advantage 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  25% human serum albumin  Gelatins – Not available in US  Plasmagel  Haemacell  Gellifundol }

92 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 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

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

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

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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


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