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
Additional New Information
Updates:
- This article is even better (Br J Anaes 2012;109(s1):139)
- You can see a full lecture by Rick from the EMCrit Conference
- Great Article from STC on choice of Anesthetics (Curr Anesthiol Rep 2014;4:225)
- Meta-analysis
- This retrospective review showed mortality benefit in patients who received high-dose opioids
More on EMCrit
EMCrit Podcast 12 – Trauma Resus: Part I(Opens in a new browser tab)
Additional Resources
You Need an EMCrit Membership to see this content. Login here if you already have one.
Editor-in-Chief, at EMCrit.org
An ED Intensivist from NY.
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Professor
Nassau University Medical Center
No conflicts of interest (coi).
Latest posts by Scott Weingart, MD FCCM (see all)
- EMCrit 389 – Massive Transfusion Update and Hemostatic Resuscitation - December 1, 2024
- EMCrit 388 – Experts' Guide to the Bougie with Barnicle and Driver - November 22, 2024
- EMCrit RACC Lit Review – October/November 2024 - November 7, 2024
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
Sux-tube-apology. I love it.
Scott
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!!!!!
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… Read more »
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… Read more »
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… Read more »
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… Read more »
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.
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… Read more »
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?
Yes they can go through same iv line.
Scott
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… Read more »
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… Read more »
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
a 6-pack of plt are taken to mean 6 platelets which would be matched to 6 of ffp and 6 of prbc.
No discussion of calcium…?
We kept it short. They use calcium as like most places use saline flushes.
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.
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… Read more »
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.
https://emcrit.org/blogstuff/Acep2010/Spinella%20and%20Holcomb.pdf
Scott
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?
Minh’s PHARM podcast at prehospitalmed.com discusses this exact topic.
This is a minor comment, but the link to the ITACCS lecture in the post doesn’t seem to be the right place, I think because it has a dot com link address instead of dot org.
Sorry to revive a long dormant post… but I am re-listening to all the podcasts (for the 6th time) and had a question. The point on avoiding vasopressors in hemorrhagic shock is well-taken; however if the mechanism of hypotension after administration of the induction agent (whichever one is used) is vasodilation d/t decrease in endogenous catecholamines, would it be appropriate to prophylactically give a small push dose of a vasopressor/inopressor with your induction agent? Would chasing the Propofol with a touch of epinephrine, norepi, neo, or vaso act to transiently replace the endogenous catecholamines and prevent or reduce the post-induction… Read more »
have no problem giving a squirt in those cases, but we don’t use anything that would lower the bp from vasodilation (we use ketamine) so we don’t have that issue
very enjoyable to hear dr richard dutton. (i guess i am seven years behind on this pod, still enlightening, and i’m sure relevant.)
i wonder if for places like mine, rural community hospitals, it may be worth calling a “code crimson” (blood banks comes rushing down with prbc’s/ffp/platelets) when we get the call pre-hospital.
it was very enlightening his see-sawing with alternating dosings of fentanyl and “fluid” (rbc/ffp). it would be trickier in my shop where they all get choppered out to the trauma center.
thank you.
Amazing module – I a an anesthesiologist in CO and Heard Dutton Speak at the CSA conference in CO Springs. Amazing Speaker and this was a great module Scott. Thank you for the CME and how easy it is to access
Heidi
Hi Scott,
I have been scouring the literature and have not found any literature to support rick’s (very intuitive) claims. The links you provide also no longer work. Do you have any recommendations? So far all of the literature I have found has claimed that ketamine supports (and even increases) blood pressure in profoundly hypovolemic patients, in addition to other claims. My personal practice has been to use ricks method, but I have been met with resistance at my shop. Would appreciate any guidance!