Resuscitation Redefined

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Resuscitation Redefined

• Kenneth L. Mattox, MD
• Houston

Trauma
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Resuscitation Redefined Kenneth L. Mattox, MD
Baylor College Medicine
Ben Taub Hospital
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Purpose to remove the word RESUSCITATION from
your vocubulary. Or at least as you have used
it in the past
Trauma
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This talk for resuscitation in ACUTE surgical
conditons

• NOT Sepsis, Obstruction, etc

Trauma
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Why must we always have to relearn the lessons
of the past?
WWII
Korea
Iraq-Afgh
WWI
VietNam
1913
1963
1938
2013
1988
Dacron
CT
Endo
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• Over
• Under
• Balanced

• Benefit
• Harm
• Adjust

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Why must we always have to relearn the lessons
of the past?
WWII
Korea
Iraq-Afgh
WWI
VietNam
1913
1963
1938
2013
1988
Dacron
CT
Endo
8
Outline - Objectives

• Historic
• 1960-1995
• 1995-2013
• Current Changes

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• Traditional

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HISTORIC-misconceptions-over resuscitation

• Legacy definitions faulted

Trauma
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• Many approaches devices have come and gone

Trauma
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Tabacco Smoke Resuscitator
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Alexander Graham Bell Resuscitation Device
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Alexander Graham Bell his ventilator
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Over a barrel - Needs resuscitation
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RESUSCITATION

• Historic Concept
• Get the patient in shape so that surgery will be
  tolerated
• This is an URBAN LEGEND

(Abandon this concept)
Trauma
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What is RESUSCITATION ?

• Historic Concept
• Assure an airway
• Control Bleeding
• Raise the BP (? Towards normal or HIGHER)

Trauma
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• OVER

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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

Trauma
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Historic Approach

• 20th Century Algorithm
• Replace blood with crystalloid in 31 ratio
• No concern for impact on bleeding

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RESUSCITATION ?

• Historic How Accomplished ?
• Position
• Dressings tourniquets
• Medications (vasoactive)
• Fluids, LOTS of fluids

Lots of Complications
Trauma
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Fast FORWARD to the PAST
Trauma
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Examine the PATIENT
Trauma
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Recognize the patient in need of EMS or EC, or OR
Intervention

• and who does NOT need it

Trauma
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Less than 4 of ALL trauma patients actually need
or benefit from Resuscitation(Whatever that is)

• REALLY

Trauma
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• Problems

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MEDICAL DISASTER RESPONSE

• NEW
• Classification

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More than 90 of ALL trauma patients need NO
Resuscitation
Trauma
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Some foundations for resuscitation
Trauma
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William Shakespeare
Trauma
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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
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• Stop the Bleeding

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Walter Cannon
Trauma
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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.

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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.

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WW IIOffice of the Surgeon General
Trauma
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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

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1954-1960CPRExternal Cardiac
Compression(Elan, Safar, Kouwenhoven)
Trauma
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Fluid 31 Rule

• DALLAS
• Original studies
• Shires, 1963
• Described three isotope model
• Showed extracellular repletion with crystalloid
  essential for survival

So? Does it work for trauma?
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NotReally
Trauma
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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

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Fluid 31 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

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RESUSCITATION ?

• Historic Assessment
• A - ALL IVs FULL Flow
• B BP higher than normal
• C Chart Looks good

NOW Call Surgeon
Trauma
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AMAZING-Patients surgery DELAYED until
resuscitated in EMS, EC, or ICU
HISTORIC
This is a NO NO
Trauma
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• Vietnam experience
• Approach to hypotension was 2 large caliber IVs
• Give crystalloid as rapidly as possible.

And NEW Problems happened
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Resuscitation CoursesATLSACLSPALS(12 others)

• Almost identical cirriculum
• Teach ABCs
• Encourage FLUID bolus
• Lots of Urban Legends

Trauma
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Fill the tankFluid Challenge

• Commonly quoted phrases

Trauma
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Three Peaks in Mortality
Lethal
MOF

• Early resuscitation
• Pop the Clot

Early fluid type DOES effect Death MOF
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Residual, quiet continuing questions(Did not
join bandwagon)
Trauma
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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.

