Update on Resuscitation for Trauma and Sepsis

Educational Objectives

The goal of this program is to improve techniques of resuscitation in patients with trauma or sepsis. After hearing and assimilating this program, clinicians will be able to:

1. Choose fluids for resuscitation in patients with trauma based on type of injury.
2. Integrate recommendations from current sepsis guidelines into care decisions.

Summary

Trauma: the leading causes of death by traumatic injury are bleeding or traumatic brain injury (TBI); the trimodal distribution of trauma death based on time was described in the 1970s by Trunkey; the second peak (early) has since flattened and the third peak (late) has disappeared; trauma patients who receive care in the intensive care unit (ICU) are likely to survive, according to the CRASH-2 trial (Roberts et al [2013]); most trauma-related deaths occur in the first several hr after injury; resuscitation begins with stopping bleeding; newly developed hemostatic dressings and tourniquets are available; Bickell et al (1994) showed that controlling hemorrhage before resuscitation offered a survival advantage and positive difference in organ damage; the validity of damage control resuscitation is supported by data; use of crystalloids without hemorrhage control can lead to coagulopathy, hypothermia, and acidosis, leading to death; crystalloid use should be minimized; some hypotension is acceptable until hemorrhage is controlled

Blood products: the PROPPR trial (Holcomb et al [2015]) found that 24 hr mortality was significantly reduced by giving components early in a 1:1:1 ratio of plasma, platelets, and red blood cells; this ratio is now used for massive bleeding

Thromboelastography (TEG): can be used to determine which patients need specific blood components, and can be used if point of care testing is available; use of TEG conserves blood products and offers a mortality advantage; the Eastern Association for the Surgery of Trauma guidelines give a strong but conditional recommendation for TEG and rotational thromboelastometry (ROTEM) in adult trauma patients, surgical patients with ongoing hemorrhage, and critically ill patients with ongoing hemorrhage

Plasma: prehospital plasma administration is beneficial for patients with long prehospital times (≥20 min); Sperry et al (2018) found the advantage of plasma administration is primarily in patients with TBI; the more severe the TBI (Glasgow coma scale ≤8), the more the survival advantage, but response depends on endotype; patients with severe inflammatory response are more likely to respond to plasma

Whole blood: a shift to using whole blood may occur in the future; however, having separate components helps more patients because not all patients need whole blood; whole blood was first shown to offer a survival advantage in combat injuries; the ongoing TROOP trial is looking at low-titer group O whole blood in massively bleeding patients

Tranexamic acid (TXA): coagulopathic patients often lyse clots; use of TXA to stabilize clots has become more common and encouraged; data shows that early TXA administration in patients receiving massive transfusions significantly increased survival; TXA should be given ≤3 hr after injury (ideally ≤1 hr); benefits are seen with larger dose (2 g), when given ≤1 hr after injury, and when given to severely hypotensive patients (systolic blood pressure ≤90 mmHg); TXA is inexpensive and can be given in a prehospital setting; harm has not been demonstrated; the CRASH-3 trial looked at TXA in TBI and found benefit in moderate TBI and improvement in neurologic outcomes

Vasoactive agents: may be used as adjunct to resuscitation; less blood products are needed if low-dose vasopressin is added to standard resuscitation; calcium should be given because blood products contain citrate; coagulopathy and acidosis should be corrected; hospitals should have an established massive transfusion protocol which has been evaluated and perfected

Sepsis: patients have intravascular fluid maldistribution and loss of vascular tone; blood is shunted away from tissue beds and fluid enters the tissues; the Surviving Sepsis Guidelines have been revised; some recommendations have been changed to weak, eg, a recommendation of 30 ml/kg rapid fluid bolus may be too high; resuscitation starts early and with crystalloid; antibiotics should be started early, ie, ≤1 hr after injury if shock is present and ≤3 hr if not; antibiotic administration significantly impacts outcomes; cultures should be sent quickly and broad antibiotics started initially; once enough crystalloid (20 ml/kg-30 ml/kg) have been given, albumin can be given

