Permissive Hypotension

[armymedic571]

Three comments:

1- We should really be titrating to a MAP , not systolic B/P

2- The "standard" is nothing more than consensus (read: he who argues longest or loudest, or is most stubborn ...wins) .

3- Differeng standards exist for general trauma and head Injury.

Our guidelines verbally have been 80-90 for general trauma, 100-110 for CHI.

Mobey/firefly.....there you have it.

Low volume resuscitation is not a new concept. It has been around for years, particularly in the Military. Yes, our success rates are much greater than the civilian equivelent. As a general rule, we try to keep our trauma patients between 80-90 systolic. In those terms we use two markers as a guide for titration or restriction of fluid. Radial Pulse and mentation.

If a patient is mentating apporpraitely and has a radial pulse, we restrict fluid intake. Once there mentation or radial pulses go...they get fluid. However, a few things to note.

As Croaker already mentioned. General trauma and Head trauma are two different beasts.....I will leave it at that.

Second, most military studies (especially those on trauma are based on HEALTHY Adults with insult to the body), as opposed to average adults with insults to the body. There are some caveats when treating these two destinctly different demographics.

As far as Hextend is concerned (Hespan) is one of use. The forementioned still apllies, but one of the biggest mistakes we see is providers using this substance for the wrong reasons.

Generally, this fluid should only be used for trauma patients in shocK due to Hypovolemia. We usually see this with exsanguinating extremity wounds. Once we factor Belly bleeds, femur Fx's and pelvic's, we start to alter our parameters.

Just some more food for thought.

Edited January 30, 2010 by armymedic571

[tniuqs]

Ok just me ... I look for end organ perfusion what is the normal BP, systolic or MAP when they either run at 90/50 or 150/90... I ask myself is the patient getting blood to the grey matter and are they producing urine, but my transports are typically longer than the average urban call.

In passing the artificial volume expanders are a very valuable tool in many situations and very under utilized in civilian EMS ... when we learn from the military experience ?

I am a huge fan of Pentaspan or its equivalent in lou of actual blood products.

cheers

[aussiephil]

I was discussing this with a trauma doc the other day, he was saying they are now looking at allowing systolic BP's as low as 60mmHg to be permissable.....

Food for thought

[p3medic]

Hopefully in the near future there will be great improvements in hemoglobin based solutions, the crystalloid v.s. colloid debate has been around forever, perhaps time for a change.

[LyonN]

I base my treatment off of PHTLS, It recommends >90 <100 systolic for suspected TBI, and >80 <90 for suspected internal abdominal bleeding.

[Fox800]

Our protocol is to maintain a MAP of 70 for TBI's. For noncompressible hemorrhage, we allow permissive hypotension and do not bolus until SBP drops below 70mmHg. Compressible external bleeds do not apply to that. We titrate our boluses to skin color/condition, pulse rate/location, capillary refill, and improvement in BP.