Controversies in Shock and Trauma Management

1
Controversies in Prehospital Trauma
Management
Chief Will Chapleau EMT-P, RN, TNS Chicago
Heights Fire Department wchapleau_at_aol.com
2
Controversy Has Always Been a Part of Prehospital
Care

• The increasing emphasis on Evidence Based
  Medicine will dispel some controversies, and
  stir up others.

3
Overview

• Pneumatic Anti-Shock Garment
• Time on scene
• Fluid resuscitation
• ALS in Trauma
• Spinal immobilization
• Withholding or cessation of resuscitation

4
The M.A.S.T. Suit

• Developed from G-suit concept
• Used extensively in combat
• Fell into disfavor despite the absence of
  scientific data to suggest or support its demise.

5
M.A.S.T in the U.S.

• Use expanded greatly after introduction
• At one time or another used for everything from
  fracture control to cardiac arrest

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What does it do?

• Increases peripheral vascular resistance
• Increases cardiac output
• Autotransufusion occurs to a limited degree
• Increases cerebral perfusion pressure
• Assists in controlling internal bleeding

7
NAEMSP Position Paper

• Collective review of literature by Dr. Robert E.
  OConner and Dr. Robert Domeier January/March
  1997 Prehospital Emergency Care Journal
• Over 100 studies cited

8
NAEMSP Position Paper

• Ironically..widespread condemnation of the PASG
  took place in the absence of scientific
  validation that it was detrimental in all
  situations. Negative outcomes in a limited number
  of restricted applications have been extrapolated
  to the broad gamut of clinical situations.

9
NAEMSP Position Paper

• .EMS providers should still be taught that the
  PASG is an acceptable treatment modality, and
  that medical direction may or may not elect to
  use it.

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Is PASG Harmful?

• Studies seem to support that PASG may be
  potentially harmful in treating patients with
  thoracic injuries, particularly penetrating chest
  trauma

11
Head Injured Patients

• For a long time head injured patients were listed
  as contraindications for PASG.
• Studies show no significant change in ICP with
  PASG
• In fact, the improvement in cerebral perfusion
  more than compensated for the rise in ICP.(Not
  evaluated in patients with elevated ICP)

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When is the PASG useful?

• Pelvic injuries with hypotension
• Hypotension due to rupture of AAA
• Severe traumatic hypotension
• Uncontrollable hemorrhage of lower extremities
• Anaphylactic shock (unresponsive to standard
  therapy)

13
PASG May be Useful

• Penetrating Abdominal Trauma
• PSVT
• Hypotension due to hypothermia
• Septic shock
• Urologic shock (otherwise uncontrolled)
• Uncontrolled gynecological hemorrhage
• Ruptured ectopic pregnancy

14
PASG may not be appropriate in cases of

• Penetrating Chest Trauma
• Diaphragmatic rupture
• Cardiogenic shock
• Cardiac Tamponade
• Cardiac arrest
• Bleeds above the diaphragm
• To splint lower extremity fractures

15
Time on Scene

• What do the studies tell us?
• How much time do we have?
• How should we use the time we do have?

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Studies

• Dr. R.A.Cowley and the Golden Hour
• Time to surgery

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How much time do we have on the scene?

• Golden Hour
• Platinum ten minutes
• 8 minute standard

18
Time in the Literature

• Osterwalder 2002 Prehosp Disaster Med 1775
• Swiss Study 254 patients
• Compared trauma patients with total prehospital
  time 60 minutes with those whose time was gt 60
  minutes
• Group I ( 60 mins.) mortality 14
• Group II (gt 60 mins.) mortality 10
• No statistical difference

19
The 8 Minutes or Less Benchmark

• Non-traumatic cardiac arrest
• Study from Seattle
• Survival from medical cardiac arrest was better
  when BLS arrived within 4 minutes and ALS arrived
  within 8 minutes.
• This was then applied to all EMS responses.

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The 8 Minutes or Less Benchmark

• Fiedler et al 1986, Arch Surg 121902
• Response time and outcome from abdominal gunshot
  wounds
• No difference in RT for survivors and fatalities
• Grossman et al 1997 J Trauma 42723
• 459 major trauma patients
• Compared urban to rural setting
• Urban RT 7 minutes
• Rural RT 14 minutes
• Rural patients were 7x more likely to die if RT
  was gt 30 minutes.

21
The 8 Minutes or Less Benchmark

• Pons et al 2002, J Emerg Med 2343
• Does the 8 minute RT affect outcome after
  trauma?
• 3490 patients, 2 groups based on RT
• No difference in survival
• Pons et al 2005, Acad Emerg Med 12594
• - 9559 patients (all complaints)
• - 3 groups low, moderate, high risk of death
• - No survival benefit based on 8 mins.
• - Survival benefit for RT lt 4 minutes for
  patients in moderate and high risk groups

22
The 8 Minutes or Less Benchmark

• Smith et al 1985 J Trauma 2565
• 52 trauma patients with BP lt 100 mm Hg
• Scene Time Transport Time
• BP unable 16 8
• BP lt 70 17 9
• BP 70-100 15 11

23
Fluid Resuscitation

• Studies
• How much do we need?
• What should we use?
• Whats next

24
Argument Against IVs in the Field

• Solomonov et al.
• University research laboratory using adult male
  rats with massive splenic injury
• Rats were divided into 4 groups evaluating
  aggressive and non-aggressive fluid therapy
• Conclusion vigorous infusion of saline resulted
  in increased intra-abdominal bleeding and
  decreased survival time

25
Argument Against IVs in the Field

• Bickell et al.
• 598 adult patients, penetrating torso trauma,
  systolic lt90 _at_ presentation, predominate fluid
  Ringers lactate
• Immediate Resuscitation group (IR) with 238
  patients
• Delayed Resuscitation group (DR) with 289

26
Immediate Resuscitation Group

• Received standard fluid therapy
• Average 870 mL before reaching hospital and 1608
  mL in the ED
• Systolic pressure averages 79
• Hemoglobin and platelet counts were lower
• Hemodynamic improvements on arrival did not last
  into operating theater
• 62 survival/increased hospital stay

27
Delayed Resuscitation Group

• Cannulated, no specific fluid infusion until OR
• Averaged 92 mL and 283 mL at corresponding stages
• Systolic pressure averages 72
• 70 survival rates/shorter hospital stays

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How much should we use?

• Fluid should be administered to replace volume
  until blood is available.
• The rule of thumb is that blood should follow 3
  liters of IV fluid.
• If blood is not available you may need to use
  more.
• Keep in mind, IV fluid does not carry oxygen.

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What should we use?

• Lactated Ringers
• Normal Saline
• Hypertonic
• Blood Substitutes

30
Protective Hypotensive Resuscitation

• How high must the systolic pressure be to perfuse
  adequately?
• Resuscitate to lower pressures slowing the rate
  of blood loss while still perfusing vital
  tissues.

31
Whats next?

• More science and development of colloid and
  plasma substitutes.
• PolyHeme trials

32
Spinal Clearance or Spinal immobilization
protocols

• 23 EMS agencies 17 Hospitals
• All used their standard immobilization protocol
• Filled out questionnaire asking for the presence
  or absence of specific clinical criteria
• Domeier 2002 J Trauma 5374

33
Spinal Clearance or Spinal immobilization
protocols

• Evaluated 8975 trauma patients
• - Spine pain
• - Spine tenderness
• - Altered mental status
• - Evidence of Intoxication
• - Focal neurologic deficits
• - Suspected extremity fracture
• Identified 280 of 295 spinal injuries

34
NEXUS Study

• Criteria for low probability of injury
• No midline spine tenderness
• No focal neurologic deficit
• Normal alertness
• No intoxication
• No painful distracting injury
• Reviewed 34,069 trauma patients
• 21 different centers
• Cervical spine injury was present in 818
• Missed only 8 patients, 2 considered significant

35
Who doesnt need immobilization?

• Blunt Trauma, if all of the following are
  present
• - No neck pain
• - No neck tenderness
• - No distracting injury
• - No alteration in mental status
• (either from head injury or intoxication)
• - No neurologic complaints or findings

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ALS In Trauma
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Arguments against ALS

• Extended scene times
• limited or poorly documented benefit to patients

40
Arguments for ALS

• Some studies show benefit when adequate personnel
  is available
• Improved outcome may be possible with ALS care
  delivered enroute to Hospital
• There is a point at which prehospital must end
  and intrahospital must begin for the patient to
  receive definitive care

41
Airway and Ventilation

• Intubation
• Ventilation

42
DELAYED SCENE TIME

• Annals of Surgery
• Vol. 237, No.2, 2003
• Study shows an overall higher mortality rate
  by advanced level providers on-scene.
• Includes ET intubation.

43
INCREASED MORBIDITY MORTALITY RATES WITH ETI

• The Journal of Trauma, Vol. 54,
• 2, 2003.
• Study shows pts who
• were intubated in the
• field had significant
• higher morbidity,
• nearly double the
• mortality rate.

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INCREASED MORBIDITY MORTALITY RATES WITH ETI

• The Journal of Trauma Vol. 54,
• 2, 2003.
• Study shows pts who were intubated in the
  field had longer hospital stays more
• nosocomial infections.

45
Prehospital Emergency Care2005 April/June
9(2)163-6Garza AG, Algren DA, Gratton MC, Ma OJ

• Populations at risk for intubation nonattempt and
  failure in the prehospital setting.
• In Kansas City they did a retrospective
  analytical study analyzing oral endotracheal
  intubations on pediatric cardiac arrest, adult
  traumatic arrest and adult cardiac arrest
  patients over 66 months.

46
Prehospital Emergency Care2005 April/June
9(2)163-6Garza AG, Algren DA, Gratton MC, Ma OJ

• 2,669 intubations were included.
• Conclusions
• There was a significant risk of intubation
  nonattempt and intubation failure in the
  pediatric cardiac arrest and adult traumatic
  arrest cohorts compared with the adult cardiac
  arrest population with the pediatric cohort being
  at particularly high risk for failure and the
  adult traumatic arrest cohort for higher risk for
  nonattempt.

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J Trauma 2005 May, 58(5)933-9Davis DP, Peay J,
Sise MJ, Vilke GM, Kennedy F, Eastman AB, Velky
T, Hoyt DB

• The impact of prehospital intubation on outcome
  in moderate to severe traumatic brain injury
• In San Diego, patients with moderate to severe
  TBI were identified from their trauma registry.

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J Trauma 2005 May, 58(5)933-9Davis DP, Peay J,
Sise MJ, Vilke GM, Kennedy F, Eastman AB, Velky
T, Hoyt DB

• Results
• 13,625 patients were identified from five trauma
  centers. Overall mortality was 22.9 and 19.3
  underwent prehospital intubation. Logistic
  regression revealed an increase in mortality with
  prehospital intubation. With the exclusion of
  aero medical transports, patients intubated in
  the field had worse outcomes.

49
J Trauma 2004 Mar, 56(3)531-6Stockinger ZT,
McSwain NE Jr.

• Results
• Of 5,773 patients, 316 (5.5) had ETI and 217
  (3.8) had BVM. Patients receiving ETI were
  significantly more likely to die (88.9 vs.
  30.9).

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More Intubation Studies

• A variety of studies show prehospital success
  rates in the 85 range while anecdotal reports
  can be lower.
• Seems to be at least some coloration between
  frequency of opportunity and performance.

51
Withholding Resuscitative Measures
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Obvious signs of death

• Dependant livido
• Rigor Mortis
• Algo Mortis (steady lowering of body temperature
  after death)
• Injuries incompatible with life

53
DNRs Living Wills

• Know your state laws and system protocols for
  recognizing DNRs Living Wills and Advance
  Directives
• Participate in local education about patients
  rights to determine their own destiny

54
Trauma

• Injuries not compatible with life
• Pulse less and non-breathing blunt trauma victims

55
Trauma NAEMSP ACS COT Position Paper

• Resuscitation efforts may be withheld in any
  blunt trauma patient who, based on out of
  hospital personnels primary survey is found
  apneic and pulseless upon arrival of EMS at scene

56
Trauma NAEMSP ACS COT Position Paper

• Victims of penetrating trauma found apneic and
  pulseless by EMS based on their patient
  assessment, should rapidly be assessed for the
  presence of other signs of life such as pupillary
  reflexes, spontaneous movement or organized ECG
  activity.

57
Trauma NAEMSP ACS COT Position Paper

• If any of these are present the patient should
  have resuscitation performed and be transported
  to the nearest emergency department or trauma
  center. If these signs of life are absent
  resuscitation efforts may be withheld.

58
Trauma NAEMSP ACS COT Position Paper

• Resuscitation efforts should be withheld in
  victims of penetrating or blunt trauma with
  injuries obviously incompatible with life such as
  decapitation or hemicorporectomy.

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Trauma NAEMSP ACS COT Position Paper

• Resuscitation efforts should be withheld in
  victims of penetrating or blunt trauma with
  evidence of a significant time lapse since
  pulselessness including dependent lividity, rigor
  mortis, and decomposition.

60
Trauma NAEMSP ACS COT Position Paper

• Cardiopulmonary arrest patients in whom the
  mechanism of injury does not correlate with
  clinical condition, suggesting a nontraumatic
  cause of the arrest, should have standard
  resuscitation initiated.

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Trauma NAEMSP ACS COT Position Paper

• Termination of resuscitation efforts should be
  considered in trauma patients with EMS witnessed
  cardiopulmonary arrest and 15 minutes of
  unsuccessful resuscitation and CPR.

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Trauma NAEMSP ACS COT Position Paper

• Traumatic cardiopulmonary arrest patients with a
  transport time to an emergency department or
  trauma center of greater than 15 minutes may be
  considered nonsalvageable and termination should
  be considered.

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Trauma NAEMSP ACS COT Position Paper

• Guidelines and protocols for TCPA patients who
  should be transported must be individualized for
  each EMS system. Consideration should be given to
  factors such as the average transport time within
  the system, and the definitive care capabilities
  (ie., trauma centers) within the system. Airway
  management and IV placement should be
  accomplished during transport when possible.

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Trauma NAEMSP ACS COT Position Paper

• Special consideration must be given to victims of
  drowning, lightning strike, and in situations
  where significant hypothermia may alter prognosis.

65
Trauma NAEMSP ACS COT Position Paper

• EMS providers should be thoroughly familiar with
  guidelines and protocols affecting the decision
  to withhold or terminate resuscitative measures.

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Trauma NAEMSP ACS COT Position Paper

• All termination protocols should be developed and
  implemented under the guidance of the system EMS
  medical director. On-line medical control may be
  necessary to determine the appropriateness of
  termination of resuscitation.

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Trauma NAEMSP ACS COT Position Paper

• Policies and protocols for termination of
  resuscitation efforts must include notification
  of the appropriate law enforcement agencies and
  notification of the medical examiner or coroner
  for final disposition of the body.

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Trauma NAEMSP ACS COT Position Paper

• Families of the deceased should have access to
  resources including clergy, social workers, and
  other counseling personnel as needed. EMS
  providers should have access to resources for
  debriefing and counseling as needed.

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Trauma NAEMSP ACS COT Position Paper

• Adherence to policies and protocols governing
  termination of resuscitation should be monitored
  through a quality review system.

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The Data on Trauma

• In TCPA patients, Shimazu et al report that 2.3
  of blunt trauma and 4 of penetrating trauma
  survived. 3 of the 5 blunt trauma patients had
  isolated head trauma.

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The Data on Trauma

• Rosemurgy et al looked at 410 TCPA patients.
  After excluding patients with injuries
  incompatible with life, 96 blunt and 42
  penetrating trauma patients remained, non of
  which survived.

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The Data on Trauma

• Stratton et al looked at 1,051 patients with
  prehospital TCPA. After excluding 116 patients
  who were pronounced dead in the field or met
  other exclusionary criteria such as primary
  cardiac arrest, 879 unconscious and pulseless
  were urgently transported. 4 or.08 survived, one
  of which was neurologically devastated.

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The Data on Trauma

• There is some evidence that the initial ECG
  rhythm obtained by EMS may predict survival. In a
  study by Barttistella et al, none of the
  asystolic or bradycardic (less than 40) patients
  survived out of 134. The 16 survivors all had
  initially detectable systolic pressures with
  subsequent loss of vital signs and PEA between 80
  150 bpm. They argued that PEA with HR less than
  40 may be a reliable discriminator.

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Cessation of Resuscitation efforts

• Asystole most frequently represents the end of
  life
• Except in extreme situations, there is no
  evidence to support transporting an asystolic
  patient to the hospital.
• Electrocution Hypothermia

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Science

• Blaives M, Fox JC
• Journal of the Academy of Emergency Medicine
• Concluded that patients presenting with cardiac
  standstill on bedside electrocardiogram do not
  survive to leave the ED regardless of their
  electrical rhythm. This finding was uniform
  regardless of downtime

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Cessation of Resuscitation efforts

• Since 1992, AHA has recommended resuscitation
  cessation and non-transport protocols for
  patients receiving continuing CPR

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Fixed Criteria for cessation?

• Devita MA
• Progressive Transplant
• Rejects fixed notion of irreversibility

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More Science

• Prehospital Emergency Care Jan-Mar 2001
• Regardless of medical futility criteria,
  specialized training of EMS providers and
  targeted related testing of operational issues
  need to precede field implementation of on-scene
  pronouncement policies.

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So what do we do?

• Know our own state laws local rules about DNRs,
  Living Wills and Advanced Directives
• Educate ourselves and our communities about DNR,
  Living Wills and Advanced Directives

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So what do we do?

• Recognize obviously dead patients
• Respect properly documented patients wishes

81
References

• American Heart Association ACLS guidelines and
  course materials, 2001
• Devita MA, Progressive Transplant, 2001Mar
  11(1)58-66 The Death Watchcertifying death
  using cardiac criteria

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References

• Pepe PE, Swor RA, Ornato JP, Racht EM, Blanton
  DM, Griswell JK, Blackwell T, Dunford J, Turtle
  Creek Conference II, Prehospital Emergency Care
  2001 Jan-Mar 5(1)79-87 Outcome in cardiac
  arrest patients found to have cardiac standstill
  on the bedside emergency department
  electrocardiogram
• Blaivas M, Fox JC, Academy of Emergency Emergency
  Medicine Journal 2001 Jun8(6)616-21,
  Resuscitation in the out of hospital setting
  medical futility criteria for on-scene
  pronouncement of death

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Pre-Hospital Science

• Whats been done?
• Whats needed?

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A single study contributes to a body of
knowledge. It is not the final word
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www.phtls.org

• PHTLS Symposium
• Research that drives the program
• 6th edition information
• International faculty

86
Questions?
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• Will Chapleau EMT-P, RN, TNS
• Chief
• Chicago Heights Fire Department
• Chicago Heights, Illinois
• Chairman PHTLS Division
• of NAEMT
• Board of Directors NAEMSE
• Board of Directors
• Society of Trauma Nurses
• wchapleau_at_aol.com