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Trauma Resuscitation 2015

Dessy Boneva MD, FACS


USF/Kendall Trauma Center
Professor

Exemplary Care Cutting-edge Research World-class Education

Trauma case
23 yo male
GSW epigastrum
HR 140, BP 80/p
Distended, tender abdomen

Standard Treatment
Advanced Trauma Life Support guidelines
Start resuscitation in field
1-2 liters lactated Ringers
Blood
Normalize blood pressure ASAP
Acceptable if BPS goes over 120

Walter B. Cannon
Hemorrhage in a case of shock may not have
occurred to a marked degree because blood
pressure has been too low and the flow too scant to
overcome the obstacle offered by a clot. If the
pressure is raised before the surgeon is ready to
check any bleeding that may take place, blood that is
sorely needed may be lost.

Cannon WB, Fraser J, Cowell EM. JAMA 1918:618-621

Initial Clot Formation

Prior to surgical
control of an injury in
a named blood
vessel, what is the
best fluid
resuscitation
strategy to keep the
victim alive until
hemostasis can be
achieved and to
promote intact

Aggressive fluid resuscitation


May lead to more bleeding via
Increased pressure (BPS >90)
Decreased viscosity
Hemodilution
Loss of clotting factors

Hypotensive (Moderate) Fluid


Resuscitation
Laboratory studies-in animal studies with
traumatic injury, hypotension leads to early clot
formation and limits blood loss
Clinical studies-human studies are (mostly)
similar to animal studies
Unanswered questions still remain

Uncontrolled hemorrhagic shock

Stern, et al. Acad Emerg Med, 1995.

Moderate Fluid Resuscitation leads to


better survival than no resuscitation or
aggressive resuscitation in animals
I MAP 40
II MAP 80
III No fluid

Kowalenko, et al. J Trauma,1992.

Uncontrolled Hemorrhagic Shock Model in Rat

Capone, et al. JACS, 1995.

Survival After Uncontrolled Hemorrhagic Shock

Groups: 1=Untreated controls-all dead


2=No prehospital Fluid Resus-nearly all dead
3=Fluid Resus to MAP 40 mmHg-best (note MAP in rat is ~to 60 in human
4=FR to MAP 80 mmHg-all dead

Capone, et al. JACS, 1995.

What about the effect on the


brain?
Limited fluid resuscitation leads to
better outcomes in animals but is
the brain negatively impacted by
the hypotension?
How do you test a rat brain?-Rat
maze!

Exemplary Care Cutting-edge Research World-class Education

Hypotensive Resuscitation and the (Rat) Brain

Carrillo, et al. J Trauma, 1998.

Hypotensive Resuscitation and the Brain

Worst time

Best time

Normal (untouched) rats found the hidden platform the fastest,


but moderate fluid resus rats did as well or better than the sham rats that
only underwent anesthesia but no bleeding

Carrillo, et al. J Trauma, 1998.

Summary of preclinical studies


Traumatized rats do better with moderate
resuscitation
No resuscitation or aggressive resuscitation lead
to higher death rates in traumatized rats
Goldilocks zone (not too much, not too little)
What about humans?

Houston Delayed Fluid Resuscitation Trial


598 adults
All with Penetrating injuries
Torso
SBP <90

Waived consent(not legal in Florida)


Randomized by odd or even day
Standard ATLS resuscitation or nothing until OR
control of bleeding
Bickell, et al. NEJM, 1994.

Houston Delayed Fluid Resuscitation Trial


(Similar demographics)

Bickell, et al. NEJM, 1994.

Houston Delayed Fluid Resuscitation Trial

Bickell, et al. NEJM, 1994.

Fluids Administered-the delayed resus group received less


fluid (not surprising)

Bickell, et al. NEJM, 1994.

Labs on Arrival-the delayed resus


group had better labs on arrival
Immediate
Resuscitation

Delayed
Resuscitation

P
Value

Hgb

11.2+/-2.6

12.9+/-2.2

<0.001

Platelets

274+/-84

297+/-88

0.004

PT

14.1+/-16

11.4+/-1.8

<0.001

PTT

31.8+/-19.3

27.5+/-12

0.007

Bickell, et al. NEJM, 1994.

Houston Delayed Fluid Resuscitation Trialthe delayed resus group had better survival
Immediate
Resuscitation

Delayed
Resuscitation

p Value

193/309 (62%)

203/289 (70%)

0.04

Estimated intraoperative blood


lossmL

3127+4937

2555+3546

0.11

Length of hospital staydays

14+24

11+19

0.006

Length of ICU staydays

8+16

7+11

0.30

Variable
Survival to dischargeno. of
patients/total patients (%)

Bickell, et al. NEJM, 1994.

