The Science Behind Trauma Care

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The Science Behind Trauma Care

• Dr. Bryan E. Bledsoe
• Professor, Emergency Medicine
• The George Washington University Medical Center

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Audience Interaction

• Which of the following actresses is my favorite?
• A. Sandra Bullock
• B. Angelina Jolie
• C. Salma Hayek
• D. Nicole Kidman
• E. George Michael

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Science in Trauma Care
Positive Evidence
Negative Evidence
No Evidence Or Equivocal Evidence
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Levels of Evidence

• Not all scientific evidence is the same.

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Audience Interaction

• My ambulance service practices evidence-based
  prehospital care?
• A. Strongly agree
• B. Agree
• C. Neither agree nor disagree
• D. Disagree
• E. Strongly disagree.

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Levels of Evidence

• Center for Evidence-Based Medicine (Oxford)
• Ia. Meta-analysis of RCTs
• Ib. One RCT.
• IIa. Controlled trial without randomisation.
• IIb. One other type of quasi-experimental study.
• III. Descriptive studies, such as comparative
  studies, correlation studies, and case-control
  studies.
• IV. Expert committee reports or opinions, or
  clinical experience of respected authorities or
  both.

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Levels of Evidence

• American Heart Association
• 1. Positive randomized controlled trials.
• 2. Neutral randomized controlled trials.
• 3. Prospective, non-randomized controlled
  trials.
• 4. Retrospective, non-randomized controlled
  trials
• 5. Case series (no control group)
• 6. Animal studies
• 7. Extrapolations
• 8. Rational conjecture (common sense)

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Levels of Evidence
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Levels of Evidence

• The closer a study adheres to the scientific
  method, the more valid the study.
• The more valid the study, the closer it is to the
  truth.

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Ranking the Evidence

• Class I
• Derived from the strongest studies of therapeutic
  interventions (RCTs) in humans.
• Used to support treatment recommendations of the
  highest order called practice standards.

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Ranking the Evidence

• Class II
• Derived from the comparative studies with less
  strength (nonrandomized cohort studies, RCTs with
  significant design flaws, and case-control
  studies).
• Used to support recommendations called guidelines.

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Ranking the Evidence

• Class III
• Derived from the other sources of information,
  including case series and expert opinion.
• Used to support practice options.

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Ranking the Evidence

• Overall term for all of the recommendations is
  practice parameters.

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EMS Practice Changes

• EMS Practices refuted by empiric evidence
• Critical Incident Stress Management (CISM)
• MAST/PASG
• Trendelenburg Position
• High-Volume Fluid Resuscitation

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EMS Practice Changes

• EMS Practices unsupported by empiric evidence
• Medical Priority Dispatch
• System Status Management
• High-Dose Epinephrine
• High-Dose Steroids for Acute Spinal Cord Injury
• Intraosseous Needles
• CPR Compression Vest

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EMS Practice Changes

• EMS Practice changes based upon empiric evidence
• AED usage (first 6-8 minutes)
• CPR
• Field death pronouncement in blunt traumatic
  cardiac arrest.

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EMS Practice Changes

• EMS Practices at risk for change because of
  empiric evidence
• Pediatric Endotracheal Intubation
• Rapid Sequence Intubation (RSI) in Traumatic
  Brain Injury (TBI)
• Endotracheal Intubation in TBI

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Guiding Prehospital Care

• There should be a link between the available
  evidence and treatment recommendations.
• Empirical evidence should take precedence over
  expert judgement in the development of guidelines.

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Guiding Prehospital Care

• In science, there are no authorities.
• Carl Sagan, PhD
• 1934-1996

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Guiding Prehospital Care

• 3. The available research should be searched
  using appropriate and comprehensive search
  terminology.
• 4. A thorough review of the scientific literature
  should precede guideline development.

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Guiding Prehospital Care

• 5. The evidence should be evaluated and weighted,
  depending upon the scientific validity of the
  method used to generate the evidence.
• 6. The strength of the evidence should be
  reflected in the strength of the recommendations
  reflecting scientific certainty (or the lack
  thereof).

