EMCrit Podcast 30 – Hemorrhagic Shock Resuscitation

This week we discuss the resuscitation of the hemorrhagic shock patient with Dr. Richard Dutton, MD.

Rick was director of trauma anesthesia at the Shock Trauma Center when I trained there. He is an incredible teacher, clinician, and researcher.

Here are the take home points:

  • Induction agent choice does not matter in these patients; what matters is DOSE! Reduce dose to 1/10 of full intubating dose.
  • Blood products need to be available in the trauma bay for when these patients arrive. If you need to give crystalloid while awaiting the products, give only small amounts just to keep the patients heart beating.
  • A systolic of 80 with good perfusion and normal sized vessels is very different than that same SBP in a patient who is clamped down. The former is a resuscitated state, the latter =spiral of death.
  • The resuscitation fluid for trauma is equal parts PRBC and FFP.

To read more of Dr. Dutton’s thoughts, go to this article:

ITACCS Damage Control Anesthesia

Update: This article is even better (Br J Anaes 2012;109(s1):139)

photo from trauma.org
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Comments

  1. Love it – “the dose matters, not the drug”, “shock is an anesthetic”. I once had a boss who’d say the basic RSI was ‘sux-tube-apology’ in the really sick patient ( could swap roc for sux, of course). The rest is a bonus.
    Always annoyed me when an attending/ consultant criticised an RSI plan on the choice of induction agent when an appropriate dose and back up plan is in place!
    There’s always more than one way to skin a cat…
    Great work Scott – keep on delivering!
    Chris

  2. I really enjoyed this podcast… The therapeutic hypotension to control bleeding makes sense…. As someone who works with ECMO ( a highly anti-coagulated patient), I really appreciate these points…. I think it is exciting to see how cerebral oximeters can now help us tweak the way we manage patients or allow us to feel comfortable with numbers that we would never have allowed before… I can’t wait to see how in ten years we manage patients!!! Hopefully we will be more progressive about treating physiologies and science rather than just numbers… It is a very exciting time in medicine!!!!!

  3. I’m not sure about sux-tube-apology, but point well taken.

    You and Dr. Dutton beautifully reinforce the limitations of blood pressure, especially in patients with deep vasomotor reserve such as healthy young trauma victims. The proposed approach is sympatholytic resuscitation, and until we have real-time dynamic measures of end-organ perfusion that correlate with patient-oriented endpoints (maybe cerebral oximetry, as mentioned by Rick, above) it may be the best way to know how well you’re supporting the patient’s physiology.

    I wonder how well a sympatholytic resuscitation model applies to

    a. hemorrhagic shock patients with less vasomotor reserve, such as the 75 year old with massive GI bleed.
    b. other forms of shock. doesn’t make theoretical sense in neurogenic, anaphylactic, or obstructive shock, so I guess I’m talking about cardiogenic shock and especially septic shock, where once again the catecholamine response to stress, which served us well when we spent our days running from lions, now undermines our survival.

    I suppose that’s not completely fair as there are some shifts when I feel like I’m running from lions.

    • Reub,
      Really great points/questions.
      What Rick taught for the elderly, is most of them can’t mount a sympathetic response. They won’t shed much of their BP with the fentanyl all, b/c they are already without compensation. They will present hypotensive and you just need to resus the heck out of them. Way they will fool you is when their baseline BP is high from hypertension, they can come in with a normal looking BP, and be quite blood-down.

      Prototypical septic shock is already a vasodilated state. Just the opposite of traumatic. These folks will perfuse so long as you give them enough tank filling. They need fluids and vasoconstriction. Their catecholamines have already failed them by the time their BP drops. Most septic shock patients will need some degree of exogenous pressors.
      I guess a lesson we can take from Rick’s thoughts on trauma shock is in the situation of poor sepsis resus in which little fluids and large amounts of pressors are used. That can create the badly perfused patient with no blood volume, cold hands, and dying organs.

      Cardiogenic is a failing pump. When the pump fails there is nothing you can do to fix the situation, you can only temporize. In this case we add pressors for the sole reason of maintaining back pressure on the coronaries and then we pray that by whipping the heart with inotropes, we’ll get enough squeeze out of the dying organ to perfuse the body. Only solution is fix the pump with intervention or replace it. Bridge therapies like IABP and LVAD are just to give more time.

      So I think this therapy for traumatic shock is not applicable to the others.

