Permissive Hypotension

[tniuqs]

Jeff Guy MD does a great podcast on this http://media.libsyn.com/media/prehospitalp...logy/fluids.mp3

Thanks for the link ... I think I have been saying pretty much the same thing, wish I got his paycheck.

1- I have a bit of a difficult time re: BP over 90 systolic a highly subjective finding with radial pulse "felt/ located" my rational is that I have found radial pulse and successful completed radial artery ABGs, this with when NIBP stated 60/40 but basing whether one will treat with fluids or NOT ... well interesting.

2- Frankly shocking to hear that Pouselles law is not discussed in REMT-P programs, besides Pouselles law not only is radius but length/ temp as well that affects flow. I just shake my head when I see a large bore placed and no stopcock when hanging blood.

(but interestingly intubation to prevent hypoxia was not mentioned as being of any benefit, or, made outcomes worse).

Yes ... can you believe that high levels of PaO2 can actually decrease blow flow in the Head ... remember the old days when we believed that Hyperventilation CaO2s > 30 would decrease blood (circle of Willis) flow hence limiting the bleed size ... well we were soo wrong, look back to the CPP math. Intubating and providing FiO2 of 1.0 could also be a mitigating factor in the outcome studies.

cheers

[Kiwiology]

Thanks for the link ... I think I have been saying pretty much the same thing, wish I got his paycheck.

Yeah no kidding; I hadn't thought of the dilution of clotting factors and fibrin and whatnot; interesting; maybe we should start carrying blood in the truck I mean what, the military has been doing it is since world war two .... hmm

1- I have a bit of a difficult time re: BP over 90 systolic a highly subjective finding with radial pulse "felt/ located" my rational is that I have found radial pulse and successful completed radial artery ABGs, this with when NIBP stated 60/40 but basing whether one will treat with fluids or NOT ... well interesting.

2- Frankly shocking to hear that Pouselles law is not discussed in REMT-P programs, besides Pouselles law not only is radius but length/ temp as well that affects flow. I just shake my head when I see a large bore placed and no stopcock when hanging blood.

1: I don't really trust NIBP; treating one with fluids because thier BP is below X is like treating the heart rate simply because it's above Y; seems to me to be a rather broad superficial policy. That said

2: We're not taught Pouselles law per-se (i.e. by that term) but we are taught, obviously, the smaller the catheter the less flow you are going to get through it; that's pretty simple I think even your 600 hour tech school fire-medic could tell you that

A WAY more rapid response with tourniquet to limb (injury/loss) due mines and/or IED, packing off penetrating Abdo wounds, hemostat application and if time permits tie off bigger bleeders this is seldom done unless long transport times on civy side

We are bringing back tourniquets for massive bleeding or bleeding you can't get at; e.g. femoral bleed when trapped in a car wreck.

Yes ... can you believe that high levels of PaO2 can actually decrease blow flow in the Head ... remember the old days when we believed that Hyperventilation CaO2s > 30 would decrease blood (circle of Willis) flow hence limiting the bleed size ... well we were soo wrong, look back to the CPP math. Intubating and providing FiO2 of 1.0 could also be a mitigating factor in the outcome studies.

I'm going to have to look that one up. This made for interesting reading -- http://www.nda.ox.ac.uk/wfsa/html/u08/u08_013.htm

[tniuqs]

CORRECTION:

Yes can you believe that high levels of PaO2 can actually decrease blow flow in the Head ... remember the old days when we believed that Hyperventilation PaCO2 < 30 would decrease blood (circle of Willis) flow hence limiting the bleed size ... well we were soo wrong, look back to the CPP math. Intubating and providing FiO2 of 1.0 could also be a mitigating factor in the outcome studies.

cheers and oops

Edited August 9, 2009 by tniuqs

[chbare]

You can also download Dr. Guy's podcasts free from iTunes. The most interesting podcast is called ICU Rounds. Much of it is directed at residents, therefore I suggest you have a good foundation of A&P along with a working knowledge of how studies and EBM applies to clinical practice. Definitely not like picking up your favorite copy of "JEMS."

The truth about all this permissive hypotension is that we are not quite sure of the optimal resuscitation modality. There are many new studies in the pipe line and the next decade will most likely be exciting. Anybody go to the SATNET conference this year in Tucson Arizona? I am just back from this conference, and there were several physicians commenting on resuscitation, EBM, and head injury treatment modalities. Much of it is a crap shoot.

If anybody knows a Dr. Peter Rhee, you are most likely aware of his "suspended animation" research on pigs. In addition, a large multi centre study is in the works. So, we will see how things pan out.

