Prehospital and ED Fluid Resuscitation in Trauma to give or not to give

1
Prehospital and ED Fluid Resuscitation in
Traumato give or not to give

• Corinne M. Hohl, MD, CCFP
• R5, Royal College Emergency Medicine Training
  Program
• April 2, 2003

2
Objectives

• What are you going to learn?
• Cases How would you manage these now?
• Current guidelines and controversies.
• EBEM review
• Assessment of vital signs as indicators of
  hypovolemia
• Clinical evaluation of fluid loss.
• Evidence for and against prehospital fluids.
• Evidence for none vs. hypotensive vs normotensive
  resuscitation.
• Penetrating trauma, head trauma.
• Hypertonic saline, colloid resuscitation.
• What have you learned? Cases what would you do
  now?

3
Case 1 Pedestrian versus car
4
Case 1 Pedestrian versus Car

• 60 yo, hit and run.
• Brought in by EMS, youre in the resus bayhes
  thrashing around
• GCS 14, HR 120, SBP 80, RR 24, T n.
• O/E flail chest right, left chest sounds OK,
  abdomen nontender (but GCS
• is 14), unstable pelvis.

5
Case 1 Pedestrian versus Car

• Chest tube R 300 cc blood air
• Intubated with 20mg Etomidate and paralysis
• Vitals after this HR 120, SBP 95
• FAST negative
• Pelvis bound
• CXR R CT good position, L lung OK.
• The nurse asks you what fluids you want and at
  what rate? Do you want bld? How much?
• Where will you go with this pt next?

6
Case 2 Penetrating Torso Trauma
7
Case 2 Penetrating Torso Trauma

• 22 year old, GSW left torso, no exit.
• EMS calls you SBP of 80 en route, they cannot
  get an IV. What do you tell them? (They are 10min
  out.)
• On arrival what is the first thing you are going
  to do, and how fast?
• His BP recovers to 100 and hovers around there
  after this intervention what are your fluid
  orders? What and how much?

8
Case 3 Head Injury
9
Case 3 Head Injury

• 18 year old, MVA driver - head vs. dashboard.
• GCS 10 (withdraws to pain, inappropriate verbal,
  eye opening to command), HR 120, BP 100/70,
  normal temp, no toxidrome, Glu the surgeons
  refuse to check!!!
• Exam pupils equal withdraws to pain.
• What fluid orders would you give?

10
Case 4 Fall 36 ft
11
Case 4 Fall

• 11 year old boy, skied off the ski run and fell
  down into ravine 36ft below.
• You are the doc in the ambulance GCS 15, HR
  125-130, radial pulse absent, good carotid pulse.
  Abdominal pain. Pt states hes cold.
• Two IV attempts unsuccessful. What do you do?
  Scoop and run or stay and play (i.e. try for
  IVs)? (25 min out)

12
Who coined the term the Golden Hour, and why?
13

• Lockey, Resuscitation 2001
• The concept of the golden hour was a
• marketing strategy by Dr. Cowley in
• 1963 in a letter to the Governor of
• Maryland, the purpose of which was to
• get ensure that police helicopters
• would over-fly local hospitals and bring
• severely injured pts to his Baltimore
• Shock Trauma Centre.
• with no scientific evidence to support this
  statement at the time!

14

• Blunt trauma Bimodal Distribution
• Meislin, J Trauma, 1997 1999.
• Retrospective review 710 blunt penetrating
  trauma deaths 91-93 in Arizona
• ? 52 DOA (on EMS arrival) ? nonsalvagable
• 48 transported died in hosp. (ISS 25)
• ? Bimodal deaths
• ? Peak at 0-60min and 24-48hrs.
• Early deaths 48 CNS, 31 circulatory.