Hypotensive Resuscitation
Maryland Shock Trauma
In hospital
Inclusion criteria
SBP <90 mmHg
Ongoing hemorrhage
Blunt or penetrating trauma

Treatment

SBP >100 mmHg


SBP >70 mmHg
Better than the Houston trial, more recent, moderate resus
in Maryland vs full resus, the Houston was no resus vs. full
resus.
Dutton, et al. J Trauma, 2002

Hypotensive Resuscitation

Dutton, et al. J Trauma, 2002

Hypotensive Resuscitation-a target goal is difficult


to obtain but most BPS were <100

Dutton, et al. J Trauma, 2002

Hypotensive Resuscitation
SBP>100

SBP>70

55

55

SBPduring
hemorrhage

114+12

100+17

ISS

20+12

24+14

Predicted
survival

94%

90%

Actual
survival

93%

93%

#patients

No significant difference in outcome

Dutton, et al. J Trauma, 2002

Ben Taub Operative Study (Houston 2


Trial)

Morrison et al. J Trauma 2011;70:652 663.

Fluids-less fluids were used

Morrison et al. J Trauma 2011;70:652 663.

Postoperative Findings-the restricted


fluid group had better coagulation
profiles post op

Morrison et al. J Trauma 2011;70:652 663.

Survival

No difference at 30 days

Morrison et al. J Trauma 2011;70:652 663.

EAST Guidelines
Should of vascular access be obtained?
Level II: placement at the scene should not be performed if
it delays transport
Level III: placement during transport is feasible

Where should access be obtained


Level II: peripheral is best, intraosseous access ok if
peripheral fails
Level III: 2 attempts at peripheral access, then move to
another method (IO, CVC)

Cotton et al. J Trauma, 2009.

EAST Guidelines
Should IV fluids be given?
Level II: IV fluids should be withheld in patients with
penetrating torso injuries
Level III: IV fluid resuscitation should be withheld or limited
until active bleeding has been addressed. Fluid
administration should be titrated to maintain a palpable
radial pulse

Which fluid should be given?


Level III: blood administration if feasible
Level III: rapid infusion systems or pressurized systems
should not be used until bleeding controlled

Cotton et al. J Trauma, 2009.

(The next big trial)

Field Trial of Hypotensive Resuscitation


versus Standard Resuscitation in Patients
with Hemorrhagic Shock after Trauma
RESUSCITATION OUTCOMES CONSORTIUM

Goals: Primary aim


To determine the feasibility and safety of
hypotensive resuscitation for the early treatment of
patients with traumatic shock compared to
standard fluid resuscitation.

Goals
Primary Hypotheses:
The null hypothesis regarding feasibility is that hypotensive
resuscitation will result in the same volume of early
crystalloid (normal saline) fluid administration, compared to
standard crystalloid resuscitation.
The null hypothesis regarding safety, is that hypotensive
resuscitation will result in the same percent of patients
surviving to 24 hours after 9-1-1 call received at dispatch,
compared to standard fluid resuscitation.

Inclusion criteria
Blunt or penetrating injury
Prehospital SBP <90 mmHg
Age >15 y/o
Or >50 kg, if age unknown

Absence of severe head injury


Or GCS >8

Absence of spinal cord injury

Exclusion criteria
>250 ml intravenous fluid given*
Prehospital CPR
Known prisoners
Known/suspected pregnancy
Drowning or hanging
Burns >20% TBSA
Time from dispatch >4 hrs

Fluid intervention protocol

*Reassess SBP or radial pulse and repeat


algorithm after each bag is infused.

In-Hospital Procedure
Randomization continued for 2 hours after arrival,
or until hemorrhage controlled:
Bleeding vessel ligated.
Solid organ removed or bleeding stopped by packing or
other means.
Bleeding site embolized by interventional techniques.

Outcome measures
Feasibility
Volume of crystalloid (normal saline) given from time of
injury until either hemorrhage is controlled or 2 hours into
the hospital stay whichever comes first

Safety
Survival to 24 hours
The trial ended last month,
Results expected this year

Questions
Optimal blood pressure goal is unclear
Optimal fluid is unclear
Safe duration of hypotensive resuscitation is
unclear
What about the brain
What about comorbidities

Take home points


Aggressive fluid resuscitation before hemostasis
may increase bleeding
Large amounts of fluids increase coagulopathy
Moderate resuscitation may be best for now
Give blood, FFP, plts if bleeding

Thank you
Dessy Boneva MD, FACS
USF/Kendall Trauma