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Resuscitation Redefined

Resuscitation Redefined. Kenneth L. Mattox, MD Houston. Trauma. Resuscitation Redefined Kenneth L. Mattox, MD. Baylor College Medicine. Ben Taub Hospital. Purpose: to remove the word “RESUSCITATION” from your vocubulary. Or at least as you have used it in the past. Trauma.

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Resuscitation Redefined

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  1. Resuscitation Redefined Kenneth L. Mattox, MD Houston Trauma

  2. Resuscitation Redefined Kenneth L. Mattox, MD Baylor College Medicine Ben Taub Hospital

  3. Purpose: to remove the word “RESUSCITATION” from your vocubulary. Or at least as you have used it in the past Trauma

  4. This talk for resuscitation in ACUTE surgical conditons NOT Sepsis, Obstruction, etc Trauma

  5. “Why must we always have to relearn the lessons of the past?” WWII Korea Iraq-Afgh WWI VietNam 1913 1938 1963 2013 1988 Dacron CT Endo

  6. Over • Under • Balanced • Benefit • Harm • Adjust

  7. “Why must we always have to relearn the lessons of the past?” WWII Korea Iraq-Afgh WWI VietNam 1913 1938 1963 2013 1988 Dacron CT Endo

  8. Outline - Objectives • Historic • 1960-1995 • 1995-2013 • Current Changes

  9. Traditional

  10. HISTORIC-misconceptions-over resuscitation Legacy definitions faulted Trauma

  11. Many approaches & devices have come and gone Trauma

  12. Tabacco Smoke Resuscitator

  13. Alexander Graham Bell Resuscitation Device

  14. Alexander Graham Bell & his ventilator

  15. “Over a barrel” - Needs resuscitation

  16. RESUSCITATION Historic Concept • “Get the patient in shape so that surgery will be tolerated” • This is an URBAN LEGEND (Abandon this concept) Trauma

  17. What is RESUSCITATION ? Historic Concept Assure an airway Control Bleeding Raise the BP (? Towards normal or HIGHER) Trauma

  18. OVER

  19. FluidsHow Much (1963-1995) • 2 LARGE BORE IVs • 3 liter LR (or NS) in ambulance • 3 liter LR (or NS) in ER • “If a little bit is good a lot is better” • Massive transfusion protocols • End Points vague Trauma

  20. Historic Approach • 20th Century Algorithm • Replace blood with crystalloid in 3:1 ratio • No concern for impact on bleeding

  21. RESUSCITATION ? Historic How Accomplished ? Position Dressings & tourniquets Medications (vasoactive) Fluids, LOTS of fluids Lots of Complications Trauma

  22. Fast FORWARD to the PAST Trauma

  23. Examine the PATIENT Trauma

  24. Recognize the patient in need of EMS or EC, or OR “Intervention” …and who does NOT need it Trauma

  25. Less than 4% of ALL trauma patients actually need or benefit from “Resuscitation”(Whatever that is) REALLY Trauma

  26. Problems

  27. MEDICAL DISASTER RESPONSE NEW Classification

  28. More than 90% of ALL trauma patients need NO “Resuscitation” Trauma

  29. Some foundations for “resuscitation” Trauma

  30. William Shakespeare Trauma

  31. …..or not so new “ ..to stop his wounds, lest he do bleed to death.” Shakespeare, The Merchant of Venice, Act IV, Scene I 1597 Stop the Bleeding – Go to OR

  32. Stop the Bleeding

  33. Walter Cannon Trauma

  34. Cannon – World War I "The injection of a fluid that will increase blood pressure has dangers in itself. Hemorrhage may not have occurred to a marked degree because the blood pressure has been too low to overcome the obstacle offered by a clot.“

  35. Less Resuscitation is Best WWI lessons • Cannon – JAMA • “It is wasteful of time, resources and people to give fluid prior to operative control of hemorrhage.”

  36. WW IIOffice of the Surgeon General Trauma

  37. Office of the Surgeon General, U. S. Army WWII lessons • 2 reports • “BP should not be elevated and fluid not given till operative control of bleeding” • Do not pop the clot and loose precious blood

  38. 1954-1960CPRExternal Cardiac Compression(Elan, Safar, Kouwenhoven) Trauma

  39. Fluid 3:1 Rule • DALLAS • Original studies • Shires, 1963 • Described three isotope model • Showed extracellular repletion with crystalloid essential for survival So? Does it work for trauma?

  40. NotReally Trauma

  41. The Three to One Rule • Original studies • Shires, 1963 • Described three isotope model • Showed extracellular repletion with crystalloid essential for survival

  42. Fluid 3:1 Rule • Developed in “controlled hemorrhage” model • NEVER tested in people • Pre-dated EMS and Trauma Systems • Became “doctrine” without any class I, II, or III data

  43. RESUSCITATION ? Historic Assessment A - ALL IVs FULL Flow B – BP higher than normal C – Chart Looks good NOW Call Surgeon Trauma

  44. AMAZING-Patient’s surgery DELAYED until “resuscitated” in EMS, EC, or ICU HISTORIC This is a NO NO Trauma

  45. Vietnam experience • Approach to hypotension was 2 large caliber IVs • Give crystalloid as rapidly as possible. And NEW Problems happened

  46. Resuscitation CoursesATLSACLSPALS(12 others) Almost identical cirriculum Teach ABCs Encourage FLUID bolus Lots of Urban Legends Trauma

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