Did not describe whether these injuries would
have been survivable
15
Are early deaths preventable?
16
Are early deaths preventable?
17
Paradox

• ALS procedures BLS intubation, IV fluids and
  medications ( application of PASG/MAST suits).
• ALS procedures are expected to reduce mortality
  by restoring physiologic hemodynamic parameters
  and delaying hemodynamic compromise in the
  prehospital phase.
• However, they may increase risk of death by
  significantly delaying time to definitive care,
  impairing physiologic responses to hemorrhage and
  inducing coagulopathy and hypothermia.
• (Sampalis et al. J Trauma 1997)

18
Rosens 5th ed. 2002

• p.2622
• ..interventions for traumatic injuries should be
  performed en route to hospital, and all efforts
  should be extended to reduce on-scene time.
• Controversy surrounds the issue of IV fluid
  administration. High volume IV fluid for
  hemodynamic instability ... has been the
  accepted standard in most prehospital care
  systems. Some data, however, support a paradigm
  shift to restrictive or hypotensive resuscitation
  for penetrating traumatic injuries. Restoration
  of hemodynamic stability with aggressive fluid
  resuscitation before definitive surgical
  hemostasis may lead to increased morbidity.

19
Tintinalli 5th ed. 2000

• p.223
• The concept of field stabilization of trauma
  victims has been discredited for those with
  hemorrhagic shock. The prehospital interventions
  that improve survival include attention to the
  airway, ventilation, immobilization, and rapid
  transport not fluid resuscitation. Standard
  prehospital interventions directed at restoring
  blood pressure, such as application of PASG and
  infusion of intravenous fluids, have not been
  shown to improve survival.

20
ATLS, 6th ed. 1997

• Prehospital Phase
• Every effort should be made to minimize scene
  time.
• No comment on fluids.
• ED Phase
• Fluid resuscitation must be initiated when early
  signs and symptoms of blood loss are apparent or
  suspected, not when the blood pressure is falling
  or absent.
• 2 lg bore IVs, initial bolus of 1-2L, 20cc/kg for
  a child.
• Ongoing replacement of 31 with Ringers.

21
Fluid Resuscitation in Pre-Hospital Trauma Care
a Consensus View.(Greaves et al. J Royal College
of Surgeons of Edinborough. 2002)

• Consensus guidelines methods not explicit.
• When treating trauma victims in the prehospital
  arena cannulation should take place en route.
• Only 2 attempts at cannulation ...
• Transfer should not be delayed by attempts to
  obtain IVs.
• Entrapped patients require cannulation at the
  scene.
• NS may be titrated in boluses of 250cc against
  presence or absence of a radial pulse (caveats
  penetrating torso injury, head injury, infants.)

22
What does the absence or presence of a radial
pulse mean?
23
Accuracy of the ACLS guidelines for predicting
systolic blood pressure using carotid, femoral
and radial pulses observational study.(Deakin
Low, BMJ 2000)

• Intro
• ACLS presence of carotid pulse ? SBP 60-70mm
  Hg
• presence of carotid fem pulse ? SBP 70-80mm
  Hg
• presence of radial pulses ? SBP gt 80mm Hg
• Methods
• Studied sequential pts with hypovolemic shock who
  had invasive BP monitoring.
• Observer blinded to BP reading established the
  absence or presence of pulses.
• Conclusions
• ACLS guidelines overestimate the actual BP of pts
  with hypovolemic shock by palpation of pulses.
• Not reported how pts were resuscitated prior to
  study, also some were under GA ? influence on
  pulses?

24
Accuracy of the ACLS guidelines for predicting
systolic blood pressure using carotid, femoral
and radial pulses observational study.(Deakin
Low, BMJ 2000)
No pulses palpable
carotid pulse only
carotid femoral pulses present
3 pulses present
25
Using 250cc boluses

• In normotensive individuals
• ? Initially NS will expand intravascular volume
  by 30.
• 30min 16 of NS remains intravascular.
• In hypovolemia
• ? Decreased rate of elimination of RL from
  plasma.
• Necessary replacement volume of crystalloid
  should be 3-4 times the blood volume lost i.e.
  250cc of saline would replace 70cc of blood

