Ali Haedar

Department of Emergency Medicine

Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital
Indonesia
Dr. Ali Haedar, Sp.EM, FAHA
 Clinical Lecturer, Universitas Brawijaya
 Emergency Medicine Physician, Saiful Anwar General Hospital
 Vice Chairman of South East Asia Chapter of the Asian Association of
Emergency Medical Services (AAEMS)
 Professional Associate of the American Heart Association (AHA) &
American Stroke Association (ASA)
 Instructor for BLS & ACLS - The American Heart Association (AHA)
 Instructor for Advanced HAZMAT Life Support (AHLS) - The
University of Arizona College of Medicine at the Arizona Health
Sciences Center
 Board Member, International Training Consortium of Disaster Risk
Reduction (ITCDRR)

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Conflict of Interest
 Nothing to declare

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Get the right patient . . .

. . . to the right place

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. . . in the right amount of time.
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Issues in Emergency Trauma Care
1. Trauma Center Vs Closest Hospital
2. Scene stabilization Vs Scoop and Run
3. Large volumes of IV fluids Vs IV Fluid
Restriction
4. Permissive Hypotension Vs
Normotension
5. CPR Vs No CPR

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 Our Goal: To increase Probability of Survival for
Trauma Patients
Trauma and Injury Severity Scoring (TRISS) and Patients’ Outcome
(mean = 0,86482; standard deviation = 0,32259)
Probability of Survived Died Total
survival (Ps)
10745 97.97% 223 2.03%
> 0.5 10968 100%
Expected survivals Unexpected deaths
1471 92.28% 123 7.72%
< 0.5 1594 100%
Unexpected survivals Expected deaths
12216 97.25% 346 2.75%
Total 12562
Actual number of Actual number of deaths
survivals
The actual mortality was lower than what was predicted based on TRISS norms – that is, W score of 9.93,
the number of excess survivals per 100 patients

Haedar, 2005. Probability of Survival for Trauma Patients at IGD RSSA. 7

Effect of Trauma-Center Care on
Mortality
 In-hospital mortality :
 Trauma center: 7.6%; relative risk 0.80
 Non-trauma center: 9.5%
 One year mortality rate:
 Trauma center 10.4%, relative risk 0.75
 Non-trauma center: 13.8%

Lilja, C. P. (2004). Emergency Medical Services. In J. Tintinalli, Emergency Medicine a

Comprehensive Study Guide (pp. 1-14). Chicago: McGraw-Hill.
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Trauma Center vs Closest Hospital
Closest Hospital
 CRASH!
 8 minute EMS response
 10 min scene time
 5 min transport time
 10 min ED evaluation
 30 min surgeon call-in
 30 min OR call-in
 5 min transfer to OR
Total Time, injury to OR= 98 mins
Trauma Center
 CRASH!
 8 minute EMS response
 10 min scene time
 15 min transport time
 10 min ED evaluation
 5 min transfer to OR
Total Time, injury to OR= 48 mins
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Prehospital ALS for Trauma
Scene stabilization of trauma
patients by ALS crews were
disastrous
(† 5/6)

Vs

Improved outcome when victims

of penetrating cardiac trauma
were transported by BLS scoop
and run
(† 0/7)

First publication: Gervin A, J Trauma, 1982

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Prehospital ALS for Trauma
Authorities questioned the role of prehospital advanced life support:
 Prehospital stabilization of critically injured patients: a
failed concept
 Smith J, et al, J Trauma, 1985
 Emergency Medical Services (EMS) vs Non-EMS Transport of
Critically Injured Patients; A Prospective Evaluation
 Edward E. Cornwell III E, et al, Arch Surg, 2000
 Prehospital care − Scoop and run or stay and play?
 Smith RM, et al, Injury, 2009
 Is advanced life support better than basic life support in
prehospital care? A systematic review
 Ryynänen O, et al, Scandinavian Journal of Trauma, Resuscitation and
Emergency Medicine, 2010

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Basic Competencies for Pre-Hospital?
 Pre-Hospital Trauma
Life Support
 ITLS
 BLS
 Ambulance Protocol
Course
Prehospital interventions beyond the BLS level have not been shown to be
effective and in many cases have proven to be detrimental to patient
outcome.

Smith RM, et al, 2009. Prehospital care − Scoop and run or stay and play? Injury, Volume 40,
Supplement 4, November 2009, Pages S23-S26 14
How about rural area?
 Limited, key field interventions:
 Airway control
 Oxygenation and ventilation support
 Hemorrhage control
 Spinal Immobilization
 Rapid Transport to appropriate facility
 Initiate IVs enroute

There may be more need for scene stabilization in the rural

environment or where transport times are prolonged!
Smith RM, et al, 2009. Prehospital care − Scoop and run or stay and play? Injury, Volume 40,
Supplement 4, November 2009, Pages S23-S26
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Should EMS personnel
administer large
volumes of IV fluids
rapidly to trauma
victims
Or
delay fluid
resuscitation until
hospital arrival?

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IV Fluid Restriction;
Previous Recommendation

 Traditional approach to
trauma patient with
hypotension was 2 large
bore IVs and wide open
crystalloid administration.

