Download - Frederick A. Moore MD November 8, 2012 Resuscitation Beyond the Abdominal Compartment Syndrome (ACS)
Frederick A. Moore MD
November 8, 2012
Resuscitation Beyond the
Abdominal Compartment Syndrome (ACS)
1)Discuss 4 advances in trauma care that occurred in the 1980s that caused an epidemic of ACS in 1990s.
2) Discuss implementing and studying a ICU resuscitation protocol that helped us recognize that ACS is iatrogenic.
3) Discuss fundamental changes in early management of patients who arrive with severe bleeding to eliminate ACS.
Objectives
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
High Volume Trauma Centers with Shock Trauma ICU
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
Early High Volume Isotonic Crystalloid Resuscitation to Achieve Normal Blood Pressure as Standard of Care
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented Resuscitation
Severely injured patients do not bleed to death in OR
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented ICU Resuscitation
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented ICU Resuscitation
Advances in Trauma Care in 1980s
Epidemic of ACS in the mid 1990s
Problematic gut edema in the nonresponders
Memorial Hermann Hospital UT Houston Med School
Moved to Houston in December 1995
Memorial Hermann Hospital UT Houston Medical School
LIFE FLIGHTFOUNDED IN 1976
Dr James H “Red” Duke Jr
BLUNT TRAUMA PLUS SHOCK
A Decision Making Conundrum
LDS Hospital Salt Lake City, Utah
Alan Morris MD Tom East PhD
LDS Hospital Salt Lake City, Utah
Computerized Clinical Decision Support (CCDS) For Mech Vent Of ARDS
“Significant problems we face cannot be solved at the same level of thinking we were at when we created them.”
Albert Einstein
Bruce McKinley
J Trauma 2002
Matt Sailors
J Trauma 2002
Bioengineer Informatics Expert
J Trauma 2001J Trauma 2001J Trauma 2001
Bedside Algorithm
DENVER GENERAL HOSPITAL
Crit Care Med 1988
William Shoemaker
Berfauk 1991 Peri-Op Surg Yes
Fleming 1992 Trauma Yes
Tuchschmidt 1992 Septic Shock ? Yes
Yu 1993 Sick ICU No
Boyd 1993 Peri-Op Surg Yes
Hayes 1994 Sick ICU No
Durham 1995 Trauma No
Gattinoni 1995 Med ICU No
Yu 1998 Surg > 50 yrs Yes
PRCT’s TESTING “ SUPRANORMAL DO2 ” RESUSCITATION DOES IT REDUCE MORTALITY?
DO2
goal
1) Hb (PRBC; Hb 10 )
2) volume (LR; PCWP >15 )
3) Optimize CI - PCWP(Starling curve)
4) low dose Inotropes 5) vasopressor
Yes No
Yes
No
Met inclusion criteria
On ICU admission:art, PA, NG tonometer catheters
baseline ABG, Hb, lactate
24 hours?24 hours?
Echocardiographystop resuscitationstandard ICU carestop resuscitationstandard ICU care
lactate, BD, PrCO2
bladder pressureQ 4h (reassess sooner if
abnormal)
Monitor:
Q 4h (reassess sooner if abnormal)
> 600
Started 1997 DG MOF Database
1.1. Iterative processIterative process2.2. Evaluation / testing at each stepEvaluation / testing at each step3.3. Never “done” – always monitoring / refiningNever “done” – always monitoring / refining
ICU Shock Resuscitation
Me Algorithms Matt
J Trauma 2002J Trauma 2002
COMPUTER DIRECTED RESUSCITATION OF MAJORTORSO TRAUMA
Bruce A. McKinley, R. Matthew Sailors, Christine S. Coconour, Alicia ValdiviaRosemary M. Kozar, and Frederick A. Moore
Standard of Care in 1999
J Trauma 2002J Trauma 2002
PROSPECTIVELY COLLECT DATA
HOW PATIENTS RESPOND TO INTERVENTIONS
J Trauma 2002J Trauma 2002
ONGOING DATA ANALYSIS
REFINEMENTS IN THE PROTOCOL
Ann Surg Sept 2000
Mm
George Velmahos
Los Angeles County
Ann Surg Sept 2000
DO2
goal
1) Hb (PRBC; Hb 10 )
2) volume (LR; PCWP > 15 )
3) Optimize CI- PCWP(Starling curve)
4) low dose Inotropes 5) vasopressor
Yes No
Yes
No
Met inclusion criteria
On ICU admission:art, PA, NG tonometer catheters
baseline ABG, Hb, lactate
24 hours?