26
Fluid Resuscitation for the trauma pt.(Nolan J.
Resuscitation 2001)

• Vital signs may not be reflective of degree of
  shock
• Pure hemorrhage ? relative bradycardia.
• Response to injury ? tachycardia and elevated BP.
• Philosophy of immediate fluid resuscitation to
  normotension was based on animal models of
  controlled hemorrhage ? philosophy of permissive
  hypotension based on animal studies of
  uncontrolled hemorrhage as well as some human
  studies.
• Suggests the following resuscitation endpoints
• BP gt80 U/O gt0.5cc/kg/hr
• HR lt 120 GCS 15
• O2 sat gt96 lactate lt1.6
• base def gt -5 Hb gt90

27
Vagal slowing of the heart during hemorrhage
observations from 20 consecutive hypotensive
patients.(Sander-Jensen et al. BMJ, 1986)

• Methods
• Observation of 20 consecutive adults (btw 19-91
  yrs) in hemorrhagic shock.
• Mean blood loss 2.3L ( 0.3L).
• Treated with 2.0L blood and albumin, and 3.3L
  crystalloid.
• BP was measured by sphygmanometry, HR by monitor.
• Results
• Both medical (PUD, aneurysms, extrauterine
  pregnancies) and traumatic hypovolemia.
• Mean BP prior resuscitation 81/55
• Mean HR prior resuscitation 73 3 bpm
• With fluid resuscitation the HR increased to 100
  and the BP to 111/72 within 30 minutes of
  resuscitation

28
Vagal slowing of the heart during hemorrhage
observations from 20 consecutive hypotensive
patients.(Sander-Jensen et al. BMJ, 1986)
Prior fluid resuscitation
29
Prehospital Time Stay Play or Load go?
30
Pro ALS
31
Against ALS/Equivocal
32
Against ALS/Equivocal

• Conclusions (with a grain of salt)
• Long prehospital times are probably bad.
• Pro ALS studies measured physiologic indices, no
  hard
• outcomes. Mortality outcome studies favor BLS.

33
puzzling in the urban settingThe
Relationship Between Total Prehospital Time and
Outcome in Hypotensive Victims of Penetrating
Injuries(Pepe et al. Ann Emerg Med 1987.)

• Objective
• Survival of pts w/ hemorrhagic shock from pen.
  trauma vs. prehosp time
• Methods
• Prospective hypotensive trauma pts transported
  to a trauma center.
• Outcome prehospital time vs. survival.
• Standard care Ett prn, IVs en route,
  immobilization, MAST prn.
• Results
• n498 victims with penetrating trauma and SBPlt90
  in the field.
• Average prehospital time 30min.
• Survival was related to TS and not to prehospital
  time.
• Comments
• In an urban model time to definitive therapy in
  hypotensive victims of penetrating trauma did not
  influence survival in pts 40min or less away from
  trauma center ? consider bypassing smaller
  centers
• Did not report prehospital interventions!

34
IV access Feasibility?Stay and play or Load
and get a bumpy IV?
35
Prehospital Venous Access in an Urban Paramedic
System Prospective On-scene Analysis(Pons et
al. J Trauma, 1988)

• Objectives
• Measure time to establish IV in prehosp pts
  document on-scene times.
• Methods
• Prospective observational study with convenience
  sample of pts. Nonblinded. Controls were
  patients that paramedics judged did not need an
  IV.
• Observers timed paramedics.
• On site IVs only, did not assess time in moving
  ambulance.
• Results
• n 125 pts in whom IV access was attempted.
• First attempt success rate 90 in trauma pts, 83
  in medical pts.
• Time required to start first IV and obtain bld
  sample 2 min 20 sec. On-scene times for trauma
  pts with IVs 11.0 min vs. 9.4 min w/o IV.
• Commentary
• Observer not blinded, paramedics chose who they
  put IV on and who not. Does not report the
  usefulness of these IVs.

