1. This was an absolutely phenomenal lecture. As a medic, I really appreciate the fact that so much of the information on this blog is presented at a level that those of us without the fancy letters behind our names can understand. I can’t wait for some of this to filter down to the prehospital folks so we can finally get away from the 20 cc/kg crystalloid dogma. Great stuff. Keep it coming.

  2. I agree with Mike – a bloody (excuse the pun) great talk on the state of the art in hemostatic resuscitation. Will be spreading the word on this must see video lecture.
    Thanks for sharing Scott,

  3. thanks Scott for posting this video of Dr Dutton. I thoroughly enjoyed his lecture. its great to see an enthusiastic and knowledgeable teacher at work!

    I must say I still have doubts about what this all means in the prehospital and retrieval setting. With long transport times I believe some resuscitation is worthwhile even if that means using crystalloid. We had a recent case in a remote area of Australia where the retrieval team responded without access to blood products to a man who had been hit by an aircraft propeller blade in the upper back. They used all their crystalloids as well as a noradrenaline infusion to keep the guy alive for the 3 hr flight to the trauma hospital. Remember the rat study which showed the no resuscitation group had 100% mortality. Is it that we must now start trying to ensure we have blood products availabe in a prehospital setting rather than crystalloid? I am aware of a proposed trial in Australia looking at giving tranexamic acid in a prehospital setting using a clinical prediction tool to assess for ACOTS. This seems to be more viable than trying to get blood products available for all prehospital services.

    One thing to point out that Dr Dutton did touch on is that ACOTS is not universal and many trauma patients with haemorrhage have no objective evidence of coagulaopathy. he did mention that perhaps there exists a genetic predisposition for ACOTS. My question in that case is that does haemostatic resuscitation need to be done in every bleeding trauma patient or is there some way to select this? In prehospital setting this would be relevant.

    My other doubt I have is the extrapolation of this research and strategy to the extremes of age. Paediatric trauma and elderly trauma..does accepting a lower MAP in a 4 yo work just as well as an adult ?? And what about the 75yo man with a normal BP of 160/90, would keeping his systolic at 80 be the right thing for him?

    Anyway it is still great to hear the issues discussed so eloquently and by such an experienced resuscitationist as Dr Dutton so thanks again for sharing.

    • Minh- I didn’t mean to imply that crystalloids have no place in trauma. At least in the US, PHTLS typically calls for massive amounts of fluid to maintain a systolic of 90-100. We’re taught to be terrified of giving opioids to hypotensive pts. I think the idea of giving small amounts of crystalloid and tiny doses of fentanyl to maintain a lower MAP is a revolutionary concept (at least in the system I’m in). I wasn’t suggesting putting blood products on every ambulance; I just want to see a more moderate approach to giving the fluids we currently use.

      • agree in EMS, until something new comes around crystalloid but with much lower MAP goals. My favorite is fluid until palpable radial pulse. Quick, dirty, and probably efficacious.

          • i see what you mean. even more surprising is this paragraph I found while reading it:
            If massive transfusion of stored blood is necessary, every second unit should be
            supplemented with one ampoule of sodium bicarbonate (44.3 mEq) and one ampoule
            of calcium chloride (10 g) by a separate i.v. line. As with crystalloid fluids, blood should
            be warmed to body temperature to avoid increasing hypothermia. This can be achieved
            through the use of locally-made water baths or the body heat of staff members.

            v. interesting. they are in effect giving a simulacrum of a balanced form of hypertonic saline, whether inadvertently or not.

    • Those are great points regarding the patients with long transport times. The vast majority of trauma research is done in urban academic centers that have shorter transport times so you have to take that into account when you are in the middle of nowhere with a 3 hour transport time instead of a 3 minute transport time. As a former EMS person (now EM resident) in a busy suburban/rural system I saw these differences in care a lot- things change drastically when there is a level 1 trauma center just around the corner vs. a long drive or helicopter flight.

      I have flown with one helicopter service in the US that carried blood products- I don’t know if this is standard of care or not and I know that the logistics are challenging but it is out there.

    • Rick did not touch on it extensively, but part of the variability of ACOTS is that ir requires two hits: shock (from the bleeding) AND tissue damage. If you slice open someone’s brachial and bleed them out, you can give crystalloid back to them and over-resus and no ASCOTS. You need the tissue damage as well.

      Have no idea about peds, I shoot for a slightly higher MAP on the elderly with no evidence to back me up.

      • Thanks Scott
        thats good to know that concept of two hits for ACOTS. I must say I am a bit surprised about the lack of understanding of the role of haemostatic resuscitation in peds overall. I would have imagined that a busy trauma hospital like Baltimore would almost certainly see lots of peds trauma and reviewed the role of this strategy in resuscitation for peds haemorrhagic shock?

        I wanted to thank Dr Dutton for citing the Lady Diana trauma case once again as I have done previously. its a good reminder that with short transport times our list of resuscitation goals should be equally short. Everyone remember the assassination attempt on Ronald Reagan with a .38 pistol at short range? He was shot in the left chest with similar haemothorax to Lady Diana. He was 70 yo compared with Diana who was 30 + years younger. Yet he survived . Why? Perhaps short transport time and surgery within 1 hr of his wounding helped? I guess Secret Service agents get training in being basic EMS providers!

        • All serious peds trauma in Baltimore goes to John Hopkins across town. We see no pediatrics at Shock Trauma; part of the source of my self-imposed ignorance.

  4. Really excellent and eye-opening lecture.

    2 questions:

    1) is the EmCrit conference an annual, open to the public CME event? It sounds awesome.

    2) when he speaks about giving 100 mL boluses of fluid balanced with fentanyl for anesthesia, I assume by fluid he means 1:1:1 blood products? Are they somehow mixed back together? I’m trying to wrap my head around the logistics of that. What dose of fentanyl is commonly used in that scenario?

    • When Rick says fluid he means 1:1 prbc:ffp. fentanyl dosing is 25-50 mcg a shot
      see previous EMCrit Podcast #30 for the full explanation.

  5. Great lecture. Real interesting and practice changing stuff. Two questions.
    1. Dose the principle stand for non-trauma massive blood loss. e.g. massive GIH?
    2. What about the multi-trauma inc. head injured patient? Prior to insertion of ICP monitoring we use MAP 90 as target with fluids/pressors.

    • I use same principles on GIB, but have not seen great evidence as of yet.

      For what Rick recommends in Head Trauma, see the end of podcast 30.


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