Echocardiography
lactate, BD, PrCO2bladder pressureQ 4h (reassess sooner if abnormal)
Monitor:
Q 4h (reassess sooner if abnormal)
> 500
Computerized Protocol
stop resuscitationstandard ICU care
Changed DO2 goal
January 2001
STANDARD OF CARE
Field / ED / OR / IR Suite ATLS
“ Damage Control ” surgery
Early triage to the ICU
Optimize systemic perfusion
SAVES LIVES
Jim Cross
ABDOMINAL COMPARTMENT SYNDROME
Open abdomens
Organ failure
Prolonged ICU stays
Field / ED / OR / IR Suite ATLS
“ Damage Control ” surgery
Early triage to the ICU
Optimize systemic perfusion
SAVES LIVES – BUT ???????
STANDARD OF CARE
PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES
Case Reports in the 1980s
PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES
Case Reports in the 1980s
Recognized Entity by mid 1990s
Patient Type Incidence Mortality
Morris
1993
Damage Control 15% 63%
Hirshberg
1994
Damage Control 3% 100%
Meldrum
1997
E-Lap
ICU Admit
14% 30%
Ivatury
1998
Penetrating Severe, E-Lap
32% 44%
Raeburn
2001
Damage Control 36% 43%
PRIMARY ACS ASSOCIATED ABDOMINAL INJURIES
Case Reports in the late 1990s
SECONDARY ACSNO ABDOMINAL INJURIES
Case Reports in the late 1990s
Recognized Entity by early 2000s
SECONDARY ACSNO ABDOMINAL INJURIES
N ISS Mortality (%) UBP (mmHg)
Hours to decompression
Lived Died
Maxwell
1999
6 25 67 33 3 25 *
Kopelman
2000
6 17 67 31 48 192 *
Biffl
2001
14 NA 38 30 12 5
Balogh
2002
11 28 54 34 14 10
CASE SERIES
SECONDARY ACSNO ABDOMINAL INJURIES
N ISS Mortality (%) UBP (mmHg)
Hours to decompression
Lived Died
Maxwell
1999
6 25 67 33 3 25 *
Kopelman
2000
6 17 67 31 48 192 *
Biffl
2001
14 NA 38 30 12 5
Balogh
2002
11 28 54 34 14 10
CASE SERIES
SECONDARY ACSNO ABDOMINAL INJURIES
Shock 2003
Zsolt Balogh
Visiting Research Fellow
Hungarian Trauma Surgeon
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
J Trauma 2003J Trauma 2002
#2
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D.,Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D. J Trauma 2002
J Trauma 2003J Trauma 2002J Trauma 2002
# 3
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Charles C. Cox, M.D.and Frederick A. Moore, M.D.
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., John B. Holcomb, M.D., Charles C. Miller, Ph.D.,Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, RN Drue N. Ware, M.D. and Frederick A. Moore, M.D.
# 3
#2
Am J Surg 2003
152 Resuscitation Protocol Patients
85 Patient16 months ending Jan 2001 DO2I Goal > 600
71 Patient16 months after Jan 2001 DO2I Goal > 500
# 4
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., Alicia Valdivia, R.N. R. Mathew Sailors, B.S.,Frederick A. Moore, M.D.