36
Zero-time Prehospital IV(OGorman et al, J
Trauma 1989)

• Methods
• n350 (86 trauma) pts, prospective recording of
  time from tourniquet placement to IV fluids
  infusing.
• Data self-reported by paramedics.
• Results
• On scene IV attempts successful 70/90 (77) ?
  average time 3.8min.
• En route IV attempts successful 213/260 (81)
  ? average time 4.1min.
• Lower rates of successful IVs for hypotensive
  pts.
• Conclusions
• Huge potential biases self-reporting and only
  started calculating time once turniquet applied.
• Small study.
• Utility of IV.
• ISS or TS?

37
IV Fluidsto give or not to give - allcomers
Early models of controlled hemorrhagic insults to
animals indicated that volume resuscitation was
beneficial.
38
Animal Models of Uncontrolled Hemorrhage
39
Preventable Death Evaluation of the
Appropriateness of the On-Site Trauma Care
Provided by Urgences-Sante Physicians(Sampalis
et al. J Trauma, 1995)

• Methods
• Analyzed the 73 deaths on the 1987 cohort by
  expert panel review.
• Expert committee 3 surgeons, 3 EPs, 3
  anesthesiologists were blinded to pt outcome.
• Classified injuries as survivable, potentially
  survivable and nonsurvivable.
• Results
• 44/73 (62) of injuries were classified as
  potentially survivable.
• Mean ISS 28 68 had injuries to the HN, 64
  injuries to chest and 32 to the abdomen. 64 of
  these pts were in MVAs.
• Mean prehosp time 40min ?? maximal allowable
  time 23 min.
• Expert committee classified IV fluids as harmful
  for 16 (42), as neutral for 19 (50), and
  beneficial for 3 (8).
• Commentary
• Retrospective based on expert opinion.
• Estimate that IV placement took 5min took
  valuable time on scene when pt should have been
  transported already

40
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)

• IV fluid replacement on scene is associated with
  increased mortality even with short prehospital
  times.
• Methods
• Observational quasi-experimental design2
  cohorts, one from 1987 (n360), second from
  1993-94 in Mtl all pts transported by US.
• Included pts with on-site PHI gt3 who were
  transported alive to hospital.
• Pts txed w/ fluids matched to controls not txed
  w/ IV fluids (matched PHI adjusted for age,
  gender, mech of injury, body region injured,
  ISS).
• Results
• n217 pairs 164 exact matches for PHI scores.

41
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)

• Baseline characteristics
• IV treated group had higher ISS score (14.7 vs
  9.7), had higher incidence of head neck,
  abdominal and chest trauma, higher incidence of
  MVAs, GSWs and SWs.
• Non-IV txed group older pts, higher proportion
  of males, more falls.
• Physician on-scene in 100 of pts treated w/
  IVs, 65 of pts w/o IVs.
• Prehospital times
• Overall the group without IVs got to hospital
  later
• Mean prehospital time 42min in the IV group vs.
  47min in the no IV group.

42
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)
43
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)
44
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)
45
Ineffectiveness of On-Site Intravenous Lines Is
Prehospital Time the Culprit?(Sampalis et al. J
Trauma, 1997)

• After adjusting for ISS, patient age, GSW, MVA
  and prehosp time odds of dying with prehosp
  fluids was still 2.3 (95 CI 1.0-5.3).
• Commentary
• Selection bias significant differences in
  baseline characteristics sicker pts probably
  got an IV.
• Adequate adjustment for differences in baseline
  characteristics?
• More no-IV gp pts from 1993 cohort matched them
  w/ 1987 pts
• Does this reflect a change in physician paradigm
  about IV fluids?
• Or could this have favored the no-IV cohort
  unfairly because of improvements in surgical
  technique, standard of care
• No-IV group 65 had physician on-scene does the
  fact that he/she chose not to put in a line
  reflect the fact that pts were less sick?
• Validity of PHI (i.e. VS) in gaging injury
  severity?