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Guiding Prehospital Care

• 7. Expert judgement should be used to evaluate
  the quality of the literature and to formulate
  guidelines when the evidence is weak or
  nonexistent.
• 8. Guideline development should be a
  multidisciplinary process, involving key groups
  affected by the recommendations.

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Audience Interaction

• In regard to the OPALS study
• A. I follow the OPALS study regularly.
• B. I have read some of the OPALS study papers.
• C. I have heard of the OPALS study but not seen
  any results.
• D. What is the OPALS study?
• E. None of the above applies.

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Empiric Research in EMS
Phase I Determined baseline survival rate for
each study community (36 months) prior to Phase
II. Phase II Assessed the survival for 12 months
after the introduction of rapid defibrillation
and demonstrated that relatively inexpensive
community rapid defibrillation programs increase
survival for cardiac arrest patients (n5,000
patients). Phase III Assessed survival outcomes
months after the introduction of full ALS
programs for 36 months for cardiac arrest
patients and major trauma patients, and for 6
months for respiratory distress patients.
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Empiric Research in EMS

• Phase I Survival improved with
• Decreasing EMS response intervals
• Bystander-CPR
• First responder CPR by fire or police
• Phase II Survival improved with
• Rapid defibrillation (survival increased from
  3.9 to 5.2) resulted in 33 improvement in
  survival
• An additional 21 lives saved each year
• Increased survival was also associated with
  bystander and first responder CPR.

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Empiric Research in EMS

• Phase III
• Cardiac Arrest
• The addition of advanced-life-support
  interventions did not improve the rate of
  survival after out-of-hospital cardiac arrest in
  a previously optimized emergency-medical-services
  system of rapid defibrillation.
• 8-minute response time too long.

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Empiric Research in EMS

• Phase III
• Cardiac Arrest
• Most cardiac arrests occur in private locations
  (84.7) compared to public places (15.3).
  Communities should review locations of their
  cardiac arrests when designing CPR training and
  public access defibrillation programs.

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Empiric Research in EMS

• Phase III
• Cardiac Arrest
• Among ALS interventions, intubation, atropine and
  epinephrine had a negative association and only
  lidocaine had a positive association with
  survival.
• Pediatric cardiac arrests are most often due to
  respiratory arrests or trauma, SIDS, trauma and
  drowning.
• Citizen-initiated CPR is strongly and
  independently associated with better quality of
  life.

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Empiric Research in EMS

• Phase III
• Chest Pain
• Clearly showed important benefit from ALS
  programs for mortality and other outcomes.

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Empiric Research in EMS

• Phase III
• Respiratory Distress
• After adjustment for demographic, clinical, and
  EMS factors, the only interventions associated
  with better survival were salbutamol and NTG.
• Most children are not severely ill, most do not
  receive ALS interventions, there is a high rate
  of non-transport, and the vast majority are
  discharged home from the ED.

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Empiric Research in EMS

• Phase III
• Pediatric Care
• The majority of patients did not require
  immediate or urgent medical care and had good
  short-term outcomes.

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Science in Trauma Care

• Practices with strong positive evidence
• Access to trauma centers
• Specialized care (pediatrics, burns, spinal cord
  injury)

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Science in Trauma Care

• Practices with positive evidence
• Permissive hypotension
• Splinting
• Pain management
• Head injury management
• Hemoglobin-Based Oxygen Carrying Solutions
  (HBOCs)

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Science in Trauma Care

• Practices with no evidence or equivocal evidence
• The Golden Hour
• Medical helicopters
• Trendelenburg position
• Traction splints
• Rapid sequence intubation (RSI) in traumatic
  brain injury (TBI)

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Science in Trauma Care

• Practices with negative evidence
• MAST/PASG
• Steroids for acute SCI
• High-volume fluid therapy
• Prehospital intubation in traumatic brain injury
• Pediatric endotracheal intubation

