Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay Paula Ferrada, MD, David Evans, MD, Luke Wolfe, MS, Rahul J. Anand, MD, Poornima Vanguri, MD, Julie Mayglothling, MD, James Whelan, MD, Ajai Malhotra, MD, Stephanie Goldberg, MD, Therese Duane, MD, Michel Aboutanos, MD, and Rao R. Ivatury, MD, Richmond, Virginia BACKGROUND: We hypothesize that limited transthoracic echocardiogram (LTTE) is a useful tool toguide therapy during the initial phase of resuscitation in trauma patients. METHODS: All highest-level alert patients with at least one measurement of systolic blood pressure less than 100 mm Hg, a mean arterial pressure less than 60 mm Hg, and/or a heart rate greater than 120 beats per minute who arrived to the trauma bay (TB) were randomized to have either LTTE performed (LTTEp) or not performed (non-LTTE) as part of their initial evaluation. Images were stored, and results were reported regarding contractility (good vs. poor), fluid status (empty inferior vena cava [hypovolemic] vs. full inferior vena cava [not hypovolemic]), and pericardial effusion(present vs. absent). Time from TB to operating room, intravenous fluid administration, blood product requirement, intensive care unit admission, and mortality were examined in both groups. RESULTS: A total of 240 patients were randomized. Twenty-five patients were excluded since they died upon arrival to the TB, leaving 215 patients in the study. Ninety-two patients were in the LTTEp group with 123 patients in the non-LTTE group. The LTTEp and non-LTTE groups were similar in age (38 years vs. 38.8 years, p = 0.75), Injury Severity Score (ISS) (19.2 vs. 19.0, p = 0.94), Revised Trauma Score (RTS) (5.5 vs. 6.0, p = 0.09), lactate (4.2 vs. 3.6, p = 0.14), and mechanism of injury (p = 0.44). Strikingly, LTTEp had significantly less intravenous fluid than non-LTTE patients (1.5 L vs. 2.5 L, p G 0.0001), less time from TB to operating room (35.6 minutes vs. 79.1 min, p = 0.0006), higher rate of intensive care unit admission (80.4% vs. 67.2%, p = 0.04), and a lower mortality rate (11% vs. 19.5%, p = 0.09). Mortality differences were particularly evident in the traumatic brain injury patients (14.7% in LTTEp vs. 39.5% in non-LTTE, p = 0.03). CONCLUSION: LTTE is a useful guide for therapy in hypotensive trauma patients during the early phase of resuscitation. (J Trauma Acute Care Surg. 2014;76: 31Y38. Copyright * 2014 by Lippincott Williams & Wilkins) LEVEL OF EVIDENCE: Therapeutic study, level II. KEY WORDS: Hemodynamic monitoring in the trauma bay; echocardiogram in the trauma bay; inferior vena cava as a hemodynamic parameter in trauma patients; echocardiogram in trauma; echocardiogram for fluid status management. D etermination of intravascular volume status continues to be an important dilemma in the care of the trauma pa- tient. 1 Recent data suggest a role for fluid restriction even in trauma patients presenting with hypovolemic shock, 2,3 em- phasizing the need for accurate assessment of volume status in the care of these patients. The role for invasive hemodynamic monitoring in the trauma bay (TB) has not been well established, 4 which is surprising, because vital signs alone have been shown to be an inaccurate tool for the assessment of intravascular volume. 5 Underresuscitation and overresuscitation have life-threatening consequences. 6,7 Because of recent data, the paradigm of trauma resuscitation has changed, and the pendulum has swung from giving excessive crystalloid infusion to avoiding it almost completely and replacing intravenous crystalloid solutions with blood products. 8Y11 It is still a challenge to predict the necessity to resuscitate before the patient oxygen debt is too great to recover from the physiologic insult. 12,13 Inferior vena cava (IVC) diameter and collapsibility as well as visualization of ventricular filling via transthoracic echocardiogram have been used in several patient populations as a hemodynamic monitoring tool. 14,15 At our institution, limited transthoracic echocardiogram (LTTE) was introduced as a teachable tool for intravascular volume evaluation in critically ill patients. 16 We previously published an article describing a simplified course with hands-on training for attending trauma surgeons. After this training, the providers were able to perform LTTE examinations and to obtain information to guide therapy in patients admitted to the intensive care unit (ICU) from August to December of 2010. The LTTE findings were compared with a formal echo- cardiogram performed by cardiologists, and the correlation between the trauma surgeons’ perception of ejection fraction and the cardiologist report was 100%. In this study, the lactate level decreased in all patients in which LTTE was used to guide AAST 2013 PLENARY P APER J Trauma Acute Care Surg Volume 76, Number 1 31 Submitted: June 10, 2013, Revised: July 5, 2013, Accepted: July 9, 2013. From the Virginia Commonwealth University, Richmond, Virginia. This study was presented at the 72nd annual meeting of the American Association for the Surgery of Trauma, September 18Y21, 2013, in San Francisco, California. Address for reprints: Paula Ferrada, MD, Trauma, Critical Care and Emergency Surgery, Virginia Commonwealth University, West Hospital, 15th Floor East, 1200 E. Broad St, PO Box 980454, Richmond, VA 23298; email: pferrada@ mcvh-vcu.edu. DOI: 10.1097/TA.0b013e3182a74ad9 Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.