Arch Surg 2003
GroupAge
(years)Male (%)
ISS BD (mEq/L)
Pre-ICU
LR (L)
Pre-ICUPRBC
(U)
DO2I600 37 ±3 76 28 ±3 9 ±1 6 ±1 5 ±1
DO2I500 33 ±2 74 27 ±2 9 ±1 5 ±1 5 ±1
GROUPS WERE SIMILAR PRIOR TO ICU ADMIT
Cardiac Index during ICU resuscitation
2.5
3
3.5
4
4.5
5
5.5
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)
Car
diac
Inde
x (m
L/m
in/m
2)
DO2I>600DO2I>500
Base Deficit During ICU Resuscitation
-1
0
1
2
3
4
5
6
7
8
1 5 9 13 17 21 25Time (hours)
Bas
e D
efic
it (m
Eq/
L)
DO2I>600
DO2I>500
P = 0.07
SvO2 During ICU Resuscitation
70
71
72
73
74
75
76
77
78
79
80
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)
SvO
2 (%
)
DO2I>600
DO2I>500
Serum Lactate Concentration
1.5
2.5
3.5
4.5
5.5
6.5
1 5 9 13 17 21 25Time (hours)
Ser
um
Lac
tate
(mm
ol/L
) DO2I>600
DO2I>500
CARDIAC INDEX
BASE DEFICIT
SvO2
LACTATE
Lactated Ringer's Infusions
0
2
4
6
8
10
12
14
16
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24Time (hours)
Lact
ated
Rin
ger's
(Lite
rs)
DO2I>600
DO2I>500
Packed Red Blood Cell Transfusions
0
1
2
3
4
5
6
7
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Time (hours)P
RB
C (U
nits
)
DO2I>600
DO2I>500
P < 0.05 P = 0.07
Group IAH % ACS % MOF % Death %
DO2I600 42 * 16 * 22 * 27 *
DO2I500 20 8 9 11
* p< 0.05IAH = UBP > 20 mm Hg
Shock 2003
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
Shock 2003
Epidemiology of Primary and Secondary ACS
Surprizingly Early Decompressive Lap ~ 12 hrs
Accurately Predict within 3 hrs after ED Arrival
Strongly Associated with MOF and Death
Shock 2003
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
Shock 2003
ACS and ICU Resuscitation Protocol
Impending ACS patients are non-responders
Decreasing D02 goal decreased ACS, MOF & Death
Shock 2003
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
Shock 2003
ACS is not an ICU resuscitation problem
It starts in the ED in patients arriving with severe bleeding
Fundamental changes in early care of these patients
Shock 2003
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
Shock 2003
ACS is not an ICU resuscitation problem
It starts in the ED in patients arriving with severe bleeding
Fundamental changes in early care of these patients
Shock 2003
Secondary abdominal compartment syndrome is an elusive early complication of traumatic shock resuscitation
Zsolt Balogh, M.D., Bruce A. McKinley, Ph.D., Christine S. Coconour, M.D.,Rosemary A. Kozar, M.D.,Ph.D., John B. Holcomb, M.D., Drue N. Ware, MD. Frederick A. Moore, M.D.