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Audience Participation

• In regard to current prehospital practice in my
  system, which of the following best describes
  trauma care?
• A. We still used MAST/PASG and administer large
  volumes of fluid to restore normal BP.
• B. We do not use the MAST/PASG but administer
  large volumes of fluid to restore BP.
• C. We administer enough fluid to maintain a blood
  pressure 100 mm Hg.
• D. We administer enough fluid to maintain a blood
  pressure 90 mm Hg.
• E. We administer enough fluid to maintain a blood
  pressure 80 mm Hg.

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Science in Trauma Care

• Practices with strong negative evidence
• Scene stabilization

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Changes in US Trauma Practice

• IV Fluid Restriction
• Permissive Hypotension
• Hemoglobin-Based Oxygen Carrying Solutions
  (HBOCs)
• Less Aggressive Airway Management
• Helicopter Overutilization

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IV Fluid Restriction

• Should prehospital personnel administer large
  volumes of IV fluids rapidly to trauma victims or
  delay fluid resuscitation until hospital arrival?

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IV Fluid Restriction

• Traditional approach to trauma patient with
  hypotension was 2 large bore IVs and wide open
  crystalloid administration.

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IV Fluid Restriction

• Recommendation has been to replace lost blood
  with isotonic crystalloids at a 31 ratio
  (IVFblood loss)

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IV Fluid Restriction

• High volume IV fluid administration was based on
  several animal studies from the 1950s and 1960s.

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IV Fluid Restriction

• High volume IV fluid treatment was used in Viet
  Nam and transferred to US and western civilian
  prehospital care practices.

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IV Fluid Restriction

• Several animal studies in the 1980s and 1990s
  found that treatment with IV fluids before
  hemorrhage was controlled increased the mortality
  rate, especially if the BP was elevated.

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IV Fluid Restriction

• Raising the BP and restoring perfusion to vital
  organs are clearly believed to be beneficial
  after hemorrhage is controlled.
• Growing evidence indicates that raising it before
  achieving adequate hemostasis may be detrimental.

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IV Fluid Restriction

• Administering large quantities of IV fluids
  without controlling the hemorrhage results in
• hemodilution with decreased hematocrit
• decreased available hemoglobin (and
  oxygen- carrying capacity)
• decreased clotting factors.
• This effect is found regardless of the fluid used
  (blood, LR, NS, hypertonic saline).

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IV Fluid Restriction

• Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate
  versus delayed fluid resuscitation for
  hypotensive patients with penetrating torso
  injuries. N Eng J Med. 19943311105-9
• 598 patients with penetrating torso injury and
  systolic BP 90 mmHg in prehospital setting.
• Randomized to receive standard high-volume fluids
  or fluids delayed until patient in OR.

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IV Fluid Restriction

• Results
• Group Divisions
• Delayed n289
• Standard fluids n309
• Survival
• Delayed 70
• Standard fluids 62
• Complications
• Delayed 23
• Standard fluids 30

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IV Fluid Restriction

• CONCLUSIONS For hypotensive patients with
  penetrating torso injuries, delay of aggressive
  fluid resuscitation until operative intervention
  improves the outcome.

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IV Fluid Restriction

• Tentative Hypothesis
• At this time, intravenous fluid resuscitation
  should probably be delayed until hemostasis is
  obtained.

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IV Fluid Restriction

• Literature has primarily looked at penetrating
  trauma.
• The role of fluid resuscitation in patients with
  blunt trauma is less clear.
• Further studies are needed.

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IV Fluid Restriction

• Current recommendation for blunt trauma is to
  administer just enough fluid to maintain
  perfusion.
• Rapid, high-volume fluid administration is
  discouraged.

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IV Fluid Restriction

• Fluid resuscitation may be of value in patients
  who are moribund with systolic pressures

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IV Fluid Restriction

• Patients with hypotension due to severe
  hemorrhage from isolated extremity injuries may
  do better with aggressive prehospital IV fluid
  resuscitation after hemostasis.

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IV Fluid Restriction

• Complications of preoperative fluid
  resuscitation
• Secondary bleeding or acceleration of ongoing
  hemorrhage
• Adult respiratory distress syndrome (Danang Lung)
• Sepsis
• Coagulopathies
• Renal failure

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IV Fluid Restriction

• Conclusions
• More research is needed.
• Data on penetrating trauma is compelling.
• Fluid resuscitation probably indicated for
  moribund patients.
• Best management strategies for blunt trauma and
  head injuries is to administer just enough fluid
  to maintain perfusion.
• Rapid transport probably remains the best
  treatment for most trauma cases.

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IV Fluid Restriction

• Limitations
• Most studies on urban trauma patients with short
  transport times.
• Findings may not be applicable to rural trauma
  patients.

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Permissive Hypotension

• Should prehospital personnel attempt to restore
  blood pressure in trauma patients to pre-trauma
  levels or practice permissive hypotension?

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Permissive Hypotension

• Animal studies in the 1980s and 1990s indicated
  that treatment with IV fluids before hemorrhage
  was controlled increased the mortality rate,
  especially if the blood pressure is elevated.

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Permissive Hypotension

• Human research seems to support this premise.
• Primarily the Bickell, Wall, Pepe, et al. study
  previously detailed.

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Permissive Hypotension

• There is a natural physiologic compensation when
  blood pressure is maintained between 70-85 mmHg.
• Urine output and cerebral perfusion usually
  maintained when the BP is within this range.

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Permissive Hypotension

• Elevation of BP to pre-injury levels, without
  hemostasis, has been associated with
• Progressive and repeated re-bleeding
• Decrease in platelets and clotting factors.
• Dislodgement of a clot at the site of injury.

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Permissive Hypotension

• Interestingly, the standard treatment for
  ruptured AAAs has been to keep patients
  hypotensive until proximal control of the aorta
  (above the leakage) is attained.
• This preserves intravascular blood volume and
  prevents new additional blood loss from the
  rupture.

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Permissive Hypotension

• Large animal studies of uncontrolled hemorrhage
  indicate that the clot is popped at about 80
  mmHg systolic pressure.
• This level has been reproducible in human
  subjects.

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Permissive Hypotension

• Many hypothesize that one should not raise blood
  pressure to more than ¾ of pre-injury levels (80
  mmHg).

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Permissive Hypotension

• Dutton RP, MacKenzie CF, Scalea TM, et al.
  Hypotensive resuscitation during active
  hemorrhage Impact on in-hospital mortality. J
  Trauma. 200352(6)1141-1146
• 110 patients with hemorrhagic shock were
  randomized into two groups BP maintenance 100
  (n55) or BP maintenance of 70 (n55).
• Conclusion Titration of initial fluid therapy to
  a lower than normal SBP during active hemorrhage
  did not affect mortality in this study. Reasons
  for the decreased overall mortality and the lack
  of differentiation between groups likely include
  improvements in diagnostic and therapeutic
  technology, the heterogeneous nature of human
  traumatic injuries, and the imprecision of SBP as
  a marker for tissue oxygen delivery.

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Permissive Hypotension

• Holmes JF, Sakles JC, Lewis G, Wisner DH. Effects
  of delaying fluid resuscitation on an injury to
  the systemic arterial vasculature. Acad Emerg
  Med. 20029(4)267-274
• 21 sheep underwent thoracotomy and transection of
  the left internal mammary artery.
• Group 1 No fluid resuscitation
• Group 2 Resuscitation 15 minutes after injury
• Group 3 Resuscitation 30 minutes after injury
• CONCLUSIONS Rates of hemorrhage from an arterial
  injury are related to changes in mean arterial
  pressure. In this animal model, early aggressive
  fluid resuscitation in penetrating thoracic
  trauma exacerbates total hemorrhage volume.
  Despite resumption of hemorrhage from the site of
  injury, delaying fluid resuscitation results in
  the best hemodynamic parameters.

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Permissive Hypotension

• This paradigm shift has significant implications
  on emergency care
• Trendelenburg position
• Use of rapid infusers
• Intraosseous infusions

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Permissive Hypotension

• Fluid restriction and permissive hypotension go
  hand-in-hand.
• Fluid resuscitation should be administered in
  small boluses to maintain peripheral pulse
  (systolic BP /- 80 mmHg)

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Permissive Hypotension

• During prolonged transport the prehospital care
  provider must attempt to maintain perfusion to
  the vital organs. Maintaining the systolic blood
  pressure in the range of 80-90 mm Hg or the MAP
  in the range of 60-65 mm Hg, can usually
  accomplish this with less risk of renewing
  internal hemorrhage.

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Permissive Hypotension

• Gain IV access en route but give only enough
  Ringers lactate solution or normal saline
  solution to maintain a blood pressure high enough
  for adequate peripheral perfusion. Maintaining
  peripheral perfusion may be defined as producing
  a peripheral pulse, maintaining level of
  consciousness, or maintaining blood pressure
  (90-100 mm Hg systolic).

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Permissive Hypotension

• What about patients with TBI?

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Traumatic Brain Injury

• Oxygenation and Blood Pressure
• Hypoxemia (Hg systolic) are associated with poor outcomes.
• Pulse oximetry and blood pressure must be
  monitored.
• Continuous waveform capnography beneficial.

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Traumatic Brain Injury

• Oxygenation and Blood Pressure
• In children, hypotension is
• 0-1 year Systolic
• 2-5 years Systolic
• 6-12 years Systolic
• 13-16 years Systolic

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Traumatic Brain Injury

• Why does TBI require a higher systolic BP than
  required for permissive hypotension?
• CPP MAP- ICP
• MAP DBP1/3 (SBP-DBP)

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Traumatic Brain Injury

• Slightly higher systolic pressure may be required
  to maintain CPP in TBI.

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Audience Participation

• In regard to hemoglobin-based oxygen carrying
  solutions
• A. I have administered them in the prehospital
  setting.
• B. I have seen them administered in the
  prehospital setting.
• C. I have read about them but never seen them.
• D. I have never heard of them.
• E. None of the above.

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Oxygen-Carrying IV Fluids

• Do oxygen-carrying IV fluids have a future role
  in prehospital care?

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Oxygen-Carrying IV Fluids

• Crystalloid solutions have been the primary IV
  fluid used in prehospital trauma care in the
  United States.

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Oxygen-Carrying IV Fluids

• In most Commonwealth and in many Latin American
  countries colloids polygeline (Haemaccel) is
  used.

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HBOCs

• Each molecule of hemoglobin can carry 4 molecules
  of oxygen.

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HBOCs

• The amount of oxygen on the hemoglobin (oxygen
  saturation) is dependent upon the partial
  pressure of oxygen.

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HBOCs

• The amount of oxygen that can be transported is
  also dependent upon the amount of circulating red
  blood cells and the hemoglobin contained within.

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HBOCs

• Blood loss and crystalloid fluid therapy
  decreases the percentage of circulating red blood
  cells and hemoglobin.

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Oxygen-Carrying IV Fluids

• Perflurocarbon emulsions
• Hemoglobin-based oxygen carrying solutions
  (HBOCs)
• PolyHeme
• Hemopure

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HBOCs

• Hemopure
• Derived from bovine blood
• Approved for use in South Africa
• Intensive study underway in the US.

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HBOCs
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HBOCs

• Hemopure
• Jul 2002 FDA application filed.
• Sep 2002 US Army provides 908,900.00 grant to
  conduct single-center trial in trauma
  patients.
• Nov 2002 Trial expanded to include both
  in- hospital and prehospital patients.
• Feb 2003 Congress awards 4 million to fund
  clinical trials. First trials in Dallas with
  DFR and Parkland.

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HBOCs
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HBOCs

• PolyHeme
• Solution of chemically-modified hemoglobin
  derived from discarded donated human blood.
• Hemoglobin extracted and filtered to remove
  impurities.

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HBOCs

• PolyHeme
• Chemically-modified to create a polymerized form
  of hemoglobin designed to avoid problems
  previously experienced with hemoglobin-based
  blood substitutes
• Vasoconstriction
• Renal dysfunction
• Liver dysfunction
• GI distress
• Polymerized hemoglobin incorporated into a
  solution that contains 50 grams of hemoglobin per
  unit (the same as transfused blood).

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HBOCs
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HBOCs

• PolyHeme
• Product must be refrigerated.
• Shelf-life is 1 year.
• Clinical prospective randomized controlled trial
  of prehospital usage started Sep 2003 in several
  US cities (1-year, 700-800 patients).
• Paramedics cannot be blinded for study as
  PolyHeme looks like blood.
• Patients who receive PolyHeme will receive up to
  6 more units if needed during the first 12 hours.

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HBOCs

• California
• UCSD (San Diego
• Scripps Mercy (San Diego)
• Colorado
• Denver HH (Denver)
• Delaware
• Christiana (Newark)
• Illinois
• Loyola (Chicago)
• Indiana
• Wishard (Indianapolis)
• Methodist Hospital (Indianapolis)
• Kentucky
• U of K (Lexington)

• Minnesota
• Mayo (Rochester)
• Ohio
• Metro Health (Cleveland)
• Pennsylvania
• Lehigh Valley (Allentown)
• Tennessee
• UT (Memphis)
• Texas
• Memorial-Hermann (Houston)
• UTHSCSA (San Antonio)
• Virginia
• Sentara (Norfolk)
• VCU (Richmond)

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HBOCs

• Artificial polymerized hemoglobin can transport
  oxygen within the plasma.

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HBOCs

• Gould SA, Moore EE, Hoyt DB, et al. The first
  randomized trial of human polymerized hemoglobin
  as a blood substitute in acute trauma and
  emergency surgery. J Am Coll Surg.
  1998187(2)113-20
• 44 trauma patients (33 male, 11 female) were
  randomized to receive red cells or PolyHeme as
  their initial fluid replacement after trauma.
• There were no serious or unexpected outcomes
  related to PolyHeme.
• CONCLUSIONS PolyHeme is safe in acute blood
  loss, maintains total Hb in lieu of red cells
  despite a marked fall in RBC Hb, and reduces
  the use of allogenic blood. PolyHeme appears to
  be a clinically-useful blood substitute.

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HBOCs

• Gannon CJ, Napolitano LM. Severe anemia after
  gastrointestinal hemorrhage in a Jehovahs
  Witness new treatment strategies. Critical Care
  Medicine. 2002301930-1931
• 50year-old Jehovahs Witness had massive UGI
  bleed from pre-pyloric ulcer (Hb3.5 grams).
  Hemorrhage control with injection of epinephrine.
• Patient became hemodynamically unstable.
• Received 7 units of bovine HBOC and human
  erythropoietin.
• Within 24 hours patient stable and Hb 7.2 grams.
• Conclusions Survival without allogenic blood
  attained.

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HBOCs

• HBOCs look quite promising for prehospital and
  battlefield emergency care.
• Further recommendations await result of first
  prehospital study.

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Audience Participation

• In my ambulance service, we use medical
  helicopters for scene responses
• A. Very Frequently
• B. Often
• C. Occasionally
• D. Rarely
• E. Never

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Helicopters

• Are EMS helicopters effective in decreasing
  mortality and enhancing trauma care?

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Helicopters

• Initial studies in the 1980s showed that trauma
  patients have better outcomes when transported by
  helicopter.
• Today, other than speed, helicopters offer little
  additional care than provided by ground
  ambulances.

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Helicopters

• The number of medical helicopters in the United
  States has increased from 400 to 700 in the last
  4 years.

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Helicopters

• Considerations
• Severe injury
• ISS 15
• TS
• RTS 11
• Weighted RTS 4
• Triss Ps
• Non-life-threatening injuries
• Patients not in above criteria
• Patients who refuse ED treatment
• Patients discharged from ED
• Patients not admitted to ICU

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Helicopters

• Shatney CH, Homan SJ, Sherek JP, et al. The
  utility of helicopter transport of trauma
  patients from the injury scene in an urban trauma
  system. J Trauma. 200253(5)817-22
• 10-year retrospective review of 947 consecutive
  trauma patients transported to the Santa Clara
  Valley trauma center.
• Blunt trauma 911
• Penetrating trauma 36

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Helicopters

• Mean ISS 8.9
• Deaths in ED 15
• Discharged from ED 312 (33.5)
• Hospitalized 620
• ISS 9 339 (54.7)
• ISS 16 148 (23.9)
• Emergency surgery 84 (8.9)

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Helicopters

• Only 17 patients (1.8) underwent surgery for
  immediately life-threatening injuries.
• Helicopter arrival faster 54.7
• Helicopter arrival slower 45.3
• Only 22.4 of the study population were possibly
  helped by helicopter transport.
• CONCLUSION The helicopter is used excessively
  for scene transport of trauma victims in our
  metropolitan trauma system. New criteria should
  be developed for helicopter deployment in the
  urban trauma environment.

111
Helicopters

• Eckstein M, Jantos T, Kelly N, et al. Helicopter
  transport of pediatric trauma patients in an
  urban emergency medical services system a
  critical analysis. J Trauma, 200253340-344.
• Retrospective review of 189 pediatric trauma
  patients (scene in LA.
• Median age 5 years
• RTS 7 82
• ISS
• Admitted to ICU 18
• Discharged from ED 33

112
Helicopters

• CONCLUSION The majority of pediatric trauma
  patients transported by helicopter in our study
  sustained minor injuries. A revised policy to
  better identify pediatric patients who might
  benefit from helicopter transport appears to be
  warranted.

113
Helicopters

• Braithwaite CE, Roski M, McDowell R, et al. A
  critical analysis of on-scene helicopter
  transport on survival in a statewide trauma
  system. J Trauma. 199845(1)140-4
• Data for 162,730 Pennsylvania trauma patients
  obtained from state trauma registry.
• Patients treated at 28 accredited trauma centers
• 15,938 patients were transported from the scene
  by helicopters.
• 6,273 patients were transported by ALS ground
  ambulance.

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Helicopters

• Patients transported by helicopter
• Significantly younger
• Males
• More seriously injured
• Had lower blood pressure
• Helicopter patients
• ISS
• Logical regression analysis revealed that when
  adjusted for other risk factors, transportation
  by helicopter did not affect the estimated odds
  of survival.
• CONCLUSION A reappraisal of the
  cost-effectiveness of helicopter triage and
  transport criteria, when access to ground ALS
  squads is available, may be warranted.

115
Helicopters

• Cocanour CS, Fischer RP, Ursie CM. Are scene
  flights for penetrating trauma justified? J
  Trauma. 199743(1)83-86
• 122 consecutive victims of non-cranial
  penetrating trauma transported by helicopter from
  the scene.
• Average RTS 10.6
• Dead patients 15.6
• Helicopter did not hasten arrival in for any of
  the 122 patients.
• Only 4.9 of patients required patient care
  interventions beyond those of ground ALS units.
• CONCLUSION Scene flights in this metropolitan
  area for patients who suffered noncranial
  penetrating injuries demonstrated that these
  flights were not medically efficacious.

116
Helicopters

• Cunningham P, Rutledge R, Baker CC, Clancy TV. A
  comparison of the association of helicopter and
  ground ambulance transport with the outcome of
  injury in trauma patients transported from the
  scene. J Trauma 199743(6)940-946
• Data obtained from NC trauma registry from
  1987-1993 on trauma patients and compared
• 1,346 transported by air
• 17,144 transported by ground
• CONCLUSION The large majority of trauma patients
  transported by both helicopter and ground
  ambulance have low severity measures. Outcomes
  were not uniformly better among patients
  transported by helicopter. Only a very small
  subset of patients transported by helicopter
  appear to have any chance or improved survival.

117
Helicopters

• Moront ML, Gotschall CS, Eichelberger MR.
  Helicopter transport of injured children system
  effectiveness and triage criteria. J Pediatr
  Surg. 199631(8)1183-6
• 3,861 children transported by local EMS
• 1,460 arrived by helicopter
• 2,896 arrived by ground
• Helicopter transported patients
• ISS
• But survival rates for children transported by
  air were better than those transported by ground.
• CONCLUSION The authors conclude that (1)
  helicopter transport was associated with better
  survival rates among injured urban children (2)
  pediatric helicopter triage criteria based on GSC
  and heart rate may improve helicopter utilization
  without compromising care (3) current air triage
  practices result in overuse in approximately 85
  of flights.

118
Helicopters

• Wills VL, Eno L, Walker C, et al. Use of an
  ambulance-based helicopter retrieval service.
  Aust N Z J Surg. 200070(7)506-510
• 179 trauma patients arrived by helicopter during
  study year.
• 122 male
• 57 female
• Severity of injuries
• ISS
• ISS 16 17.9
• 12 (6.7) discharged from the ED
• 46 (25.7) discharged within 48 hours.
• Results
• 17.3 of patients were felt to have benefited
  from helicopter transport
• 81.0 of patients were felt to have no benefit
  from helicopter transport
• 1.7 of patients were felt to have been harmed
  from helicopter transport

119
Helicopters

• Bledsoe BE, Wesley AK, Eckstein M, Dunn TM,
  OKeefe MF. Helicopter Transport of Trauma
  Patients A Meta-Analysis J Trauma (In Press).
• Meta-Analysis of 22 papers with a cohort of
  37,350 patients.
• ISS 15 (minor injuries) 60 (99 CI
  54.5-64.8)
• TS 13 (minor injuries) 61.4 (99 CI
  60.8-62.0)
• TRISS Ps 0.90 (minor injuries) 69.3 (99 CI
  58.5-80.2)
• Discharged

120
Helicopters
121
Helicopters (US Accidents)
122
Helicopters
Occupational Deaths per 100,000/year (U.S.
1995-2001)
Source Johns Hopkins University School of Public
Health
123
Helicopters

• An EMS helicopter (HEMS) pilot or crew member
  flying 20 hours/week for 20 years would have a
  40 chance of a fatal crash.
• Since 2002, more people have been killed in air
  ambulance crashes than aboard U.S. commercial
  airlines, though the helicopters travel just a
  fraction of the distance.

124
Conclusions

• Helicopter transport of trauma patients is over
  utilized.
• Utilization criteria must be studied and revised.
• Few trauma patients benefit from helicopter
  transport.

125
Conclusions

• Data show that helicopters are over utilized for
  trauma scene responses.
• Over triage of trauma patients primary factor
• Costs and risks may not justify benefit for the
  vast majority of trauma patients.
• Triage criteria should be based on physiological
  parameters and not mechanism of injury.

126
Conclusions

• More research is needed.
• Proliferation of helicopter operations reflects
  economic factors more than patient outcome
  factors.
• Data may not be applicable to rural areas.

127
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128
Audience Participation

• In my opinion, which country has the best EMS
  system?
• A. United Kingdom
• B. United States
• C. Australia
• D. South Africa
• E. France

129
Airway Management

• And then, there is airway management. Do you have
  the rest of the afternoon?

130
Audience Questions

• Questions?
• For details on publications, presentations, or
  biography, see
• http//www.bryanbledsoe.com