  4. Hey Scott,
    Thanks a lot for this piece.
    As a soon-to-be certified Anesthesiologist/Intensivist, I’ve learned to appreciate this blog because every now and then I hear a message that’s quite different from what opinion leaders openly broadcast in my country (France). Indeed, we got a few very active (i.e. loud) hemorrhagic shock gurus proning relatively early norepinephrine use (don’t choke, they also deem blood products to be paramount) on the arguments that
    1.) it can be useful to quickly reach a minimum perfusion pressure (a MAP of 65 is a cherished target over here too, but they advocate 85 to 90 (or just whatever is necessary to normalize transcranial doppler parameters) if brain trauma is associated. by the way, Dr Dutton’s honesty about what to expect in the unlucky brain-injured and shocked patient was refreshing…;),
    2.) it can be helpful in counteracting anesthetic-induced vasodilation perceived (as I did until today) as a deleterious side effect,
    3.) it can mobilize a little further the unstressed venous volume, thus leading to an “internal” fluid loading.
    The same researchers are also very excited about microcirculation monitoring (they never fail to show pictures of clamped down vs. circulating capillaries) so I would think they have taken the microcirculation into account when they recommend using pressors early on as an adjunct therapy.
    The approach of Dr Dutton to use anesthesia/opiates as a vasodilator in conjunction to “blood loading” to restore perfusion is quite new to my ear and I am glad you’re giving us the opportunity to hear about it.

    As a last question, what’s your (and maybe Dr Dutton’s) take on Hypetonic Saline ?
    In France (and maybe europe), we are quite cautious about using isotonic cristalloids as fluid loading in Trauma resuscitation and colloids (starches mainly) are even recommended as first line fluid in a patient who has bled more than 20% of his blood volume or presenting with severe bleeding and a MAP below 80 (again all of this waiting for the blood products) (alright it’s a consensus from 1997 but it has not been struck by the seal of heresy to this day…).

    Good day, and thanks for your work, keep the good stuff coming!
    Nico, Transatlantic EMcrit enthusiast!

    • Nico,

      Wonderful comments!
      I wish either side (pressors vs. no pressors) had some data. We are all flying blind. The one thing I can say is with the method Dr. Dutton describes, which Rebuen Strayer below has dubbed, sympatholytic resuscitation, the patient usually clears their lactate intraop. A pure pressor resus, I can only see it going up. But what your hemorrhagic shock gurus seem to be advocating is a mixture of blood resus and norepi. I don’t know how that would play out, I guess it all depends on what you do with the norepi once the products are infusing and the patient’s BP is getting better. There was a surge of vasopressin use for trauma for a while in the states for many of the reasons you mentioned, but it did not pan out in later studies.

      as to hypertonic, I can tell you at Rick’s center, they are just using FFP/Blood intraop as their fluid choice. Post-op not much hypertonic for straight trauma. They probably had the largest use in the nation of 3% for traumatic brain injury. Our available colloids all have the potential to worsen coagulopathy and they have not gained much toehold. I am more curious about the gelatins you folks have that we do not.

      I personally use hypertonic when I am substituting PCC for FFP during the initial rounds of trauma.

      • PPC are, to my best knowledge only approved in France for emergent reversal of VKA anticoagulation, or the rare case of severe bleeding in a patient with a deficit in factor II or X.
        Using PPC in trauma would be off label over here.
        Do you use them as you wait for FFP or is there any other reason?

        • We use it during the 40 minutes FFP is thawing. Pretty much everything we are doing is off label here as well.

  5. Donald W Crowe, MD says:

    Scott,
    I have enjoyed your podcasts. As an Emergency Physician with thirty years of front line practice experience, I have really appreciated your perspective. I have come to believe that finding a reliable and easy to obtain marker that signals a given pateints “tank is full” is the Holy Grail of resuscitation. The idea of “sympatholytic” resuscitaion in the “healthy” trauma victim is an approach I had not encountered and I certainly will consider it. I was wondering if Dr Dutton always has an arterial line in place for his BP monitoring? Also, are the PRBC’s and FFP always infused through separate IV’s? Keep up the good work.
    Donald W. Crowe, MD
    Ocala, Fl

    • Donald,

      Yes a-line is always in place. I place them in the ED for all of our sick traumas. Ultrasound-guided femoral a-line takes < 60 seconds to place.
      At shock trauma they dump all blood products into the bucket of a rapid infusion system and they are mixed together and infused. For us, the take-home is they can definitely be given in the same IV line. I just spike PRBC on one port of my level I and FFP on the other and keep alternating which side is pressurized.

      scott

      • Also, are the PRBC‘s and FFP always infused through separate IV‘s?
        – Seen your response to Donald about spiking PRBC and FFP and alternating infusing through same IV line.