46
Penetrating Torso Trauma
47
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries(Bickell et al. NEJM, 1994)

• Methods Prospective controlled study, quasi
  random assignment.
• Prospective trial Immmediate vs. delayed (IV but
  no fluids till OR) fluid resuscitation in adults
  (gt16 yrs) with GWS or SW to the torso with SBP
  lt90 mm Hg.
• Urban, single EMS and receiving facility
  (Houston), data collection 1989-1992.
• Alternate day assignment (not randomized).
• Early resuscitation group received fluids as per
  paramedic judgment in field, and to BP of 100 mm
  Hg in trauma center.
• In the OR, both groups were resuscitated to BP
  100 mmHg, Hct 25 and u/o 50cc/hr.
• Results
• n 598 (309 immediated resuscitation, 289 delayed
  resuscitation) adults with penetrating torso
  injuries with a prehospital BP lt90.
• Simillar in baseline characteristics.
• Average SBP on scene was 58 (immediate) vs. 59
  mmHg (delayed).

48
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries(Bickell et al. NEJM, 1994)
Baseline characteristics
49
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries(Bickell et al. NEJM, 1994)
On arrival in trauma center
50
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries(Bickell et al. NEJM, 1994)
At initial operative intervention
51
Immediate versus Delayed Fluid Resuscitation for
Hypotensive Patients with Penetrating Torso
Injuries(Bickell et al. NEJM, 1994)

• Volume infused in prehospital phase 870 cc
  vs. 90cc
• Volumes administered in the trauma center
  1600cc vs. 280cc
• 2470cc vs. 370cc
• Intraoperative volume infusion Ringers 6.7L
  vs. 6.5L
• starch 0.5L vs. 0.54L
• PRBP 1.9 vs. 1.7L
• FFP 0.35 vs 0.3L
• immediate versus delayed
• Estimated intraoperative blood loss 3.1L
  2.5L (pNS)
• Length of hospital stay 14d 11days
  (p0.006)
• Survival to hospital discharge 62 (CI
  65-75) 70 (CI 57-68)(p0.04)
• Length of ICU stay 8d 7d (p0.3)
• Complications 30 23
• (sepsis, ADRS, ARF, coagulopathy, infection,
  pneumonia)
• Survival advantage maintained after adjustment
  for prehospital and trauma-center intervals.

52
In response to letters to the editor(Bickell et
al. NEJM, 1995)

• Commentary
• Interestingly, the BP in the OR was the same in
  both groups even though by that point both groups
  had received significantly different volumes of
  resuscitation ? physiologic mechanisms kicking in
  in the delayed group?
• Lack of standardized protocol for fluid
  administration in prehospital setting what were
  the paramedics titrating fluids to?
• Did not report final diagnoses in both groups
  were they similar?
• Pt assignment not random ? alternate day
  assignment.
• Longer intraoperative period delay in the delayed
  resuscitation group ? does this indicate greater
  need for initial intraop resuscitation in the
  delayed resuscitation gp?
• Need for large RTCs to confirm these findings.
• In response to letters to the editor questioning
  the severity of injuries
• Posthoc analysis excluding all minor injuries by
  analyzing only data from pts with ISS gt25 showed
  survival rate of 48 vs. 61 (p0.02) favoring
  the delayed resuscitation group ? confirming that
  baseline differences in severity of injury is
  unlikely to account for the difference in outcome.

53
Hypotensive Resuscitation during Active
Hemorrhage Impact on In-Hospital
Mortality(Dutton RP et al. J Trauma 2002)

• Methods
• RTC hypotensive (SBP 70) vs. normotensive (SBP
  100) resusc
• Included trauma pts with SBP lt90mm Hg documented
  once in the first hour after injury and evidence
  of ongoing hemorrhage.
• Fluid resusc fluid boluses of 200-500ccs until
  target BP reached, if over target BP
  analgesia/sedation was administered if
  indicated.
• Enrolled randomized patients on arrival to
  trauma center.
• Fluids to SBP of 70 vs. 100 while maintaining Hct
  of gt25.
• Results
• n 110 pts, 55 in each group 80 male, 50
  penetrating.
• Baseline characteristics higher rate of blunt
  trauma in hypotensive resusc gp, higher rate of
  pen. trauma in normotensive resusc gp, ISS higher
  in hypotensive resusc gp (19.5 vs. 24)

