Fluid resuscitation of trauma patients: how fast is the optimal rate? Yasuaki Mizushima MD*, Hideo Tohira MD, Yasumitsu Mizobata MD, Tetsuya Matsuoka MD, Junichiro Yokota MD Osaka Prefectural Senshu Critical Care Medical Center, Osaka, , Japan American Journal of Emergency Medicine (2005) 23, 833 – 837 Presented by: Intern Dr. 顏少君

1. Introduction ► ► Hypovolemic shock  Tx   Arrest of bleeding &   Replacement of circulating fluid volume. ► ► Initial rapid fluid infusion as diagnostic procedure Recommendation of Advanced Trauma Life Support guidelines (6/e, American College of Surgeons, 1997) [Rapid responders, transient responders, or minimal or nonresponders] Responders  observed to identify those patients with ongoing bleeding requiring surgical control Nonresponders  immediate surgical intervention

1. Introduction ► ► 1-2 L crystalloid infusion Recommended by the Advanced Trauma Life Support guidelines ► ? Rate ► ? End point [3] Aggressive fluid resuscitation before control of bleeding.  May disrupt thrombus formation, increase bleeding, and decrease survival [4,5] Restricted fluid resuscitation  negative effect on tissue perfusion in shocked patients who respond to fluid with stabilization of their vital signs

2. Material and methods ► ► Retrospective analysis ► ► Inclusion   Adult (age <16 years)   Blunt trauma victims + SBP ≤ 90 mmHg   Standard trauma resuscitation protocols ► ► Exclusion   No prehospial intravenous fluid   Not dead on arrival   Referred from other hospital

2. Material and methods ► ► Rapid bolus infusion of Ringer ’ s lactate ► ► Data Collected   Total fluid volume and   Time of initial resuscitation until surgical intervention or transfer to the intensive care unit (ICU)   The clinical outcome, Injury Severity Score (ISS), Revised Trauma Score (RTS) and predicted probability of survival (  TRISS)

3. Results ► ► May 1999 ~ Oct 2002, ► ► 99 patients (66 males, 33 females)

3.1. Patient groups (included radiological transarterial embolization) (  ICU)

3.2. Clinical characteristics (20.5%)

3.3. Hemodynamic response to initial fluid resuscitation OA: On Admission ER: End of Resuscitation

3.4. Fluid resuscitation ► Patients requiring fluid infusion at more than 60 mL/min were all hemodynamically unstable and required immediate surgical intervention. Limitation to this study: Rate of fluid administration was not always consistent throughout the resuscitation (patients in Group A and B) ► the mortality rate can be reduced in such patients if the time between initial resuscitation and surgical intervention was decreased.

3.5. Receiver operating characteristic curves 0.95 (98%CI, 0.92~0.99) mL/min ► The rate of infusion was the best predictor of whether uncontrolled hemorrhage requiring urgent surgical intervention ► The cutoff value for the rate of infusion fluid (the value closest to the upper left corner of the ROC plot) was 45 mL/min (sensitivity, 79.5%; specificity, 91.7%).

4. Discussion ► ? Rate

0.95 (98%CI, 0.92~0.99) 45mL/min

4. Discussion ► ? Rate ► ? End point [3]

4. Discussion ► ? Rate ► ? End point [3] ► KMUH 能在多短的時間內讓 nonresponders 病患接受 surgical intervention? ► 最佳 / 最合理的時間應該多短 ? ► 上個星期的 case?

Thank You for Your Attention! Intern Dr. 顏少君

Notes Shock: shock is the clinical syndrome that results from inadequate tissue perfusion. Usually accompanied by hypotension.

Notes Rapid responders, transient responders, or minimal or nonresponders ► Rapid responders  ? mild hypovolemia, blood loss, < 20%. (Class I) ► Transient responders  ? Moderate hypovolemia, blood loss, between 20~40. (Class II & III) ► Non responders  ? Severe hypovolemia, blood loss, > 40%, Class IV

Notes 1. Injury Severity Score (ICS) 2. Revised Trauma Score (RTS) 3. Trauma Score-Injury Severity Score (TRISS)  predicted survival rate 4. Receiver operating characteristic (ROC) curves way analysis of variance, Tukey test, or χ 2 and Fisher exact tests.

