Would you push fluids or not?

[p3medic]

At that point, why would you? He's not in shock....In THIS scenario, permissive hypotension is not called for. So, here's another question for you...as you stated (please see the underlined sentence above), if you don't have an IV warmer, it sounds like you wouldn't treat sock with fluid replacement, which is called for (except in the instance of applicable permissive hypotension).

As a courtesy, can you site the "Patients treated with large volumes of crystalloid have been shown to do worse; increased degree of acidosis, hypothermia, coagulopathy, SIRS, MOF, etc..." reference? Point me in a direction where I can verify that statement for PREHOSPITAL treatment? And if you could also qualify it, are you talking PREHOSPTIAL or IN HOSPITAL? Big difference. It's an issue IN HOSPITAL.

Reason I ask...the FD I used to work for was about 30-40 minutes from the area level 1 trauma center, "flying-low." I can tell you...I've only been able to get in about 3 almost 4 liters (pressurized) on trauma patients who were hypovolemic and shocky during transport. 3-4 liters is NOTHING fluid wise for a severe trauma. But, it's all we have to work with. Now...once the patient is turned over to the ED, it becomes a VERY different story. Then, you can get the luxury of lab work, blood, "hot-admix" if need be.

I am taking this stance from a PREHOSPITAL point of view. With this in mind, you have a limited time with the patient before transferring to the ED, and limited resources.[/quote

Why is permissive hypotension not called for in this senario? He is awake, mentating, bp greater than 90 systolic, hr in the 90's. Salt water isn't going to improve his outcome wether 5 or 50 minutes from the hospital. If he is perfusing his brain, we are doing ok. Keep him warm, limit crystalloid and optimize oxygenation.

There is a ton of data coming out of Iraq and A-stan regarding permissive hypotension and little or no pre hospital volume exansion, with improved outcomes. I realize this isn't a GI bleed senario, however death from hemmoragic shock comes via exanguination, or multisytem organ failure secondary to acidosis, hypothermia and coagulopathy. If you are infusing fluids that are not at or greater than 98.6 F, don't carry oxygen and don't carry clotting factors, you are worsening the patients condition. Doing nothing in this senario has the least likelyhood of causing harm, assuming his mental status and vitals remain as in the original senario. Clearly this patient died, but I'd be willing to bet no amount of saline would have changed that.

[p3medic]

In the OP senario, the patient has melena and hematemesis, indicating a likely upper GI source of bleeding, with the frank blood from above, and the digested from below. The senario states and EBL of 1.5 L. I wasn't there, but with this I'm more inclined to think we are deeling with an acute, active hemmorhage.

[Fox800]

This thread is getting good

[Arizonaffcep]

I still stand by my opinion. I wouldn't use permissive hypotension on this specific pt. If you have any links to the info you were talking about, I'd love to read it, as I have no connection to the military at all, and even less of a connection to new stuff they are developing. Although this does bring a good point...in civilian life...we see a lot of research in most areas in medicine. But it seems to me (perhaps I am looking the in the wrong place) that there is little research truly being done prehospital wise. Occasionally, I hear of something here and there, but not often. I have my own theories as to why, but I would think this specifically would be a HUGE area to do a large study on. After all, most of the studies I saw on Trauma.org were hospital in nature, only a couple were prehospital, and there was a great deal of all the studies that were inconclusive at best. Just a thought.

About the OP, with the HR at about 95...I still would bet real $ he's on a beta blocker, which can and will mask S/S of shock...It's one of those that they just physically can't manifest the tachycardia associated with shock...so you can't rely on it, which it's one of the key indicators for early shock.

[CTXMEDIC]

My way of thinking would be maintain BP above 90 systolic. By increasing BP to much could actually cause what ever was bleeding to start bleeding more. So I think they did right by limiting amount of fluid. There have been trauma studys that suggest our old wide open boluses may have done more harm than good by not allowing bleeding to clot or even cause internal bleeding to increase.

+1

Your director is a knob.

If you wanna argue this, tell him the next CVA patient you bring in is going to get 2L of fluid because he was 'bleeding'.

[firemed665]

I think they did right. As long as the systolic is over 90 all vital organs should be getting adequate perfusion. Additionally, although this patient probably has a GI bleed pushing more fluids than necessary to maintain a perfusing pressure may cause the bleed to become greater. Even though its not a "trauma" remember the rules from PHTLS when it comes to fluid resuscitation.