54
Hypotensive Resuscitation during Active
Hemorrhage Impact on In-Hospital
Mortality(Dutton RP et al. J Trauma 2002)
55
Hypotensive Resuscitation during Active
Hemorrhage Impact on In-Hospital
Mortality(Dutton RP et al. J Trauma 2002)

• Commentary
• Did not reach goal of hypotensive resusc the
  hypotensive gp was normotensive on arrival to
  trauma center ? this alone could explain lack of
  positive result.
• Small study, limited power.
• Analgesics sedatives given to hypertensive
  pts.
• How much fluids in prehospital? How much fluids
  in the trauma center?
• Lower mortality than in the Houston trial does
  hypotensive resusc only make a difference in sick
  pts?
• Treating physicians NOT BLINDED.
• Lower mortality may require larger studies in
  future to detect significant differences in
  survival.

56
Head Injury
57
Comparison of Standard and Alternative
Prehospital Resuscitation in Uncontrolled
Hemorrhagic Shock and Head Injury(Novak et al. J
Trauma, 1999)

• Methods
• 24 anesthetized swine, intubated, hemodynamically
  monitored.
• Arterial phlebotomy w/ ongoing hemorrhage during
  resuscitation and cryogenic brain injury.
• Randomizated to no resuscitation vs. 1000cc RL
  and 3cc/kg of 10 DCLHb
• DCLHb diaspirin cross-linked hemoglobin
  hemoglobin tetramer which has been shown to
  elevate MAP after hemorrhage, contract cerebral
  arteries reduce ischemic changes caused by
  hypotension to the brain.
• Results
• Bld loss greatest in resusc gp, least in the
  delayed resuscitation gp.
• ICP increased slightly in the RL resuscitation
  gp, cerebral perfusion pressure dropped more in
  the delayed resuscitation gp (- 45mm Hg) than in
  the DLCHb gp (-25mm Hg) and the RL gp (-40mm Hg).
• Commentary
• Small animal study. Physiologic endpoints.

58
Prehospital Resuscitation w/ Phenylephrine in
Uncontrolled Hemorrhagic Shock Brain
Injury(Alspaugh, J Trauma 2000)

• Methods
• Anesthetized swine inflicted cryogenic brain
  injury splenic lac. (uncontrolled hemorrhage
  model)
• Delayed RL resuscitation vs. standard RL
  resuscitation vs. phenylephrine to maintain MAP
  at baseline.
• Animals sacrificed and brain biopsies evaluated
  for ischemic damage.
• Results
• Hemorrhage volumes similar.
• Mortality at 8 hrs 11 in Phenylephrine gp vs.
  40 in the delayed resuscitation grp vs. 33 in
  the standard RL grp.
• CPP was not significantly different in the
  different groups.
• In the RL group trend towards smaller ischemic
  penumbra once animals were sacrificed.
• Conclusions
• Small animal study.
• May indicate a role for phenylephrine ? larger
  human studies.

59
Colloids, HS
60
Efficacy of hypertonic 7.5 saline and 6
dextran-70 in treating trauma A meta-analysis of
controlled clinical studies.(Wade et al. Surgery
1997)

• Is isotonic fluid resuscitation in the
  prehospital setting ineffective because too
  little volume can be infused in a short time?
• Methods
• Metaanlysis of RTCs comparing 250cc HS (7.5) w/
  NS/RL in trauma pts with SBP lt100mm Hg.
• Endpoint survival to hospital D/C or 30days.
• Results
• No complications of HS were reported in 11
  studies (n1798).
• No difference in survival rate between HS and
  RL/NS.
• Trend towards better survival in pts with HSD vs.
  RL/NS (NS).
• Comments
• Elusive methodology. Heterogeneity of studies
  not assessed.
• Individual studies did not have the same 30-day
  mortality endpoint.
• One of 11 studies showed greater survival for
  head injuries with HSD.

