Resuscitation Redefined

Kenneth L. Mattox, MDHouston

TraumaTrauma

Resuscitation RedefinedKenneth L. Mattox, MD

BaylorCollege Medicine

Ben TaubHospital

Purpose: to remove the word

“RESUSCITATION” from your vocubulary.

Or at least as you have used it in the past

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This talk for resuscitation in ACUTE surgical

conditonsNOT Sepsis, Obstruction, etc

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20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearnthe lessons of the past?”

•Over

•Under

•Balanced

• Benefit• Harm• Adjust

20131913 19631938 1988

WWI WWII Korea VietNam Iraq-Afgh

Dacron CT Endo

“Why must we always have to relearnthe lessons of the past?”

•Historic

•1960-1995

•1995-2013

•Current Changes

Outline - Objectives

Traditional

HISTORIC-misconceptions

-over resuscitation

Legacy definitions faulted

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Many approaches & devices have

come and goneTraumaTrauma

TabaccoSmoke

Resuscitator

Alexander Graham Bell Resuscitation Device

Alexander Graham Bell & his ventilator

“Over a barrel” - Needs resuscitation

RESUSCITATION

Historic Concept

• “Get the patient in shape so that surgery will be tolerated”

• This is an URBAN LEGEND

TraumaTrauma(Abandon this concept)

What is RESUSCITATION ?

Historic Concept

• Assure an airway

• Control Bleeding

• Raise the BP (? Towards normal or HIGHER)

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OVER

FluidsHow 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

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Historic Approach

• 20th Century Algorithm– Replace blood with

crystalloid in 3:1 ratio

– No concern for impact on bleeding

RESUSCITATION ?

Historic How Accomplished ?

• Position

• Dressings & tourniquets

• Medications (vasoactive)

• Fluids, LOTS of fluids

TraumaTrauma Lots of Complications

Fast FORWARD to

the PAST

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Examine the PATIENT

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Recognize the patient in need of EMS or EC, or OR

“Intervention”

…and who does NOT need it

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Less than 4% of ALL trauma patients actually need or

benefit from “Resuscitation”

(Whatever that is)REALLY

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Problems

NEW

Classification

MEDICAL DISASTER RESPONSE

More than 90% of ALL

trauma patients need NO

“Resuscitation”

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Some foundations for “resuscitation”

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William Shakespeare

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…..or not so new

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

Shakespeare, The Merchant of Venice, Act IV, Scene I

1597

Stop the Bleeding – Go to OR

Stop the Bleeding

Walter Cannon

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Cannon – World War I

"The injection of a fluid that will increase blood pressure has dangers in itself. Hemorrhage may not have occurred to a marked degree because the blood pressure has been too low to overcome the obstacle offered by a clot.“

Less Resuscitation is Best

WWI lessons

• Cannon – JAMA

• “It is wasteful of time, resources and people to give fluid prior to operative control of hemorrhage.”

WW IIOffice of the

Surgeon General

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Office of the Surgeon General, U. S. Army

WWII lessons• 2 reports• “BP should not be elevated and

fluid not given till operative control of bleeding”

• Do not pop the clot and loose precious blood

1954-1960CPR

External Cardiac Compression

(Elan, Safar, Kouwenhoven)

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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?

NotReally

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The Three to One Rule

• Original studies – Shires, 1963

• Described three isotope model

• Showed extracellular repletion with crystalloid essential for survival

Fluid 3:1 Rule

• Developed in “controlled hemorrhage” model

• NEVER tested in people

• Pre-dated EMS and Trauma Systems

• Became “doctrine” without any class I, II, or III data

RESUSCITATION ?

Historic Assessment

A - ALL IVs FULL Flow

B – BP higher than normal

C – Chart Looks good

TraumaTraumaNOW Call Surgeon

AMAZING-Patient’s surgery

DELAYED until “resuscitated” in EMS,

EC, or ICU

TraumaTraumaThis is a NO NO

HISTORIC

• Vietnam experience

• Approach to hypotension was 2 large caliber IVs

• Give crystalloid as rapidly as possible.

And NEW Problems happened

Resuscitation CoursesATLSACLSPALS

(12 others)Almost identical cirriculum

Teach ABCs

Encourage FLUID bolus

Lots of Urban Legends

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“Fill the tank”“Fluid Challenge”

Commonly quoted phrases

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Three Peaks in Mortality

LethalMOF

Early “resuscitation”

Pop the Clot

Early fluid type DOES effect Death & MOF

Residual, quiet continuing questions

(Did not join bandwagon)

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1960s “aggressive fluid administration in uncontrolled hemorrhage resulted in increased mortality”

Shaftan GW, Chiu CJ, Dennis C, Harris B. Fundamentals of physiologic control of arterial hemorrhage. Surgery 1965; 58: 851-856.

Milles G, Koucky CJ, Zacheis HG. Experimental uncontrolled arterial hemorrhage. Surgery 1966; 60: 434-442.