Recommendations: not giving artificial colloids or starches is a strong recommendation, as they worsen outcomes and cause renal and multiple organ damage; use of steroids has a weak recommendation; administration of steroids may reduce requirements for vasopressors; not giving blood products to improve oxygen delivery is a strong recommendation; the first line vasopressor is norepinephrine; vasopressin may be added once a maximum dose of norepinephrine is reached, followed by epinephrine; albumin is only beneficial for patients who do not respond to other drugs for resuscitation (ie, severe septic shock); higher mean arterial pressure (MAP) does not offer survival advantage because a higher pressure indicates greater vascular resistance (and not greater perfusion); target MAP should be 60 to 65 mmHg and organ perfusion should be assessed

Goal-directed resuscitation: Rivers et al (2001) started resuscitation in the emergency department rather than in the ICU and treated patients in a goal-directed manner with central lines, blood transfusions, sedation, and ventilation; mortality rates were reduced from 50% to 30%; the concept of monitoring and titrating the intervention is valid; studies have not found a survival advantage with goal-directed resuscitation, but mortality rates in control groups have dropped to 30%; good clinical judgment and ICU care is sufficient for patients who are monitored and receive treatment which is titrated in a protocolized fashion

Fluids: restriction of intravenous fluid in patients in the ICU does not impact mortality or complications; saline or balanced salt solutions can be given (outcomes are similar); norepinephrine is recommended over dopamine because dopamine causes more arrhythmias; septic patients have low oxygen delivery to tissues; however, giving blood to patients who are moderately anemic does not change outcome; fresh blood is not better than older blood (6 days vs 22 days); in critically ill patients, a hemoglobin level of 7 g/dl is the transfusion cutoff, unless the patient is bleeding; 8 g/dl is acceptable unless the patient has coronary artery disease; ARDSnet protocol (ie, low tidal volume, reasonable positive end expiratory pressure) should be followed

Readings

Bickell WH, Wall MJ Jr, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-1109. doi:10.1056/NEJM199410273311701; Bogert JN, Harvin JA, Cotton BA. Damage control resuscitation. J Intensive Care Med. 2016;31(3):177-186. doi:10.1177/0885066614558018; Bugaev N, Como JJ, Golani G, et al. Thromboelastography and rotational thromboelastometry in bleeding patients with coagulopathy: Practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2020;89(6):999-1017. doi:10.1097/TA.0000000000002944; Cannon JW. Hemorrhagic shock. N Engl J Med. 2018;378(4):370-379. doi:10.1056/NEJMra1705649; Evans L, Rhodes A, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock 2021. Intensive Care Med. 2021;47(11):1181-1247. doi:10.1007/s00134-021-06506-y; Holcomb JB, Tilley BC, Baraniuk S, et al. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial. JAMA. 2015;313(5):471-482. doi:10.1001/jama.2015.12; Prescott HC, Ostermann M. What is new and different in the 2021 Surviving Sepsis Campaign guidelines. Med Klin Intensivmed Notfmed. 2023;118(Suppl 2):75-79. doi:10.1007/s00063-023-01028-5; Rivers E, Nguyen B, Havstad S, et al. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;345(19):1368-1377. doi:10.1056/NEJMoa010307; Roberts I, Shakur H, Coats T, et al. The CRASH-2 trial: a randomised controlled trial and economic evaluation of the effects of tranexamic acid on death, vascular occlusive events and transfusion requirement in bleeding trauma patients. Health Technol Assess. 2013;17(10):1-79. doi:10.3310/hta17100; Sperry JL, Guyette FX, Brown JB, et al. Prehospital plasma during air medical transport in trauma patients at risk for hemorrhagic shock. N Engl J Med. 2018;379(4):315-326. doi:10.1056/NEJMoa1802345.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Alam was recorded at the 2024 Combined Arizona Chapter of the American College of Surgeons Annual Meeting/Phoenix Surgical Symposium, held February 8-10, 2024, in Scottsdale, AZ, and presented by the Phoenix Surgical Society and Banner Health. For information about upcoming CME activities from this presenter, please visit http://www.phoenixsurgicalsociety.com/conference-information/. Audio Digest thanks the speaker and the Phoenix Surgical Society and Banner Health for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 1.00 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 1.00 CE contact hours.

Lecture ID:

GS711102

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.