Take care,

chbare.

[tniuqs]

If anybody knows a Dr. Peter Rhee, you are most likely aware of his "suspended animation" research on pigs. In addition, a large multi centre study is in the works. So, we will see how things pan out.

Take care,

chbare.

Is that the famous B.A.C.O.N in the pan study ?

sorry some days I lack all control over my fingers

cheers

[chbare]

Is that the famous B.A.C.O.N in the pan study ?

sorry some days I lack all control over my fingers

cheers

It started with research he did in the military. They essentially let the pigs bleed out, did an open thoracotomy, infused a cold high potassium solution, repaired the wounds, infused a warm balanced solution, then resuscitated with blood products. (The solutions were based on solutions used to package organs for transplant.) Pre and post procedure, cognitive tests were performed on the pigs to identify cognitive impairment. As I said, they are now looking at large multi centre trials. So, we will see.

Take care,

chbare.

[Richard B the EMT]

1) Does Kermit The Frog's fiancee know of this study?

2) Just how does one measure porcine cognitive abilities?

3 Is this being paid for by public monies from the Pork Barrel?

(Re #1 and 3: Sometimes I can't control my fingers either! Sooooooooo-wheeeeeeeeeeeeeT.)

Edited August 10, 2009 by Richard B the EMT

[chbare]

The pig cognition concept was a tough one. Apparently it took the team six months to figure out a way. Pigs apparently have color vision and a Russian scientist on the team devised a way of testing the pigs. They took different colored boxes and put a tasty snack in the blue box. Over a period of several weeks the pigs learned that they could go directly to the blue box for the snack without turning over the other colored boxes. The time it took for the pigs to find the snack was timed before and after resuscitation.

From what I understand, this pig cognition and survival study was somewhat inadvertent. The initial study simply had the team members bleeding the pigs out, doing an open thoracotomy with the "preservative" infusion and cross clamping, and repairing the wound. However, with resuscitation following the wound repair, the pigs regained ROSC. Somewhat of a surprise to the team. They had to hastily turn their area into a pig ICU and recovery room. Apparently, they had a hell of a time keeping chest tubes in the pigs post op. The pig survival led to the team developing ways to test pig cognition.

Since this was military research, I presume the tax payers paid for this specific set of studies. I am not sure of this large multi centre study that is in the works.

Take care,

chbare.

[Arizonaffcep]

You can also download Dr. Guy's podcasts free from iTunes. The most interesting podcast is called ICU Rounds. Much of it is directed at residents, therefore I suggest you have a good foundation of A&P along with a working knowledge of how studies and EBM applies to clinical practice. Definitely not like picking up your favorite copy of "JEMS."

The truth about all this permissive hypotension is that we are not quite sure of the optimal resuscitation modality. There are many new studies in the pipe line and the next decade will most likely be exciting. Anybody go to the SATNET conference this year in Tucson Arizona? I am just back from this conference, and there were several physicians commenting on resuscitation, EBM, and head injury treatment modalities. Much of it is a crap shoot.

If anybody knows a Dr. Peter Rhee, you are most likely aware of his "suspended animation" research on pigs. In addition, a large multi centre study is in the works. So, we will see how things pan out.

Take care,

chbare.

And he's a hell of a nice guy. He will always stop to talk/discuss questions/etc (provided the timing is correct and he's not busy with a Pt). First time I met him when he started at UMC in Tucson, he introduced himself as "Peter." How many well known trauma surgons do that? He's great!

Out of curiosity, I know this thread is a few months from the last post, but I just wrote a paper on permissive hypotension for Lifeline, and was wondering if anyone had any interest in reading it. It deals with a bunch of different aspects all involved with blood pressure and trauma care. Including cited references to the thought that a systolic of 80mmHg will "pop clots"...

[fireflymedic]

And he's a hell of a nice guy. He will always stop to talk/discuss questions/etc (provided the timing is correct and he's not busy with a Pt). First time I met him when he started at UMC in Tucson, he introduced himself as "Peter." How many well known trauma surgons do that? He's great!

Out of curiosity, I know this thread is a few months from the last post, but I just wrote a paper on permissive hypotension for Lifeline, and was wondering if anyone had any interest in reading it. It deals with a bunch of different aspects all involved with blood pressure and trauma care. Including cited references to the thought that a systolic of 80mmHg will "pop clots"...

Would like very much to read it as this is definitely an area of interest for me. The doc that was discussing this at conference, will be there again this year with a follow up and so I'm interested to see how things stack up and would like to be educated prior. PM me and I will forward my personal e-mail to send it to. THanks !

Edited January 28, 2010 by fireflymedic