 Recommendation has been

to replace lost blood with
isotonic crystalloids at a 4:1
ratio (IVF:blood loss)

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 IV Fluid Restriction;
Physiology

Administering large quantities of IV fluids

without controlling the hemorrhage results in:
 hemodilution with decreased hematocrit
 decreased available hemoglobin (and oxygen-
carrying capacity)
 decreased clotting factors

Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive
patients with penetrating torso injuries. N Eng J Med. 1994;331:1105-9
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 IV Fluid Restriction;
Research
598 patients with penetrating  Group Divisions
torso injury and systolic Delayed: n=289

BP≤90mmHg in prehospital  Standard fluids: n=309
setting, randomized to  Survival:
receive standard high-volume  Delayed: 70%
fluids or fluids delayed until  Standard fluids: 62%
patient in OR.  Complications:
 Delayed: 23%
 Standard fluids: 30%

Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive
patients with penetrating torso injuries. N Eng J Med. 1994;331:1105-9 20
IV Fluid Restriction
New recommendation
 Raising the BP and restoring perfusion to vital organs are clearly
believed to be beneficial after hemorrhage is controlled.
 Current recommendation for blunt trauma is to administer just enough
fluid to maintain perfusion.
 Rapid transport probably remains the best treatment for most trauma
cases.

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 Should EMS personnel
attempt to restore blood
pressure in trauma
patients to pre-trauma
levels
or
practice permissive
hypotension?

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Permissive Hypotension;
Physiology

 There is a natural physiologic compensation to

maintain MAP maintained between 70-85 mmHg.

 Urine output and cerebral perfusion usually

maintained when the BP is within this range.

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Permissive Hypotension;
Physiology

Elevation of BP to pre-injury levels, without

hemostasis, has been associated with:
 Progressive and repeated re-bleeding
 Decrease in platelets and clotting factors.
 Dislodgement of a clot at the site of injury at
about 80 mmHg systolic pressure.

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Permissive Hypotension; Research
 110 patients with
hemorrhagic shock were
randomized into two
groups: BP maintenance >
100 (n=55) & BP
maintenance of 70 (n=55).

 Conclusion: Titration of
initial fluid therapy to a
lower than normal SBP
during active hemorrhage
did not affect mortality in
this study.
Dutton RP, MacKenzie CF, Scalea TM, et al. Hypotensive resuscitation during active hemorrhage:
Impact on in-hospital mortality. J Trauma. 2003;52(6):1141-1146 26
 Permissive Hypotension;
Researches conclusions

Studies indicated that

treatment with IV fluids
before hemorrhage was
controlled increased the
mortality rate, especially if the
blood pressure is elevated.

Holmes JF, Sakles JC, Lewis G, Wisner DH. Effects of delaying fluid resuscitation on an injury to the
systemic arterial vasculature. Acad Emerg Med. 2002;9(4):267-274
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Permissive Hypotension; Available guideline

The EMS must attempt to

maintain perfusion to the
vital organs. Maintaining
the SBP 80-90mmHg or the
MAP of 60-65mmHg, can
usually accomplish this with
less risk of renewing
internal hemorrhage.

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Permissive Hypotension; Available guideline
Gain IV access en route but
give only enough RL or NS
to maintain a blood pressure
high enough for adequate
peripheral perfusion,
defined as producing a
peripheral pulse,
maintaining level of
consciousness, or
maintaining BP (90-100 mm
Hg systolic).

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Permissive Hypotension;
Traumatic Brain Injury

Why does TBI require a higher systolic BP than

required for permissive hypotension

CPP = MAP- ICP

MAP = [DBP+1/3 (SBP-DBP)]
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Permissive Hypotension;
New recommendation

 Fluid restriction and permissive hypotension go hand-in-

hand.

 Fluid resuscitation should be administered in small

boluses to maintain peripheral pulse (systolic BP +/- 90
mmHg)

 Slightly higher systolic pressure may be required to

maintain CPP in TBI.

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Unsalvageable Patient

Traumatic cardiopulmonary arrest

survival is very rare

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Resuscitation Withheld
 No breathing, no pulse,
no organized cardiac activity

• Blunt trauma arrest on EMS arrival

• Penetrating trauma arrest

 No pupillary reflexes or spontaneous movement

• Injuries incompatible with life

• Evidence of significant time since pulselessness

 Dependent lividity, rigor mortis, etc.

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Resuscitation Initiated
 No breathing, no pulse,
no organized cardiac activity
• Mechanism of injury does not correlate
with clinical condition
 Suggestive of nontraumatic cause

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Resuscitation Terminated
 No breathing, no pulse,
no organized cardiac activity
• EMS-witnessed cardiopulmonary arrest
and 15 minutes of unsuccessful resuscitation
• Transport time to ED >15 minutes

 Special consideration
• Drowning, lightning strike, hypothermia

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Trauma Arrest
 Treat underlying cause:
• Airway problems
• Breathing problems
• Circulation problems

• Use BTLS Primary Survey to identify!

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Conclusions
 First Do No Harm
 Transfer pt to Trauma Center is better than to the Closest
Hospital
 Scoop and Run then to stabilize pt in the hospital is better
than Scene stabilization
 IV fluid restriction is better than giving Large volumes of
IV fluids
 Permissive Hypotension is better than Normotension
 Do No CPR for Unsalvageable Patient with Trauma Arrest
is better than do CPR

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