Am J Surg 2002
Shock 2003
ACS is not an ICU resuscitation problem
It starts in the ED in patients arriving with severe bleeding
Fundamental changes in early care of these patients
FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERE BLEEDING
ED Resuscitation Massive Transfusion
Whole Body CT Scanning
FAST with backup Diagnostic Peritoneal Aspirate
Pelvic Fracture
ED Resuscitation Massive Transfusion
Whole Body CT Scanning
FAST with backup Diagnostic Peritoneal Aspirate
Pelvic Fracture
FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERE BLEEDING
ED RESUSCITATION
Stabilize
BP < 90 mmHgor
BD ≥ 6 mEq/L
Place Central Line
CVP < 10 CVP > 15
? Cardiogenic Shock
Inflammation and the Host Response to Injury, a Large-Scale Collaborative Project:Patient-Oriented Research Core - Standard Operating Procedures for Clinical Care
III. Guidelines for Shock Resuscitation
Frederick A. Moore, MD, Bruce A. McKinley, PhD, Ernest E. Moore, MD, Avery B. Nathens, MD, PhD, MPH,Michael West, MD, PhD, Michael B. Shapiro, MD, Paul Bankey, MD, PhD, Bradley Freeman, MD,Brian G. Harbrecht, MD, Jeffrey L. Johnson, MD, Joseph P. Minei, MD, and Ronald V. Maier, MD
Surgical Glue Grant
J Trauma 2006
Evidence Based ED Shock Algorithm
ED RESUSCITATION
Traumatic Shock ATLS – volume load
Arterial Blood Gas
Stabilize
Place Central Line
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
ED RESUSCITATION
Traumatic Shock ATLS
ABG
Stabilize
Systolic Blood Pressure < 90 mmHgor
Base Deficit ≥ 6 mEq/L
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
ED RESUSCITATION
Traumatic Shock ATLS
ABG
Stabilize
SBP < 90 mmHgor
BD ≥ 6 mEq/L
Place Central Line
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
ED RESUSCITATION
Traumatic Shock ATLS
ABG
Stabilize
SBP < 90 mmHgor
BD ≥ 6 mEq/L
Place Central Line
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
ED RESUSCITATION
Traumatic Shock ATLS
ABG
Stabilize
SBP < 90 mmHgor
BD ≥ 6 mEq/L
Place Central Line
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
ED RESUSCITATION
Traumatic Shock ATLS
ABG
Stabilize
SBP < 90 mmHgor
BD ≥ 6 mEq/L
Place Central Line
CVP < 10 CVP > 15
Resuscitate until stableor
[Hb] ≥ 10 & CVP ≥ 10
? Cardiogenic Shock
“Waffle”
NEJM 1994
Ken Mattox
HYPOTENSIVE RESUSCITATION
Standard of Care for
Penetrating Torso Trauma
598 PatientsPenetrating Torso Trauma Field SBP < 90 mm Hg
309 ImmediateResuscitation
298 DelayedResuscitation
62 %Survival
70 %Survival
*
* p < 0.05
NEJM 1994
BLUNT TRAUMA plus SHOCK
? Hypotensive Resuscitation
NEJM 1994
More Complex Clinical Decisions
CPP Secondary Brain Injury
Volume Loading Defines Stability
BLUNT TRAUMA plus SHOCK
? Hypotensive Resuscitation
NEJM 1994
More Complex Clinical Decisions
CPP Secondary Brain Injury
Volume Loading Defines Stability
20% have associated Head Injury – very bad outcomes
BLUNT TRAUMA plus SHOCK
? Hypotensive Resuscitation
NEJM 1994
More Complex Clinical Decisions
CPP Secondary Brain Injury
Volume Loading Defines Stability
This drives early triage decisions
BLUNT TRAUMA plus SHOCK
? Hypotensive Resuscitation
NEJM 1994
More Complex Clinical Decisions
CPP Secondary Brain Injury
Volume Loading Defines Stability
SBP > 90 mm Hg and HR < 13O until Hemorrhage Control
Permissive Hypotension
ED Resuscitation Massive Transfusion
Whole Body CT Scanning
FAST with backup Diagnostiic Peritoneal Aspirate
Pelvic Fracture
FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERE BLEEDING
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
John Holcomb
Massive Transfusion Protocol
ED, OR & IR suite
Empiric replacement
ICU Protocol
Lab test driven
Recombinant Factor VIIa Protocol
Rescue therapy
Fill out approval form
Call Keith Hoots, M.D.