        Can you infuse both PRBC and FFP simultaneously through the same IV site?

  6. Minh Le Cong says:

    Hi Scott from Down Under!

    Thanks for this blog by the way..its excellent!
    What is your advice in the aeromedical transport and retrieval setting with transport times of 1-3hrs from remote clinics for the haemorrhagic shock patient?

    We can take blood on evacuations..FFP takes extra time to thaw from the lab but we now have Prothrombinex ( factor concentrate) available.

    2 years ago we had a case of a stabbing victim with a renal injury present to a remote clinic doctor. She applied minimal volume resuscitation strategy as she had recently attended a trauma lecture by a military anaesthetist. The patient deteriorated and arrested. There was some unfair criticism I thought levelled that only 1.5L of saline was given over th 1 hr of resus….I guess in that situation giving more fluid is physiologically better than less if someone is bleeding to death??

    look forward to hearing your words of wisdom!

    ta
    Minh
    Royal Flying Doctor Service, Cairns , Australia

    • Minh,

      Great to hear from you.

      blood + PCC is not a bad combo and it feeds into the 2nd part of your question.

      you use what you have.
      Blood + FFP is better than blood
      blood alone is better than saline
      saline is better than nothing

      if the doc you mention was fluid restricting the saline but giving a ton of products, then she did well. if she didn’t have products and was fluid restricting, then not so good. got to keep the heart pumpin’.

      if you are going to use red cells and PCC on your chopper, I would recommend adding a couple of 100 mls of saline per PRBC bag to the mix to make up for the lack of volume of the FFP.

  7. anthony ferkich says:

    Scott,
    I have heard many people discuss the use of platlets in a 1:1:1 massive transfusion protocol. collegues of mine and I are wondering what defines the “1” for platlets? I have heard some refer to the more commonly used “platlet pharesis pack” which is equivalent to the old “six pack”. both raise your counts an estimated avg of 30K. In your lecture, I hear you define the “1” as a single component of the old “six pack”. Could you shed some light on this for us?http://blog.emcrit.org/wp-content/plugins/wp-notcaptcha/lib/vertical_sign.png

  8. No discussion of calcium…?

  9. How would you apply this to EMS where A-lines and blood products are unavailable? Should we be trying to titrate LR/saline and fentanyl in young hemorrhagic shock patients to achieve a patient with hypotension and a radial pulse? Should are goal just be to try and titrate prehospital fluid until there is a radial pulse? If there is no radial pulses but a decent blood pressure should we give the fentanyl bolus and prepare to give some prehospital fluid when the blood pressure drops?

    Thank you.

    • i think resus to presence of radial pulse is the way to go. if your protocol allows prn pain meds with fentanyl, a 25 mcg bolus x 1 is not a bad thing.

  10. Dear Scott,
    thank you sincerely for your podcasts. This one particularly! The 1:1:1 concept is a little new to us emergency physicians and as you most probably know there are variations in the recommended ratio. I feel my colleges are even suspicious to using FFP+PLTs in general.

    Here
    http://www.sjtrem.com/content/18/1/65

    is a study just published in “Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine” the authors concluded no reduction on mortality with FFP and platelets: “Aggressive administration of FFP and PLT did not reduce mortality in the present trauma population. ”

    I was hoping that you could give your opinion on this as you have other studies to compare with?

    Thank you!

    • David,

      the study you refer to blended patients requiring massive trans with those that didn’t only 66 of the patients needed massive transfusion and no data was offered on those pts. only pts requiring massive trans benefit from 1:1:1 and infact pts that aren’t that sick may have negative sequelae as a result of 1:1:1. I think this study is indicating only that.

      See this article for a better vision of the current state of the lit.

      http://emcrit.org/blogstuff/Acep2010/Spinella%20and%20Holcomb.pdf

      Scott

  11. How does this relate to prehospital care considering we don’t carry products? We often have 1.5 hour to 2 hour trips to definitive care. Are you suggesting NS with Fentanyl bolus to maintain b/p around 70 or MAP of 65? The facility that does have blood, only has PRBC and no FFP?

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