61
Fluid resuscitation with colloid or crystalloid
solutions in critically ill patients a
systematic review of randomised
trials(Schierhout Roberts, BMJ 1998)

• Methods
• Systematic review of RTCs comparing colloids
  (albumin, pentastarch, dextran, HS, Ringers
  acetate, plama, Haemacell) with crystalloid in
  critically ill pts (trauma, burns, surgery and
  sepsis)
• Outcome all-cause mortality.
• Results
• 37 trials, 26 unconfounded, 19 reported mortality
  ? n 1315 pts.
• Absolute risk increase of mortality 4 for
  colloid (CI 0-8), trend similar with trials with
  adequate concealment of allocation.
• Trials not heterogeneous.
• Comments
• Different colloids used, different resusc
  protocols in different studies.
• ? Colloids remain the resuscitation fluid of
  choice

62
Human albumin administration in critically ill
patients systematic review of randomised
controlled trials(Cochrane Injuries Group
Reviewers, BMJ 1998)

• Methods
• Identified 32 RTC on albumin or plasma protein
  fraction supplementation vs crystalloid
  resuscitation in hypovolemic (surgery, trauma,
  burns) or hypoalbuminemic pts.
• Endpoint mortality at end of follow-up - not
  specified how long this was
• Results
• Significant increased RR of mortality w/ albumin
  overall and in all subgroups (RR 1.68 CI
  1.26-2.23) ? pooled increase in risk of death 6
  (3-9)
• No significant heterogeneity reported.
• Comments
• Mortality not reported at specific time cut-off
  (were later deaths missed?)
• Small studies, small amount of deaths, not all
  properly concealed.

63
Case 1 Pedestrian versus car

• Blunt trauma permissive hypotension vs.
  normotensive resuscitation debate not resolved,
  but he may also have a head injury and is
  unstable...
• Isotonic resuscitation, consider HS.
• STAT angio (during which dropped BP) ? surgically
  uncontrollable bleed needs to tamponade
  retroperitoneum.
• ? will need blood (and lots of it!)
• Massive resuscitation in ICU.

64
Case 1 Pedestrian versus car
65
Case 1 Pedestrian versus car
66
Case 2 Penetrating Torso Trauma
67
Case 2 Penetrating Torso Trauma

• Left chest tube STAT!!
• STAT OR if he drains more than cc immediately or
  .cc/hr.
• If BP recovers permissive hypotension. Get 2
  lines and have fluids and blood ready to go if
  needed.
• If unstable ? right chest tube and volume ? OR if
  does not stabilize, CT scan if stabilizes.

68
Case 2 Penetrating Torso Trauma
69
Case 3 Head Injury

• HS 250cc of 7.5 Saline with Dextran.
• No mannitol unless HD stable!Isotonic Fluid
  resuscitation to maintain good cerebral perfusion
  pressure.
• CT head if HD stable, otherwise OR.

70
Case 4 Fall

• Scoop and run with further attempts in the
  ambulance, continue secondary survey for
  potentially reversible causes (i.e.
  pneumothorax).
• Unfortunately, coded en route.
• Autopsy ruptured liver, retroperitoneal bleed.

71
Questions?
72
References

• American College of Surgeons. ATLS Manual, 6th
  Ed. Chicago. 1997.
• Alspaugh D, Sartorelli K, Shackford SR.
  Prehospital Resuscitation with Phenylephrine in
  Uncontrolled Hemorrhagic Shock and Brain Injury.
  J Trauma 2000 48,5851-864.
• Aprahamian et al. Traumatic Cardiac Arrest Scope
  of Paramedic Services. Ann Emerg Med 1985 14,6
  583-586.
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