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
TraumaTrauma
This talk for resuscitation in ACUTE surgical
conditonsNOT Sepsis, Obstruction, etc
TraumaTrauma
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
TraumaTrauma
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)
TraumaTrauma
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
TraumaTrauma
“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