Permissive Hypotension

• 1980s and 1990s- rodent & swine models of hemorrhagic shock

• Aggressive fluid resuscitation in uncontrolled hemorrhage resulted in increased mortality & morbidity

1994BIG BOMB

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Mattox

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Keeping the BP low saves lives – Do NOT POP

the CLOT

Permissive Hypotension

• 1994 – 1st clinical evaluation offluid restriction in uncontrolledhemorrhage

Mattox: Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Eng J Med. 1994;331:1105-9

Permissive Hypotension(Bickel et al)

598 patients with penetrating torso injury & systolic BP ≤ 90 mmHg in prehospital setting

Patients randomized to receive high-volume fluids, or fluids delayed until patient in OR

Permissive Hypotension

• Results:– Group Divisions

• Delayed: n=289• Standard fluids: n=309

– Survival:• Delayed: 70%• Standard fluids: 62%

– Complications:• Delayed: 23%• Standard fluids: 30%

Statistical SignificanceOther studies supportive

In-Theater Combat Mortality*

05

1015202530354045

18

50

18

65

18

80

18

95

19

10

19

25

19

40

19

55

19

70

Combat CasualtyMortality(Cumulative % of All Wounded)

Crimean War

American Civil War

Russian-JapaneseWar 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

In-Theater Combat Mortality*

Killed in Action (KIA) in Iraq

12.2%(Averaged 20% for all wars since

Crimean War)

WHAT WAS DIFFERENT IN IRAQ?

*Source – USUHS Symposium March 26, 2004

UNDER

Redefine RESUSCITATION

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Abandon use of Sphygmomanometer

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Mental Status

Presence of a pulse

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“NOVEL” NEW HEMORRHAGE

CONTROL

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Minimal (to NO) “resuscitation” in

the field, ambulance, or Emergency Room

Keep the BP low

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EVOLVING

Hypotensive Resuscitation

What BP PEAK is BEST?

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What BP Target is BEST?

<80/-

Higher POPS the CLOT

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New ARMY field

Tourniquet

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IntravenousHemostatic

Drugs ?

Did not work out

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? Topical Hemostatic Agents ?

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“new” topical hemostatic agents

still not proven

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NOVEL NEW UNDERSTANDING

of EMS & ER

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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

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NOVEL NEW CONCEPT

RAPID OPERATION

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EARLY (immediate) aggressive operative

(or critical care) intervention

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NOVEL NEW FLUID POLICY

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Fluid ISSUES

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Fluid Conference Proceedings 2003

Restricted Fluid Resuscitation

Restricted Fluid Resuscitation

Restricted Fluid Resuscitation

Restricted Fluid Resuscitation

FluidsWHAT KIND?

• Ringer’s Lactate• Normal Saline• Dextrans, Starches, Gelatin, Albumin• Hypertonic solutions• Designer fluids• Blood & blood products• Hemoglobin substitutes

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Crystaloids

Advantage• Readily available• Inexpensive• Repleats

intravascular & interstitial volume

• Encourages Urinary flow

Disadvantage

• Does not stay in vasculature

• Need LARGER volumes

• Edema

• Inflammation

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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

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Protein Colloids

Albumins

5% human serum albumin

25% human serum albumin

Gelatins – Not available in US

Plasmagel

Haemacell Gellifundol

}

FluidsHow 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 & NSTraumaTrauma

Permissive Hypotension

Systolic BP <80 mm Hg

“Pop the Clot” @ 80/-

Low MAP is tolerated - compensatory flow and metabolism Fluid infusion rate not to exceed 45 ml/min (no benefit to faster rates - even if systolic BP is ~ 40 mm Hg)

Permissive Hypotension

• Elevation of BP to pre-injury levels (absent definitive hemostasis) is associated with:

– Progressive and repeated re-bleeding

– Hypoxemia from excessive hemodilution

BALANCED

Major NEW Lesson

• Replace blood loss with (FRESH) blood

• Match blood with FFP (1:1)

• For each unit of blood – give 1 unit of platlets (1:1:1)

• RESTRICT crystalloidTraumaTrauma

Summary• Novel “New” Concepts WORK

• Abandon the word Resuscitate

• Keep treatment–Functional

–Simple

–Effective

• Stop hemorrhage

Hurdsfield, NDJanuary 15, 1992

Both arms severed in farm accident

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“He did not bleed to death…because he was in shock.”

--Sister of boy with two severed arms

Machiavellia “The Prince”

“There is nothing more difficult to take in hand, nor perilous

to conduct, nor more uncertain in its success than

to take the lead in introduction in a new order of

things….

Machiavellia “The Prince”

…for the innovator has for enemies, all those who

have done well under the old and lukewarm

defenders those who might do well under the

new.”

Redefine Resuscitation

Concepts

Kenneth L. Mattox, MDHouston

TraumaTrauma