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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.
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
Worst time
Best time
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
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
3127+4937
2555+3546
0.11
14+24
11+19
0.006
8+16
7+11
0.30
Variable
Survival to dischargeno. of
patients/total patients (%)
Hypotensive Resuscitation
Maryland Shock Trauma
In hospital
Inclusion criteria
SBP <90 mmHg
Ongoing hemorrhage
Blunt or penetrating trauma
Treatment
Hypotensive Resuscitation
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
Survival
No difference at 30 days
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
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
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
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
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
Thank you
Dessy Boneva MD, FACS
USF/Kendall Trauma