Intravenous Resuscitation Training Module

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Utah Trauma Systems Advisory Committee Training Module on Evidence-Based Fluid Resuscitation in Trauma for EMS and Emergency Department Providers

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Intravenous Resuscitation for Trauma:

Intravenous Resuscitation for Trauma Evidence-Based Prehospital and Emergency Department Guidelines Utah Trauma Systems Advisory Committee Utah Bureau of EMS and Preparedness

Utah Preventable Mortality Study:

Utah Preventable Mortality Study Analysis of all traumatic deaths in Utah for the year 2005 Looking for preventable contributions to trauma deaths from: EMS ED Hospital Care Sanddal T, et al. J Trauma 2011;70:970

Utah Preventable Mortality Study:

Utah Preventable Mortality Study Most common “Opportunities for Improvement” IV fluid resuscitation Airway Management Documentation This training is an effort to address the findings of the study

Goals of Resuscitation:

Goals of Resuscitation Stop hemorrhage Resuscitate Replace lost volume and blood components Maintain energy production Maintain oxygen delivery to RBC/Hgb molecule Deliver RBCs/oxygen to tissues

Goals of Resuscitation:

Goals of Resuscitation “Replace what the patient has lost” If blood has been lost, give blood (hemorrhage) If crystalloid has been lost, give crystalloid (dehydration)

Fluid Choices:

Fluid Choices Crystalloid (normal saline, Ringer’s lactate) Colloid (hetastarch, albumin, plasma) Blood (whole vs. components) RBCs, plasma, platelets

Traditional Teaching :

Traditional Teaching Hypotensive Trauma Patient IV Crystalloid to restore BP to normal range Normal Saline Lactated Ringers

New Concept :

New Concept IV Fluid given before mechanical hemorrhage control increases bleeding “ Pop the Clot ” Increasing BP causes frail clot to fail Increasing vessel width stretches clot

Other Problems with Crystalloid in Trauma:

Other Problems with Crystalloid in Trauma It’s not what the patient has lost Problems with over-hydration Peripheral edema Abdominal compartment syndrome Renal failure Dilution of clotting factors

Hemorrhage Management Protocol Accessible Site:

Hemorrhage Management Protocol Accessible Site Stop the bleeding! Direct pressure / pressure dressing Tourniquet Resuscitation with crystalloid or blood products to restore BP to near normal may then safely be carried out Goal: systolic BP 90 – 100 mmHg

Hypotensive Resuscitation Protocol (Permissive Hypotension):

Hypotensive Resuscitation Protocol (Permissive Hypotension) If bleeding from an inaccessible site: Chest /abdomen/ pelvis Stop obvious visible hemorrhage (direct pressure) Patient still may have ongoing internal bleeding Allow patient to remain hypotensive (SBP ≥ 90 ) Place saline lock (or extension set) for access Fluids replaced after surgical control of bleeding

Research Evidence Prehospital Fluids in Trauma:

Research Evidence Prehospital Fluids in Trauma Houston Penetrating trauma Half given IV fluids, half not Those without fluids did better Bickell, et al. NEJM 1994;331:1105

Research Evidence Prehospital Fluids in Trauma:

Research Evidence Prehospital Fluids in Trauma San Diego Patients who received prehospital IV fluids compared to those who didn’t No difference in mortality Kaweski, et al. J Trauma 1990; 30:1218

Research Evidence Prehospital Fluids in Trauma:

Research Evidence Prehospital Fluids in Trauma National Trauma Data Bank Analysis 2001-2005 / 776,000 patients Half with IVs, half with no IVs Overall mortality and outcomes better in group with no IVs Haut, et al. Ann Surg 2011;253:371

New Prehospital IV Fluid Recommendations for Trauma:

New Prehospital IV Fluid Recommendations for Trauma Stop visible bleeding Assess for shock Signs of shock : Hypotension, tachycardia Loss of radial pulse Decreased mental status

New Prehospital IV Fluid Recommendations for Trauma:

New Prehospital IV Fluid Recommendations for Trauma If in shock : 500 – 1000 cc crystalloid bolus Reassess Repeat bolus if necessary Goal : increase perfusion, SBP ≥ 90 Goal is not “normal BP” Rapid transport to Trauma Center / ED

New Prehospital IV Fluid Recommendations for Trauma:

New Prehospital IV Fluid Recommendations for Trauma If not in shock : No IV fluids necessary Intact radial pulse, SBP ≥ 90, normal mental status Start saline lock (or extension set / TKO fluid) Rapid transport to Trauma Center / ED Monitor carefully for shock

Head Injured Patients:

Head Injured Patients Hypotension is bad for the brain in a head injured patient! Priority: maintain cerebral perfusion Maintenance of cerebral perfusion balanced by “don’t pop the clot” Recommendation: Maintain SBP 100 – 110 IV fluids Blood products

Other Important Considerations:

Other Important Considerations Short scene times (< 10 minutes) Limited scene interventions Work in back of ambulance en route to Trauma Center / ED Future: lyophilized plasma for prehospital use Note: these are adult recommendations

Emergency Department IV Resuscitation Recommendations for Trauma:

Emergency Department IV Resuscitation Recommendations for Trauma “Replace what is lost” Limited to no crystalloid use for trauma Early administration of blood “1:1:1” 1 unit PRBCs : 1 unit FFP : 1 unit platelets Or 1 PRBC : 1 FFP (if platelets not available)

Early Blood Product Administration “1:1:1”:

Early Blood Product Administration “1:1:1” Advantages: Replaces oxygen-carrying Hgb Replaces clotting factors Replaces platelets Minimizes edema (stays in vascular space longer) Crystalloid resuscitation dilutes all of the above

Evidence for Benefit of Early Blood Products: Military Combat Experience:

Evidence for Benefit of Early Blood Products: Military Combat Experience Increased survival / decreased complications Holcomb J Trauma 2003;54(5 Suppl):46 Increased survival / decreased multi-organ failure Holcomb, et al Ann Surg 2008;248:447

Evidence for Benefit of Early Blood Products: Civilian Experience:

Evidence for Benefit of Early Blood Products: Civilian Experience Mortality decreased 80% to <30% with massive transfusion Decreased transfusion requirements Duchense, et al J Trauma 2009;67:216 Excellent current review of IV fluid resuscitation McSwain, et al J Trauma 2011;70 (5 Suppl): S2

Management of Traumatic Hemorrhage in Pediatric Patients:

Management of Traumatic Hemorrhage in Pediatric Patients DRAFT

Pediatric Hemorrhagic Shock:

Pediatric Hemorrhagic Shock PALS: ” There is insufficient evidence to make a recommendation about the best timing or extent of volume resuscitation for children with hemorrhagic shock following trauma.”

We do know that vital signs, including blood pressure, are important in pediatric patients!:

We do know that vital signs, including blood pressure, are important in pediatric patients! DRAFT

Children are not just little adults:

Children are not just little adults In adults, the progression of shock usually includes a steady reduction in blood pressure with an accompanying increase in heart rate

Children are not just little adults:

Children are not just little adults Children maintain blood pressure and cardiac output by increasing heart rate and vasoconstriction, even with a loss of significant volume A child can lose up to one third of his/her blood volume before a significant drop in blood pressure occurs Pediatric hypotension should be viewed as a “pre-arrest state”

Hemodynamic Response to Shock:

Hemodynamic Response to Shock Vascular resistance Blood pressure Cardiac output Compensated shock Decompensated shock 140 100 60 20 Percent of control

Blood Pressures in Children:

Blood Pressures in Children Hypotension is a late sign in pediatric shock Maintaining normal blood pressures are important in pediatric trauma patients

Vital Signs:

Vital Signs Vital Signs, including BP , are required for all pediatric trauma patients Range of normal pediatric vital signs are based on age for HR, RR and BP Normal temperature is 36-38.5°C for all ages

Blood Pressure Cuffs:

Blood Pressure Cuffs Determination of the appropriate BP cuff size is crucial because: A smaller cuff contributes to a higher BP reading A larger cuff underestimates the BP reading This is important in children because they have varying arm sizes at various ages

Blood Pressure Cuffs:

Blood Pressure Cuffs Labeling of BP cuffs as infant, pediatric, small adult, adult, and large adult can be misleading Cuffs should be fitted individually to the patient

Blood Pressure Cuffs:

Blood Pressure Cuffs A task Force on Blood Pressure Control in Children recommended that the width of the cuff bladder should equal 40% of the mid-upper arm circumference (UAC)

How to measure BP cuff for pediatric patients:

How to measure BP cuff for pediatric patients Most BP Cuffs have an index line (border) and a range (in cm) to determine proper size. The index line must fit within the range for a proper fit and reading

