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

1. Prehospital and ED Fluid Resuscitation in Trauma…to 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, you’re in the resus bay…he’s thrashing around… • GCS 14, HR120, 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 he’s 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. Rosen’s 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 orhypotensive resuscitationfor 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, 6thed. 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 3:1 with Ringer’s.

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 250ccagainst 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 > 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 >80 U/O >0.5cc/kg/hr HR < 120GCS 15 O2 sat >96% lactate <1.6 base def > -5 Hb >90

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 setting…The 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: • n=498 victims with penetrating trauma and SBP<90 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(O’Gorman et al, J Trauma 1989) Methods: • n=350 (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 Fluids:…to 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 H&N, 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” design:2 cohorts, one from 1987 (n=360), second from 1993-94 in Mtl: all pts transported by US. • Included: pts with on-site PHI >3 who were transported alive to hospital. • Pts tx’ed w/ fluids matched to controls not tx’ed w/ IV fluids (matched PHI; adjusted for age, gender, mech of injury, body region injured, ISS). Results: • n=217 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 tx’ed group: older pts, higher proportion of males, more falls. • Physician on-scene in 100% of pts treated w/ IV’s, 65% of pts w/o IV’s. Prehospital times: • Overall the group without IV’s 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 forISS, patient age, GSW, MVA and prehosp timeodds 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 (>16 yrs) with GWS or SW to the torso with SBP <90 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 <90. • Simillar in baseline characteristics. • Average SBP on scene was58 (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: