IV Fluids increase death rate for trauma victims

[Veneficus]

hemostasis vs resuscitation

I love this topic, because even on the trauma boards it comes up on a very regular basis. There are many theories. Many studies. Much conflicting thinking.

From the surgical expert point of view, there is no question that hemostasis needs to be accomplished before resuscitation begins. (there was a study cited in the sebastion textbook of surgery on page 100, but I don't have it in front of me this second to cite, but I remember the page) It basically demonstrated a significant decrease in survival if resuscitation was begun prior to hemostasis.

But from the EMS standpoint, it is a chicken or egg question. If you cannot control the bleed, because it is occult and you can't find it or you know it is there but as of yet don't have a damage control surgery protocol (to my knowledge, nobody does) any attempt to begin resuscitation of tissue with crystaloid is going to have a negative effect.

If you keep CVP up without a closed circuit, all you are doing is managing and treating numbers (even if you don't have them)

If you can raise MAP with crystaloid, you at least have some control of bleeding. However, the physiologic response to hypovolemia is a very excellent compensatory mechanism up to about 20-33% volume loss (depending on your favorite book) So the question becomes how much prehospital resuscitation is even required? Is the potential to reopen wounds or cause an abd compartment syndrome with arbitrary or high volume beneficial?

The answer I think is case specific, which again brings us to treating patients not protocols.

As a potential diagnostic test, you can check the response to dopamine, but I think you will not see that as a protocol and will have a vvery hard time convincing anyone but me to let you do it.

I would offer this opinion on the matter:

If the mental status is altered and the curcuit is reasonably closed, carefully start fluid at a slow rate.

If the circuit is open and uncontrolled, give no fluid.

If the mental status is intact and the circuit is closed, judiciously or precisely use fluids.

If the mental status is intact and the circuit open, focus all your attention on slowing the bleed at the expense of starting fluid.

 

[medicRob]

I love this topic, because even on the trauma boards it comes up on a very regular basis. There are many theories. Many studies. Much conflicting thinking.

From the surgical expert point of view, there is no question that hemostasis needs to be accomplished before resuscitation begins. (there was a study cited in the sebastion textbook of surgery on page 100, but I don't have it in front of me this second to cite, but I remember the page) It basically demonstrated a significant decrease in survival if resuscitation was begun prior to hemostasis.

But from the EMS standpoint, it is a chicken or egg question. If you cannot control the bleed, because it is occult and you can't find it or you know it is there but as of yet don't have a damage control surgery protocol (to my knowledge, nobody does) any attempt to begin resuscitation of tissue with crystaloid is going to have a negative effect.

If you keep CVP up without a closed circuit, all you are doing is managing and treating numbers (even if you don't have them)

If you can raise MAP with crystaloid, you at least have some control of bleeding. However, the physiologic response to hypovolemia is a very excellent compensatory mechanism up to about 20-33% volume loss (depending on your favorite book) So the question becomes how much prehospital resuscitation is even required? Is the potential to reopen wounds or cause an abd compartment syndrome with arbitrary or high volume beneficial?

The answer I think is case specific, which again brings us to treating patients not protocols.

As a potential diagnostic test, you can check the response to dopamine, but I think you will not see that as a protocol and will have a vvery hard time convincing anyone but me to let you do it.

I would offer this opinion on the matter:

If the mental status is altered and the curcuit is reasonably closed, carefully start fluid at a slow rate.

If the circuit is open and uncontrolled, give no fluid.

If the mental status is intact and the circuit is closed, judiciously or precisely use fluids.

If the mental status is intact and the circuit open, focus all your attention on slowing the bleed at the expense of starting fluid.

I suppose it is easier for me in the ICU environment, seeing as the drugs and treatments available are somewhat limitless.. For instance, if I have my patient on max levophed and they are still only able to maintain a MAP of 65, just barely, and drop their pressure as soon as the dose is taken down, then I know the patient is significantly compromised. In EMS, that luxury is not afforded, there are so many interventions that must be taken in such a little period of time you actually have with the patient that the EMS provider has to assess a patient's trending in a matter of minutes and hours as opposed to days like we can in-hospital.

 

[Veneficus]

I suppose it is easier for me in the ICU environment, seeing as the drugs and treatments available are somewhat limitless.. For instance, if I have my patient on max levophed and they are still only able to maintain a MAP of 65, just barely, and drop their pressure as soon as the dose is taken down, then I know the patient is significantly compromised. In EMS, that luxury is not afforded, there are so many interventions that must be taken in such a little period of time you actually have with the patient that the EMS provider has to assess a patient's trending in a matter of minutes and hours as opposed to days like we can in-hospital.

Easier in the ICU? Perhaps for nursing.

To whom much is given, much is expected.

I extremely caution you about getting tied up with numbers. There are more variables to MAP than peripheral constriction and if you do not find out which one is causing your problem and fix it, the patient can crash on you near instantaneously when they decompensate from something like high output failure attempting to overcome the resistance.

Use numbers to build preclinical trends. Using them as the ratio of normal only works sometimes.

 

[boingo]

There is research taking place currently using hypothermia in trauma resuscitation using a pig model, where the pig is bled out, rapidly cooled and left for a few hours, then the vascular injury is repaired and the pig is warmed up. According to the surgeon running the research the pigs are neurlogically intact after resus, after being "dead" for 2 hours. Obviously, this is an oversimplification of the process, but interesting none the less. A "suspended animation" if you will.

 

[Veneficus]

There is research taking place currently using hypothermia in trauma resuscitation using a pig model, where the pig is bled out, rapidly cooled and left for a few hours, then the vascular injury is repaired and the pig is warmed up. According to the surgeon running the research the pigs are neurlogically intact after resus, after being "dead" for 2 hours. Obviously, this is an oversimplification of the process, but interesting none the less. A "suspended animation" if you will.

That has been the elusive goal for some time.

 

[boingo]

Those Haaahvaaad docs are wicked smaaaaaht.

 

[Luno]

I'd definitely like to review this study, there is way too much open to subjective opinion, simply based on the article. Do we know that too much fluid kills? Yes, absolutely, this has been studied since the military medics in vietnam were "killing" their patients with fluids. I'll try to get my hands on that study, I reviewed it probably 5 years ago when I was working heavily in Tac-Med, and we were looking at the necessity of fluids in our medic packs, and how much. Also is this in direct relationship to creating too much pressure in the system and blowing clots, i.e. over 93 systolic? Or I guess another way to look at it, is that IV fluid is contraindicated in trauma patients because severe trauma patients die, and since they came in with IV access and fluids, that must be what killed them... Sorta like the serial killers eat cornflakes arguments... I'll try to find that vietnam study about thoracic trauma and survivability with/without IV fluids. -luno

 

[Veneficus]

I'd definitely like to review this study, there is way too much open to subjective opinion, simply based on the article. Do we know that too much fluid kills? Yes, absolutely, this has been studied since the military medics in vietnam were "killing" their patients with fluids. I'll try to get my hands on that study, I reviewed it probably 5 years ago when I was working heavily in Tac-Med, and we were looking at the necessity of fluids in our medic packs, and how much. Also is this in direct relationship to creating too much pressure in the system and blowing clots, i.e. over 93 systolic? Or I guess another way to look at it, is that IV fluid is contraindicated in trauma patients because severe trauma patients die, and since they came in with IV access and fluids, that must be what killed them... Sorta like the serial killers eat cornflakes arguments... I'll try to find that vietnam study about thoracic trauma and survivability with/without IV fluids. -luno

The earliest research I have seen on it was WWI.

We know that it is basic physics that when the pressure inside the vessle is greater than that outside, you have bleeding.

We know from the pathophysiology of coagulation disorders that serum, defined as plasma with no blood elements is hypocoaguable. Adding fluid dilutes plasma, and basic chemistry dictates in order to have reaction there has to be contact.

But one of the major issues with fluid is the post resuscitation fluid balance. This is manifest in the increase in electrolyte imbalance when isotonic saline is used as well as the water compartment shifts in conditions like abdominal compartment syndrome.

When considering that up to 50% of vascular volume can be replaced by Intracellular volume, in up to at least 900ml of blood loss, how easy is it to lose site of total body water balance in the short term efforts of increasing intravascular volume?

To what end?

Unfortunately there is no shorcut and limited knoweldge in reading studies without the knowledge of the basic science behind it when determining clinical practice. A mistake more and more common as time goes on.

So I don't think it is simply a question of if individuals had wounds incompatible with life and were given fluid, but who had wounds compatible with life and how much fluid was given and what exactly caused them to die?

Uncontrolled hemorrhage or failure to reestablished biochemical homeostasis post resuscitation because of the interventions of the resuscitation?

I advocate that trauma is perhaps one of if not the most complex medical problems known to date. It is total body biochemical level manipulation with opposing therapies. If a provider doesn't understand it, the studies and practice recommendations are moot.

I actually question whether or not a "protocol" approach is even possible considering what helps the brain hurts the heart, what helps the kidneys hurts the liver, etc.

Best practice may require sub protocols, like injury to body region X or organ Y.

 

[usalsfyre]

Any thoughts on the increased use of colloids vs isotonic solutions?