PALS: Vital Signs Concerning for Shock Based on Age:

PALS: Vital Signs Concerning for Shock Based on Age Age of Patient Heart Rate (< or >) RR (< or >) Systolic BR 0 days- < 1month 80-205 30-60 < 60 ≥ 1 - < 3 months 80-205 30-60 < 70 ≥ 3 months - < 1 year 75-190 30-60 < 70 ≥ 1 - < 2 years 75-190 24-40 < 70 + (age x 2) ≥ 2 - < 4 years 60-140 24-40 < 70 + (age x 2) ≥ 4 - < 6 years 60-140 22-34 < 70 + (age x 2) ≥ 6 - < 10 years 60-140 18-30 < 70 + (age x 2) ≥ 10 - < 13 years 60-100 18-30 < 90 ≥ 13 - < 18 years 60-100 12-16 < 90

Shock criteria: physical exam:

Shock criteria: physical exam Treat shock if patient meets a combination of: any 3 criteria or hypotension + 1 other criterion Capillary Refill > 3 seconds Mental Status Decreased, irritable, confused Pulses Decreased Skin Cool, mottled or flushed, ruddy Heart rate HR greater than normal limit for age Respiratory rate RR greater than normal limit for age Systolic BP SBP less than normal for age

Capillary Refill:

Capillary Refill Prolonged capillary refill (10 seconds) in a 3-month-old with cardiogenic shock

Palpation of Central and Distal Pulses:

Palpation of Central and Distal Pulses

Prehospital Treatment of Pediatric Hemorrhagic Shock :

Prehospital Treatment of Pediatric Hemorrhagic Shock Bolus: 20cc/kg crystalloid (NS or LR) There is currently no evidence to support the use of colloid (hetastarch, albumin) in children

Emergency Department Treatment of Pediatric Hemorrhagic Shock :

Emergency Department Treatment of Pediatric Hemorrhagic Shock After initial bolus: Give blood products, if available: Packed RBC’s: 10 cc/kg (repeat if necessary) Platelets: 10 cc/kg (repeat if necessary) FFP: 10 cc/kg (repeat if necessary) If blood products not available, give repeated boluses of 20 cc/kg of crystalloid

Take Home Points: Adult Pre-hospital Trauma Care:

Take Home Points: Adult Pre-hospital Trauma Care Identify hemorrhage (control external bleeding) Insure oxygenation (adequate airway & limited ventilation) Limited scene time (< 10 minutes)

Take Home Points: Adult Pre-hospital Trauma Care:

Take Home Points: Adult Pre-hospital Trauma Care IV Access (saline lock / extension tubing) IV Fluids only if in shock Avoid hypotension in head injured patients Rapid transport to Trauma Center / ED

Take Home Points: Pediatric Pre-Hospital Trauma Care:

Take Home Points: Pediatric Pre-Hospital Trauma Care Identify hemorrhage (control external bleeding) Insure oxygenation (adequate airway & limited ventilation) Vital signs!!

Take Home Points: Pediatric Pre-Hospital Trauma Care:

Take Home Points: Pediatric Pre-Hospital Trauma Care Limited scene time (< 10 minutes) IV Fluids en route: 20 cc/kg of NS or LR Repeat to keep SBP normal Rapid transport to Trauma Center / ED

Take Home Points: ED Management of Adult Traumatic Hemorrhage:

Take Home Points: ED Management of Adult Traumatic Hemorrhage Limited (or no) IV crystalloid Early use of blood products 1:1:1 ratio (when available) Early consultation with / rapid transport to referral Trauma Center

Take Home Points: ED Management of Pediatric Traumatic Hemorrhage:

Take Home Points: ED Management of Pediatric Traumatic Hemorrhage IV crystalloid: 20 cc/kg Early use of blood products 1:1:1 ratio (when available) Early consultation with / rapid transport to referral Trauma Center

Thanks!:

Thanks! Utah Trauma Systems Advisory Committee IV Resuscitation Working Group Nancy Chartier, RN (Moab) Majia Holsti, MD (SLC) Kevin McCarthy, EMT-P (Eagle Mountain) Tom White, MD (SLC) Deanne Wolfe, RN (Ogden) Diane Hartford, MS (BEMS) Peter Taillac, MD (BEMS)

Questions? ptaillac@utah.gov:

Questions ? ptaillac@utah.gov