Treatment of Postinjury Coagulopathy
Critical Care Fellow
MASSIVE TRANSFUSION PROTOCOLStart After 6 units of PRBCs
Attending/Fellow notifies Blood BankCall 4-3640
Send runner to pick up cooler6 Units PRBC’s6 Units FFP
Blood Bank will replace coolers6 Units PRBC’s6 Units FFP
6 Pack of platelets every 12 units PRBC’sWhen patient arrives in ICU Blood Bank stops the protocol
ICU PROTOCOL
ICU PROTOCOL
ICU PROTOCOL
ICU PROTOCOL
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
Ernest Gonzalez
Critical Care Fellow
T-32 Research Fellow
Became Trauma Attending
Inherited Massive Transfusion Protocol
Sent to us by John Holcomb
Prothrombin time, Int'l Normalized Ratio
12
14
16
0 4 8 12 16 20 24
PT
(s
ec
)
1.2
1.3
1.4
1.5
1.6
INR
PT v timeINR
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
23 ( 11 % ) had ICU admission PT > 18 sec
23 ( 12 % ) had PT > 18 sec
HOW ARE WE DOING ?
Resuscitation Protocol Shock
J Trauma 2006
Lactated Ringers 9 ± 1 liters
PRBC 11 ± 1units
FFP 5 ± 0.4 units
100 % Hemorrhage Control Interventions
94 Emergency operations
16 Interventional radiology embolizations
Arrived in STICU 6.8 ± 0.3 hrs after ED admit
97 Massive Transfusion Patients Pre-ICU Resuscitation
6 unit difference by design
Lactated Ringers 9 ± 1 liters
PRBC 11 ± 1units
FFP 5 ± 0.4 units
100 % Hemorrhage Control Interventions
94 Emergency operations
16 Interventional radiology embolizations
Arrived in STICU 6.8 ± 0.3 hrs after ED
97 Massive Transfusion Patients Pre-ICU Resuscitation
6 unit difference by design
Too much
Too long
Int'l Normalized Ratio, PRBC transfusion
1.2
1.4
1.6
0 4 8 12 16 20 24ICU TIME (hr)
INR
0
2
4
6
8
10
12
PR
BC
(uni
t)
INR
PRBC
ICU Resuscitation Protocol
Cumulative PRBC/FFP Volumes 1st 24 hrs of STICU Resuscitation
Cumulative PRBC, FFP Volumes
0
4
8
12
0 4 8 12 16 20 24
ICU TIME (hr)
PR
BC
, FFP
(un
it)
PRBC
FFP
9 ± 1 Units PRBC9 ± 1 Units FFP
INR on ICU admission vs Mortality
ICU Admission BD = 6.6 ± 0.5
Early ICU INR vsProbability of Death
0
0.2
0.4
0.6
0.8
1
1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7
INR
pro
ba
bilit
y p=0.02P = 0.02, ROC = 0.71
Patients who arrive in the ICU with a coagulopathy die
Prothrombin time, Int'l Normalized Ratio
12
14
16
0 4 8 12 16 20 24
PT
(s
ec
)
1.2
1.3
1.4
1.5
1.6
INR
PT v timeINR
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
23 ( 11 % ) had ICU admission PT > 18 sec
23 ( 12 % ) had PT > 18 sec
Start MTP as soon as the need can be identified
Do not wait until 6 units PRBCs
Give fresh thawed plasma with 1st unit PRBC
Maintain units of FFP:PRBC ratio at 1:1
Limit crystalloids
Focus on hemorrhage control
J Trauma 2006
Prothrombin time, Int'l Normalized Ratio
12
14
16
0 4 8 12 16 20 24
PT
(s
ec
)
1.2
1.3
1.4
1.5
1.6
INR
PT v timeINR
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
23 ( 11 % ) had ICU admission PT > 18 sec
23 ( 12 % ) had PT > 18 sec
Start MTP as soon as the need can be identified
Give fresh thawed plasma with 1st unit PRBC
Maintain units of FFP:PRBC ratio at 1:1
Limit crystalloids
