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Resuscitation Redefined Kenneth L. Mattox, MD Houston Trauma Slide 2 Resuscitation Redefined Kenneth L. Mattox, MD Baylor College Medicine Ben Taub Hospital Slide 3 Purpose: to remove the word RESUSCITATION from your vocubulary. Or at least as you have used it in the past Trauma Slide 4 This talk for resuscitation in ACUTE surgical conditons NOT Sepsis, Obstruction, etc Trauma Slide 5 2013 1913 1963 1938 1988 WWI WWIIKorea VietNam Iraq-Afgh DacronCTEndo Why must we always have to relearn the lessons of the past? Slide 6 Over Under Balanced Benefit Harm Adjust Slide 7 2013 1913 1963 1938 1988 WWI WWIIKorea VietNam Iraq-Afgh DacronCTEndo Why must we always have to relearn the lessons of the past? Slide 8 Historic 1960-1995 1995-2013 Current Changes Outline - Objectives Slide 9 Traditional Slide 10 HISTORIC -misconceptions -over resuscitation Legacy definitions faulted Trauma Slide 11 Many approaches & devices have come and gone Trauma Slide 12 Tabacco Smoke Resuscitator Slide 13 Alexander Graham Bell Resuscitation Device Slide 14 Alexander Graham Bell & his ventilator Slide 15 Over a barrel - Needs resuscitation Slide 16 Slide 17 Slide 18 Slide 19 RESUSCITATION Historic Concept Get the patient in shape so that surgery will be tolerated This is an URBAN LEGEND Trauma (Abandon this concept) Slide 20 What is RESUSCITATION ? Historic Concept Assure an airway Control Bleeding Raise the BP (? Towards normal or HIGHER) Trauma Slide 21 OVER Slide 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 Slide 23 Historic Approach 20 th Century Algorithm Replace blood with crystalloid in 3:1 ratio No concern for impact on bleeding Slide 24 RESUSCITATION ? Historic How Accomplished ? Position Dressings & tourniquets Medications (vasoactive) Fluids, LOTS of fluids Trauma Lots of Complications Slide 25 Fast FORWARD to the PAST Trauma Slide 26 Examine the PATIENT Trauma Slide 27 Recognize the patient in need of EMS or EC, or OR Intervention and who does NOT need it Trauma Slide 28 Less than 4% of ALL trauma patients actually need or benefit from Resuscitation (Whatever that is) REALLY Trauma Slide 29 Problems Slide 30 NEW Classification MEDICAL DISASTER RESPONSE Slide 31 More than 90% of ALL trauma patients need NO Resuscitation Trauma Slide 32 Some foundations for resuscitation Trauma Slide 33 William Shakespeare Trauma Slide 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 Slide 35 Stop the Bleeding Slide 36 Walter Cannon Trauma Slide 37 Slide 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. Slide 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. Slide 40 WW II Office of the Surgeon General Trauma Slide 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 Slide 42 1954-1960 CPR External Cardiac Compression (Elan, Safar, Kouwenhoven) Trauma Slide 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? Slide 44 Not Really Trauma Slide 45 The Three to One Rule Original studies Shires, 1963 Described three isotope model Showed extracellular repletion with crystalloid essential for survival Slide 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 Slide 47 RESUSCITATION ? Historic Assessment A - ALL IVs FULL Flow B BP higher than normal C Chart Looks good Trauma NOW Call Surgeon Slide 48 AMAZING -Patients surgery DELAYED until resuscitated in EMS, EC, or ICU Trauma This is a NO NO HISTORIC Slide 49 Vietnam experience Approach to hypotension was 2 large caliber IVs Give crystalloid as rapidly as possible. And NEW Problems happened Slide 50 Resuscitation Courses ATLS ACLS PALS (12 others) Almost identical cirriculum Teach ABCs Encourage FLUID bolus Lots of Urban Legends Trauma Slide 51 Fill the tank Fluid Challenge Commonly quoted phrases Trauma Slide 52 Three Peaks in Mortality Lethal MOF Early resuscitation Pop the Clot Early fluid type DOES effect Death & MOF Slide 53 Residual, quiet continuing questions (Did not join bandwagon) Trauma Slide 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: 851-856. Milles G, Koucky CJ, Zacheis HG. Experimental uncontrolled arterial hemorrhage. Surgery 1966; 60: 434-442. Slide 55 Permissive Hypotension 1980s and 1990s- rodent & swine models of hemorrhagic shock Aggressive fluid resuscitation in uncontrolled hemorrhage resulted in increased mortality & morbidity Slide 56 1994 BIG BOMB Trauma Slide 57 Mattox Trauma Slide 58 Keeping the BP low saves lives Do NOT POP the CLOT Slide 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 Slide 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 Slide 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 Slide 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 Slide 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 Slide 64 UNDER Slide 65 Redefine RESUSCITATION Trauma Slide 66 Abandon use of Sphygmomanometer Trauma Slide 67 Mental Status Presence of a pulse Trauma Slide 68 NOVEL NEW HEMORRHAGE CONTROL Trauma Slide 69 Minimal (to NO) resuscitation in the field, ambulance, or Emergency Room Keep the BP low Trauma EVOLVING Slide 70 Hypotensive Resuscitation What BP PEAK is BEST? Trauma Slide 71 What BP Target is BEST?Slide 72 New ARMY field Tourniquet Trauma Slide 73 Intravenous Hemostatic Drugs ? Did not work out Trauma Slide 74 ? Topical Hemostatic Agents ? Trauma Slide 75 Slide 76 new topical hemostatic agents still not proven Trauma Slide 77 NOVEL NEW UNDERSTANDING of EMS & ER Trauma Slide 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 Slide 79 NOVEL NEW CONCEPT RAPID OPERATION Trauma Slide 80 EARLY (immediate) aggressive operative (or critical care) intervention Trauma Slide 81 NOVEL NEW FLUID POLICY Trauma Slide 82 Fluid ISSUES Trauma Slide 83 Fluid Conference Proceedings 2003 Slide 84 Restricted Fluid Resuscitation Slide 85 Slide 86 Slide 87 Slide 88 Fluids WHAT KIND? Ringers Lactate Normal Saline Dextrans, Starches, Gelatin, Albumin Hypertonic solutions Designer fluids Blood & blood products Hemoglobin substitutes Trauma Slide 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 Slide 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 Slide 91 Protein Colloids Albumins 5% human serum albumin 25% human serum albumin Gelatins Not available in US Plasmagel Haemacell Gellifundol } Slide 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 Slide 93 Permissive Hypotension Systolic BPSlide 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 Slide 95 BALANCED Slide 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 Slide 97 Summary Novel New Concepts WORK Abandon the word Resuscitate Keep treatment Functional Simple Effective Stop hemorrhage Slide 98 Slide 99 Hurdsfield, ND January 15, 1992 Both arms severed in farm accident Trauma Slide 100 Slide 101 He did not bleed to deathbecause he was in shock. --Sister of boy with two severed arms Slide 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. Slide 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. Slide 104 Redefine Resuscitation Concepts Kenneth L. Mattox, MD Houston Trauma