The Injury Severity Score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. Each injury is assigned an Abbreviated Injury Scale (AIS) score and is allocated to one of six body regions (Head, Face, Chest, Abdomen, Extremities (including Pelvis), External). Only the highest AIS score in each body region is used. The 3 most severely injured body regions have their score squared and added together to produce the ISS score.Abbreviated Injury Scale An example of the ISS calculation is shown below: RegionInjury Description AI S Square Top Three Head & Neck Cerebral Contusion 39 FaceNo Injury0 ChestFlail Chest416 AbdomenMinor Contusion of Liver Complex Rupture Spleen ExtremityFractured femur3 ExternalNo Injury0 Injury Severity Score: 50 The ISS score takes values from 0 to 75. If an injury is assigned an AIS of 6 (unsurvivable injury), the ISS score is automatically assigned to 75. The ISS score is virtually the only anatomical scoring system in use and correlates slinearly with mortality, morbidity, hospital stay and other measures of severity.

Abbreviated Injury Scale The Abbreviated Injury Scale (AIS) is an anatomical scoring system first introduced in Since this time it has been revised and updated against survival so that it now provides a reasonably accurrate was of ranking the severity of injury. The latest incarnation of the AIS score is the 1990 revision. The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine. Injuries are ranked on a scale of 1 to 6, with 1 being minor, 5 severe and 6 an unsurvivable injury. This represents the 'threat to life' associated with an injury and is not meant to represent a comprehensive measure of severity. The AIS is not an injury scale, in that the difference between AIS1 and AIS2 is not the same as that between AIS4 and AIS5. There are many similarities between the AIS scale and the Organ Injury Scales of the American Association for the Surgery of Trauma.Organ Injury Scales AIS ScoreInjury 1Minor 2Moderate 3Serious 4Severe 5Critical 6Unsurvivable

Revised Trauma Score The Revised Trauma Score is a physiological scoring system, with high inter-rater reliability and demonstrated accurracy in predictng death. It is scored from the first set of data obtained on the patient, and consists of Glasgow Coma Scale, Systolic Blood Pressure and Respiratory Rate.Glasgow Coma Scale Glasgow Coma Scale (GCS) Systolic Blood Pressure (SBP) Respirator y Rate (RR) Coded Value 13-15> > RTS = GCS SBP RR Values for the RTS are in the range 0 to The RTS is heavily weighted towards the Glasgow Coma Scale to compensate for major head injury without multisystem injury or major physiological changes. A threshold of RTS < 4 has been proposed to identify those patients who should be treated in a trauma centre, although this value may be somewhat low.

Trauma Score - Injury Severity Score : TRISS TRISS determines the probability of survival (Ps) of a patient from the ISS and RTS using the following formulae: Where 'b' is calculated from:

4. Discussion ► ► Important: find the source of blood loss and stop it [rapid responders, transient responders, or minimal or nonresponders] ► ► Responders  observed to identify those patients with ongoing bleeding requiring surgical control ► ► Nonresponders  immediate surgical intervention

4. Discussion ► ► Aggressive fluid resuscitation before control of bleeding.   May disrupt thrombus formation, increase bleeding, and decrease survival ► ► Restricted fluid resuscitation   negative effect on tissue perfusion in shocked patients who respond to fluid with stabilization of their vital signs

4. Discussion ► ► Patients requiring fluid infusion at more than 60 mL/min (nonresponders) were all hemodynamically unstable and required immediate surgical intervention. ► ► The rate of infusion was the best predictor of whether uncontrolled hemorrhage requiring urgent surgical intervention ► ► The cutoff value for the rate of infusion fluid (the value closest to the upper left corner of the ROC plot) was 45 mL/min (sensitivity, 79.5%; specificity, 91.7%). ► ► It would take 20 to 45 minutes for an adult patient to receive the standard 1-2 L crystalloid infusion recommended by the Advanced Trauma Life Support guidelines at this rate.

4. Discussion ► ► Increasing the fluid administration rate did not produce hemodynamic stability. ► ► The rate of infusion was the best predictor of whether uncontrolled hemorrhage would occur

4. Discussion Limitation to this study: ► ► Rate of fluid administration was not always consistent throughout the resuscitation (patients in Group A and B)

4. Discussion ► ► A rapid infusion rate does not restore blood pressure if the concomitant bleeding is occurring at a greater rate [10] ► ► The mortality rate can be reduced in Group C patients if the time between initial resuscitation and surgical intervention was decreased.   Initial imaging assessment   The rate of infusion required

2. Material and methods ► ► P <.05, ► ► as determined by   1-way analysis of variance,   Tukey test, or   χ 2 and Fisher exact tests.

3.4. Fluid resuscitation

3.5. Receiver operating characteristic curves 0.95 (98%CI, 0.92~0.99) mL/min (sen. 79.5%; spc. 91.7%)