Resuscitation Redefined

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Resuscitation Redefined. Kenneth L. Mattox, MD Houston. Trauma. Resuscitation Redefined Kenneth L. Mattox, MD. Baylor College Medicine. Ben Taub Hospital. Purpose: to remove the word “RESUSCITATION” from your vocubulary. Or at least as you have used it in the past. Trauma. - PowerPoint PPT Presentation

Transcript of Resuscitation Redefined

  • Resuscitation RedefinedKenneth L. Mattox, MDHoustonTrauma

  • Resuscitation RedefinedKenneth L. Mattox, MDBaylorCollege MedicineBen TaubHospital

  • Purpose: to remove the word RESUSCITATION from your vocubulary.

    Or at least as you have used it in the pastTrauma

  • This talk for resuscitation in ACUTE surgical conditonsNOT Sepsis, Obstruction, etcTrauma

  • 20131913196319381988WWIWWIIKoreaVietNamIraq-AfghDacronCTEndoWhy must we always have to relearnthe lessons of the past?

  • OverUnderBalancedBenefitHarmAdjust

  • 20131913196319381988WWIWWIIKoreaVietNamIraq-AfghDacronCTEndoWhy must we always have to relearnthe lessons of the past?

  • Historic1960-19951995-2013Current ChangesOutline - Objectives

  • Traditional

  • HISTORIC-misconceptions-over resuscitationLegacy definitions faultedTrauma

  • Many approaches & devices have come and goneTrauma

  • TabaccoSmokeResuscitator

  • Alexander Graham Bell Resuscitation Device

  • Alexander Graham Bell & his ventilator

  • Over a barrel - Needs resuscitation

  • RESUSCITATIONHistoric ConceptGet the patient in shape so that surgery will be toleratedThis is an URBAN LEGENDTrauma(Abandon this concept)

  • What is RESUSCITATION ?Historic ConceptAssure an airway Control BleedingRaise the BP (? Towards normal or HIGHER)Trauma

  • OVER

  • FluidsHow Much (1963-1995)2 LARGE BORE IVs3 liter LR (or NS) in ambulance3 liter LR (or NS) in ERIf a little bit is good a lot is betterMassive transfusion protocolsEnd Points vagueTrauma

  • Historic Approach20th Century AlgorithmReplace blood with crystalloid in 3:1 ratioNo concern for impact on bleeding

  • RESUSCITATION ?Historic How Accomplished ?PositionDressings & tourniquetsMedications (vasoactive)Fluids, LOTS of fluidsTrauma Lots of Complications

  • Fast FORWARD to the PASTTrauma

  • Examine the PATIENTTrauma

  • Recognize the patient in need of EMS or EC, or OR Interventionand who does NOT need itTrauma

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

  • Problems


  • More than 90% of ALL trauma patients need NO ResuscitationTrauma

  • Some foundations for resuscitationTrauma

  • William Shakespeare


  • ..or not so new stop his wounds, lest he do bleed to death. Shakespeare, The Merchant of Venice, Act IV, Scene I 1597Stop the Bleeding Go to OR

  • Stop the Bleeding

  • Walter CannonTrauma

  • 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 BestWWI lessonsCannon JAMAIt is wasteful of time, resources and people to give fluid prior to operative control of hemorrhage.

  • WW IIOffice of the Surgeon GeneralTrauma

  • Office of the Surgeon General, U. S. ArmyWWII lessons2 reportsBP should not be elevated and fluid not given till operative control of bleedingDo not pop the clot and loose precious blood

  • 1954-1960CPRExternal Cardiac Compression(Elan, Safar, Kouwenhoven)Trauma

  • Fluid 3:1 RuleDALLAS Original studies Shires, 1963Described three isotope modelShowed extracellular repletion with crystalloid essential for survivalSo? Does it work for trauma?