Focus on hemorrhage control
J Trauma 2006
Prothrombin time, Int'l Normalized Ratio
12
14
16
0 4 8 12 16 20 24
PT
(s
ec
)
1.2
1.3
1.4
1.5
1.6
INR
PT v timeINR
0 4 8 12 16 20 24Time ( hrs after ICU Admission)
23 ( 11 % ) had ICU admission PT > 18 sec
23 ( 12 % ) had PT > 18 sec
Start MTP as soon as the need can be identified
Give fresh thawed plasma with 1st unit PRBC
Maintain units of FFP:PRBC ratio at 1:1
Limit crystalloids
Focus on hemorrhage control
J Trauma 2006
Follow-up StudyPost 1:1 FFP to PRBC Protocol
95 Patients over 24 Months ending June 07
Age = 37 ± 2 , 73.6% Male Gender
ISS = 28 ± 1 , 69 % Blunt Mechanism
ED Base Deficit = 9 ± 0.6 , ED INR = 1.6 ± 0.1 85 % Survival , ICU Stay = 17 ± 2 days
Presentation at 2008 Western Trauma Association
192 MT Patients
Age 39±2 37±1.6 0.44
ISS 29±1 28±1 0.53
ED BD 10±0 9±0.6 0.67
ED INR 1.8±0.2 1.6±0.08 0.41
97Pre 1:1
P value 95Post 1:1
Follow-up Study
192 MT Patients
97Pre 1:1
95Post 1:1 P value
Pre-ICU Cryst (L) 9±1 6±0.4 0.07
Pre-ICU PRBC 12±1 15±1.2 0.06
Pre-ICU FFP 5±0.4 11±1.0 <0.05
Hrs ED to ICU admit 6.8 ± 0.3 4.4 ± 0.2 <0.05
Follow-up Study
192 MT Patients
97Pre 1:1
P value
ICU admit 35.4 ± 0.1 36.5 ± 0.1 <0.001 Temp
ICU admit 7 ± 1 5 ± 1 0.16 BD (mEq/L)
ICU Admit 1.6±0.04 1.4±0.03 0.02 INR
Mortality 30 % 15 % 0.02
95Post 1:1
Follow-up Study
192 MT Patients
97Pre 1:1
P value
ICU admit 35.4 ± 0.1 36.5 ± 0.1 <0.001 Temp
ICU admit 7 ± 1 5 ± 1 0.16 BD (mEq/L)
ICU Admit 1.6±0.04 1.4±0.03 0.02 INR
Mortality 30 % 15 % 0.02
95Post 1:1
Follow-up Study
ED Resuscitation Massive Transfusion
Whole Body CT Scanning
FAST with backup Diagnostic Peritoneal Aspirate
Pelvic Fracture
FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERELY BLEEDING
BLUNT TRAUMA PLUS SHOCK
ATLS Volume Challenge
Unstable Stable
Operating Room Whole Body CT Scan
Critical Triage Decision
BLUNT TRAUMA PLUS SHOCK
ATLS Volume Challenge
Unstable Stable
Operating Room Whole Body CT Scan
Do You Have 30 mins?
Know All Serious Injuries
BLUNT TRAUMA PLUS SHOCK
ATLS Volume Challenge
Unstable Stable
Operating Room Whole Body CT Scan
If you don’t have 30 mins !Your Chance to Save a Life
CRUCIAL TRIAGE DECISION
ATLS Volume Challenge
Unstable Stable
Base Deficit
StO2
CVP
Age
Obvious Injuries
CT Scan AvailabilityOperating Room CT Scan
Focused Assessment for Sonography in Trauma Patients
4 Views
Right Upper Quadrant
Pericardial Area
Left Upper Quadrant
Suprapubic Area
FAST Exam has Replaced DPL
FAST: USA Series
Year # Patients Sensitivity Specificity
Rozychi 1995 371 82% 99%
Healy 1996 796 89% 98%
McKinley 1996 1000 88% 99%
Thomas 1997 300 81% 99%
Dolich 2000 2500 86% 98%
FAST: Experts Performance
Year # Patients Sensitivity Specificity
Rozychi 1995 371 82% 99%
Healy 1996 796 89% 98%
McKinley 1996 1000 88% 99%
Thomas 1997 300 81% 99%
Dolich 2000 2500 86% 98%
Positive FAST - very valuable for triage decisions
Negative FAST - does not rule out intra-abdominal bleeding
Backup Diagnostic Peritoneal Aspirate (DPA)
ED Resuscitation Massive Transfusion
Whole Body CT Scanning