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Permissive Hypotension

• 1980s and 1990s- rodent swine models of
  hemorrhagic shock
• Aggressive fluid resuscitation in uncontrolled
  hemorrhage resulted in increased mortality
  morbidity

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1994BIG BOMB
Trauma
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Mattox
Trauma
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Keeping the BP low saves lives Do NOT POP the
CLOT
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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.
  19943311105-9

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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

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Permissive Hypotension

• Results
• Group Divisions
• Delayed n289
• Standard fluids n309
• Survival
• Delayed 70
• Standard fluids 62
• Complications
• Delayed 23
• Standard fluids 30

Statistical Significance Other studies
supportive
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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
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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

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• UNDER

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Redefine RESUSCITATION
Trauma
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Abandon use of Sphygmomanometer
Trauma
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Mental StatusPresence of a pulse
Trauma
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NOVEL NEW HEMORRHAGE CONTROL
Trauma
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Minimal (to NO) resuscitation in the field,
ambulance, or Emergency Room
EVOLVING

• Keep the BP low

Trauma
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Hypotensive ResuscitationWhat BP PEAK is BEST?
Trauma
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What BP Target is BEST?lt80/-

• Higher POPS the CLOT

Trauma
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New ARMY field Tourniquet
Trauma
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IntravenousHemostaticDrugs ?

• Did not work out

Trauma
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? Topical Hemostatic Agents ?
Trauma
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new topical hemostatic agents still not proven
Trauma
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NOVEL NEW UNDERSTANDING of EMS ER
Trauma
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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
Trauma
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NOVEL NEW CONCEPTRAPID OPERATION
Trauma
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EARLY (immediate) aggressive operative (or
critical care) intervention
Trauma
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NOVEL NEW FLUID POLICY
Trauma
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Fluid ISSUES
Trauma
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Fluid Conference Proceedings 2003
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Restricted Fluid Resuscitation
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Restricted Fluid Resuscitation
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Restricted Fluid Resuscitation
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Restricted Fluid Resuscitation
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FluidsWHAT KIND?

• Ringers Lactate
• Normal Saline
• Dextrans, Starches, Gelatin, Albumin
• Hypertonic solutions
• Designer fluids
• Blood blood products
• Hemoglobin substitutes

Trauma
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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

Trauma
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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

Trauma
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Protein Colloids

• Albumins
• 5 human serum albumin
• 25 human serum albumin
• Gelatins Not available in US
• Plasmagel
• Haemacell
• Gellifundol

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FluidsHow Much (2012)

• Check for pulse CNS
• If absent- give fluid bolus (25 ml) until pulse
  (or CNS) returns
• Use Blood Plasma (11)
• Have defined end points
• -? NIR, Base Deficit, Lactate, (NOT BP)
• Markedly limit (or NO) LR NS

Trauma
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Permissive Hypotension

• Systolic BP lt80 mm Hg
• Pop the Clot _at_ 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)

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Permissive Hypotension

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

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• BALANCED

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Major NEW Lesson

• Replace blood loss with (FRESH) blood
• Match blood with FFP (11)
• For each unit of blood give 1 unit of platlets
  (111)
• RESTRICT crystalloid

Trauma
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Summary

• Novel New Concepts WORK
• Abandon the word Resuscitate
• Keep treatment
• Functional
• Simple
• Effective
• Stop hemorrhage

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Hurdsfield, NDJanuary 15, 1992Both arms
severed in farm accident
Trauma
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He did not bleed to deathbecause he was in
shock.

• --Sister of boy with two severed arms

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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.

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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.

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Redefine Resuscitation Concepts

• Kenneth L. Mattox, MD
• Houston

Trauma