  • NotReallyTrauma

  • The Three to One RuleOriginal studies Shires, 1963Described three isotope modelShowed extracellular repletion with crystalloid essential for survival

  • Fluid 3:1 RuleDeveloped in controlled hemorrhage modelNEVER tested in peoplePre-dated EMS and Trauma SystemsBecame doctrine without any class I, II, or III data

  • RESUSCITATION ?Historic AssessmentA - ALL IVs FULL FlowB BP higher than normalC Chart Looks goodTraumaNOW Call Surgeon

  • AMAZING-Patients surgery DELAYED until resuscitated in EMS, EC, or ICUTraumaThis is a NO NOHISTORIC

  • Vietnam experienceApproach to hypotension was 2 large caliber IVsGive crystalloid as rapidly as possible.And NEW Problems happened

  • Resuscitation CoursesATLSACLSPALS(12 others)Almost identical cirriculumTeach ABCsEncourage FLUID bolusLots of Urban Legends


  • Fill the tankFluid ChallengeCommonly quoted phrasesTrauma

  • Three Peaks in MortalityLethalMOFEarly resuscitation Pop the ClotEarly fluid type DOES effect Death & MOF

  • Residual, quiet continuing questions

    (Did not join bandwagon)Trauma

  • 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 Hypotension1980s and 1990s- rodent & swine models of hemorrhagic shock

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

  • 1994BIG BOMBTrauma

  • MattoxTrauma

  • Keeping the BP low saves lives Do NOT POP the CLOT

  • Permissive Hypotension1994 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 HypotensionResults:Group DivisionsDelayed: n=289Standard fluids: n=309Survival:Delayed: 70%Standard fluids: 62%Complications:Delayed: 23%Standard fluids: 30%Statistical SignificanceOther studies supportive

  • In-Theater Combat Mortality*Combat CasualtyMortality(Cumulative % of All Wounded)Crimean WarAmerican Civil WarRussian-JapaneseWarWWIWWIIKorean WarVietnam WarCombat Zone Mortality Prior to First MTFMortality after Entering Echelon Hospital ChainNo demonstrable decrease in combat zone mortality*Slide from Dr. Jane Alexander, DARPA

  • In-Theater Combat Mortality*Killed in Action (KIA) in Iraq12.2%(Averaged 20% for all wars since Crimean War) WHAT WAS DIFFERENT IN IRAQ?

    *Source USUHS Symposium March 26, 2004


  • Redefine RESUSCITATIONTrauma

  • Abandon use of SphygmomanometerTrauma

  • Mental Status

    Presence of a pulseTrauma


  • Minimal (to NO) resuscitation in the field, ambulance, or Emergency RoomKeep the BP lowTraumaEVOLVING

  • Hypotensive ResuscitationWhat BP PEAK is BEST?Trauma

  • What BP Target is BEST?
  • New ARMY field TourniquetTrauma

  • IntravenousHemostaticDrugs ?

    Did not work outTrauma

  • ? Topical Hemostatic Agents ?Trauma

  • new topical hemostatic agents still not provenTrauma


  • For the patient needing resuscitation, the purpose of the ER is to WAVE to the patient going from Ambulance dock to the OR or ICUTrauma


  • EARLY (immediate) aggressive operative (or critical care) interventionTrauma


  • Fluid ISSUESTrauma

  • Fluid Conference Proceedings 2003

  • Restricted Fluid Resuscitation

  • Restricted Fluid Resuscitation

  • Restricted Fluid Resuscitation

  • Restricted Fluid Resuscitation

  • FluidsWHAT KIND?Ringers LactateNormal SalineDextrans, Starches, Gelatin, AlbuminHypertonic solutionsDesigner fluidsBlood & blood productsHemoglobin substitutesTrauma

  • CrystaloidsAdvantageReadily availableInexpensiveRepleats intravascular & interstitial volumeEncourages Urinary flow

    DisadvantageDoes not stay in vasculatureNeed LARGER volumesEdemaInflammationTrauma

  • Non-Protein ColloidsAdvantageReadily availableEqual to protein colloids (?)DisadvantageExpensiveCoagulopathyLong half lifeRES activationShort dwell timeAnaphalaxisCross Match problemsTrauma

  • Protein ColloidsAlbumins 5% human serum albumin 25% human serum albumin Gelatins Not available in USPlasmagel Haemacell Gellifundol }

  • FluidsHow Much (2012)Check for pulse & CNSIf absent- give fluid bolus (25 ml) until pulse (or CNS) returnsUse Blood & Plasma (1:1)Have defined end points-? NIR, Base Deficit, Lactate, (NOT BP)Markedly limit (or NO) LR & NSTrauma

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

    Progressive and repeated re-bleeding

    Hypoxemia from excessive hemodilution


  • Major NEW LessonReplace blood loss with (FRESH) bloodMatch blood with FFP (1:1)For each unit of blood give 1 unit of platlets (1:1:1)RESTRICT crystalloidTrauma

  • SummaryNovel New Concepts WORKAbandon the word ResuscitateKeep treatmentFunctionalSimpleEffectiveStop hemorrhage

  • Hurdsfield,