FAST with backup Diagnostic Peritoneal Aspirate
Pelvic Fracture
FUNDAMENDAL CHANGE IN PRE - ICU CARE OF PATIENTS ARRIVING WITH SEVERE BLEEDING
Typical Friday Night Case
39 yr old male, high speed MCC
Intubated, field SBP < 90, 1.5 liter LR
1 hr from time of injury to trauma center arrival
On arrival SBP = 84 , HR = 120
Responded to a fluid bolus
39 yr old male, high speed MCC
Intubated, field SBP < 90, 1.5 liter LR
1 hr from time of injury to trauma center arrival
On arrival SBP = 84 , HR = 120
Responded to a fluid bolus
Typical Friday Night Case
SBP = 108 & HR = 110 [Hb] = 10.7 gm/dl Base deficit = 9 mEq/L INR = 1.6 , FAST negative
After 20 minutes
RESUSCITATION PROTOCOL
MassiveTransfusion Policy
FAST/DPL
+_
Unstable Stable
OR Whole Body CT Scan
Unstable Pelvic Fracture
Central Line
Open Booked Vertical Shear
Unstable Pelvic Fracture MassiveTransfusion ProtocolWrap Pelvis
FAST/DPL
+_
Unstable Stable
OR Whole Body CT Scan
Limit Crystalloids
Permissive Hypotension
RESUSCITATION PROTOCOL Central Line
PELVIC FRACTURE plus SHOCK
“Play Cards” Quickly
Pack Pelvis & do an Exploratory Laparotomy
30% Spleen/Liver/Mesenteric Bleeding
Angiography
Radiology Consult
External Fixation
Orthopedic Consult
Unstable Pelvic FractureWrap Pelvis
FAST/DPA
+_
Unstable Stable
OR Whole Body CT Scan
MassiveTransfusion Protocol
RESUSCITATION PROTOCOL Central Line
Limit Crystalloids
Permissive Hypotension
Unstable Pelvic FractureWrap Pelvis
FAST/DPA
+_
Unstable Stable
OR Pack PelvisLaparotomy
Angio
Shock Trauma ICU
OR FixationIf Appropriate
MassiveTransfusion Protocol
RESUSCITATION PROTOCOL Central Line
Limit Crystalloids
Permissive Hypotension
J Trauma 2005
Gene Moore
J Trauma 2005
Unstable Pelvic FractureWrap Pelvis
FAST/DPA
+_
Unstable Stable
Whole Body CT Scan
Angio PelvicBlush
Shock Trauma ICU
OR FixationIf Appropriate
MassiveTransfusion Protocol
Limit Crystalloids
Hypotensive Resuscitation
RESUSCITATION PROTOCOL Central Line
“ The connection between cause and effect
has no beginning and can have no end “
Leo Tolstoy
War and Peace
Trauma System Development
Advanced Trauma Life Support
Damage Control Surgery
Goal Oriented ICU Resuscitation
ADVANCES IN TRAUMA CARE
Saved Patients Who Used to Bleed to Death in OR
ADVANCES IN TRAUMA CARE
EPIDEMIC ABDOMINAL COMPARTMENT SYNDROME
J Trauma 2003J Trauma 2002
Am J Surg 2003
Shock 2003
By implementing & studying an ICU resuscitation protocol
ACS starts in the ED in patients arriving with severe bleeding
Fundamental changes in early care of these patients
has largely eliminated this iatrogenic complication!
SHOCK 2003
J Trauma 2003J Trauma 2002
Am J Surg 2003
Shock 2003
By implementing & studying an ICU resuscitation protocol
ACS starts in the ED in patients arriving with severe bleeding
Fundamental changes in early care of these patients
has largely eliminated this iatrogenic complication!
2010’ s: What will kill next generation of trauma patients ?
SHOCK 2003
Rosemary Kozar
John Holcomb
Trey Miller Zsolt Balogh
Chris Cocanour
Ernest GonzalezNeel Ware Chuck Cox