Working in an ER I'm sure after he got there they gave him a liter bolus while he was being typed and matched for blood. However, the IV pumps don't run any faster that one liter per hour. So when your crew gave a 250cc bolus it provided the patient with more fluid than the ER most likely would have given him in that time period. Therefore, when your crew said that 250 was all that was able to be run in during transport, they very well could have been right. I think your medical director is probably off base. However, not to say that they did, but I have found that even though you may have provided excellent patient care a poorly written PCR will always cause you to have to explain your actions further. Your crew did the right thing and was prepared witih a second line in case the patient crashed. Good for them!

[CTXMEDIC]

I think they did right. As long as the systolic is over 90 all vital organs should be getting adequate perfusion. Additionally, although this patient probably has a GI bleed pushing more fluids than necessary to maintain a perfusing pressure may cause the bleed to become greater. Even I think your medical director is probably off base. However, not to say that they did, but I have found that even though you may have provided excellent patient care a poorly written PCR will always cause you to have to explain your actions further. Your crew did the right thing and was prepared witih a second line in case the patient crashed. Good for them!

Exactley. In the end what this patient needs is blood, not a bunch of NS or LR, and maybe even surgical intervention depending on whats going on with him. Just because the good book says 'dump fluid' doesnt mean this is the best course of action for the patient. IMO, if this was my patient and going off of what we've been told, i probally would have given him a 500 bolus and TKO'd it and some O's on a nasal canula.

in this scenario we were told that there was a liter or more of blood lost at the scene mixed with feces. to me this sounds like a clot blew, so why make it worse? so although this patient isnt 'in shock' i think permissive hypotension may be indicated and a systolic of 90-100mmhg is not uncalled for.

[medic_texas]

I don't see how 1-2 liters of fluid is "a bunch". I also don't think a Hgb of 8.4 is very low (in ICU we usually don't transfuse unless they are under 8.0).

Do you really think a couple liters of fluid would dilute him to a Hgb of 4? No. He has lost volume and needs it replaced, along with blood, to perfuse appropriately. Also, how come every thinks that because his SBP is 90 that his organs are perfusing? Does anyone know what a MAP is? That would be the best way to see if his kidney's are perfusing in this situation and it's on most monitors these days.

I agree with the doctor in this case. Fluid would NOT hurt this guy and I would have bolused him with 1 liter and had a 2nd going at 100ml/hr for transport. Expand the volume, infuse the blood and get him into surgery where he probably would have gotten another 2-3k/L of LR and possibly some albumin (volume expander) on top of the blood.

[wilsteev]

My way of thinking would be maintain BP above 90 systolic. By increasing BP to much could actually cause what ever was bleeding to start bleeding more. So I think they did right by limiting amount of fluid. There have been trauma studys that suggest our old wide open boluses may have done more harm than good by not allowing bleeding to clot or even cause internal bleeding to increase.

I am in agreement under the protocals we use here in NB Canada as aPCP we are permited to bolus 500ml if bp is less than 100 systolic. We can bolus twice on our own than must contact medical control for permission to contune to bolus

[p3medic]

I don't see how 1-2 liters of fluid is "a bunch". I also don't think a Hgb of 8.4 is very low (in ICU we usually don't transfuse unless they are under 8.0).

Do you really think a couple liters of fluid would dilute him to a Hgb of 4? No. He has lost volume and needs it replaced, along with blood, to perfuse appropriately. Also, how come every thinks that because his SBP is 90 that his organs are perfusing? Does anyone know what a MAP is? That would be the best way to see if his kidney's are perfusing in this situation and it's on most monitors these days.

I agree with the doctor in this case. Fluid would NOT hurt this guy and I would have bolused him with 1 liter and had a 2nd going at 100ml/hr for transport. Expand the volume, infuse the blood and get him into surgery where he probably would have gotten another 2-3k/L of LR and possibly some albumin (volume expander) on top of the blood.

Giving fluids WITH blood is fine, the patient needs blood. Giving salt water in an ambulance does nothing for this patient other than make him more likely to present to the ED staff hypothermic. This patient needs volume resus when he has blood and a surgeon available, not before.