Permissive Hypotension

[HERBIE1]

I was recently reading up on a topic for my students and ran across this info. Interesting to say the least.

I brought it up to my students and asked them about the potential impact on an EMS system if BP's cut off point changes for a trauma center transport.

We came up with quite a list.

Sounds like they need to do more research- as in what type of patients would this affect, etc.

[DwayneEMTP]

I'm curious firefly,

If your source is so well respected, why have you been so careful not to name him?

A "well respected source" for intelligent debate is cheap and lazy. Name him, let us look at what he has to offer for ourselves.

Kind of like the "A source close to the celebrity!" bullshit in the paper. This is a learning forum. What I'd like you to learn today is that it's proper, intelligent and logical to name those that 'you' consider well respected and leaders in their fields.

Right?

Dwayne

[Kiwiology]

This is quite interesting and something I'll be keeping an eye on.

For hypovolemic shock from uncontrolled bleeding our guideline says

Only give IV fluid if profoundly shocked e.g. no radial pulse or unrecordable blood pressure. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus.

Give further fluid boluses only if they remain profoundly shocked. Give adults 250-500 ml and children 5-10 ml/kg

.... or from controlled bleeding

Penetrating trauma and other forms of uncontrolled bleeding with shock must be considered a completely separate disease process to hypovolaemic shock from relatively controlled bleeding (e.g. blunt trauma). Mortality rates from shock associated with uncontrolled bleeding appear to be reduced if the patient is deliberately allowed to be hypotensive prior to operative control of the bleeding.This is why fluid is restricted in this group of patients to maintain the minimum blood pressure compatible with life.

Blood pressure is a poor guide to the level of a patients shock. Fluid therapy should be titrated to evidence of end organ perfusion, taking into account blood pressure, pulse pressure, heart rate, level of consciousness, level of agitation, pulse volume, capillary refill and distal limb temperature.

Give IV fluid if the patient has signs of poor perfusion (e.g. hypotension, narrowed pulse pressure, tachycardia, reduced consciousness, agitation, absent or weak pulses, poor capillary refill or cool extremities). Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus.

Note that there is a systolic BP target of 120 mmHg if the patient has traumatic brain injury.

... for TBI (which I had an interesting dream about the other night ... is that bad? )

Give IV fluid if the patient is unable to obey commands and has a systolic BP < 120 mmHg. Give adults one litre of 0.9% NaCl as a bolus and children 20 ml/kg of 0.9% NaCl as a bolus.

Give further fluid boluses of 0.9% NaCl as required to maintain systolic BP > 120 mmHg.Give adults 250-500 ml and children 5-10 ml/kg.

[medic_texas]

This issue will always be difficult due to many factors. As someone said before, different guidelines exist for trauma and neuro patients. Generally with EMS, we have multiple things going on at one time.

Does the patient have a brain injury or hypoxia? If they are just "unconscious" it could be difficult to determine this (unless there is obvious s/s of skull fracture, CSF coming from the ears, posturing, etc). If you suspect any neurological issues on your trauma patient, make sure you do a thorough neuro assessment (GCS, pupils, extremities, etc).

Hint: If their LOC is decreased - try to assess all extremities, not just one side. Ex: nail bed pressure to both hands (withdrawing, posturing, no response), babinksi reflexes (correct or reversed?), etc.

Basically, ASSESS ASSESS ASSESS!

As a pre-hospital provider you need to do everything you can to assess, treat (IV, ECG, intubation if indicated, bleeding controlled, etc), reassess, and transport accordingly (air support, correct facility).

Don't base everything on the numbers (SBP 90.. 110.. etc) because every patient will be different. As long as you have done a good assessment, treated life-threatening injuries, and relay this information during report (HEMS or ER staff) you should be ok.

Working with many neurosurgical/trauma patients I can tell you that albumin is never given to them. Of course, this is in the hospital. Pre-hospital as a volume expander, I could see it's potential. The post-op CABG patient's receive albumin on a regular basis, however that's obviously different criteria.

Hope this helps..

[aussiephil]

my thoughts are at what point do we decide the patient with decreased or altered mental status is suffering that due to a head injury or lack of brain perfusion?

Isnt a person with a closed head injury alone more likley to be hypertensive rather than hypotensive? If the patient is hypotensive, then the laws of probability dictate they are probably compromised somewhere else, what we are now being taught is to bolus 100-200 ml of fluids to maintain a radial pulse, this wil maintain adequate perfusion until we get the patient to difinitive care.

[Kaisu]

*** post deleted *****

Edited August 3, 2009 by Kaisu

[Kiwiology]

Isnt a person with a closed head injury alone more likley to be hypertensive rather than hypotensive? If the patient is hypotensive, then the laws of probability dictate they are probably compromised somewhere else, what we are now being taught is to bolus 100-200 ml of fluids to maintain a radial pulse, this wil maintain adequate perfusion until we get the patient to difinitive care.

Yup I'd say so. A quick review of PubMed evidence says that survival (but not necessarily outcomes) are better if we prevent hypotension (i.e. promote cerebral perfusion) and secondary brain injury (but interestingly intubation to prevent hypoxia was not mentioned as being of any benefit, or, made outcomes worse). Interestingly one study said that TBI patients treated by EMS show increased signs of stress markets e.g. glucose and lactate, hell, dare I say poor treatment provision?

I think numbers are very subjective; one Austrian study said > 110mmHg, we say 120, I've heard 80 or 90 and everything in-between. Not sure if a number game is the best path to follow here but I'd be lying if I said I wasn't reaching to think of some marker of adequate brain perfusion that we could use instead of BP beyond say, good basic vital signs, SPO2/ETCO2 (airway dependant) and lack of posturing or tachycardia .

Edited August 3, 2009 by kiwimedic

[Richard B the EMT]

Without bringing trauma/conscious/unconscious into my entry, I note that I have had a few patients that I screen for B/Ps, all uniformed members of the FDNY and FDNY EMS (with a few fire marshals here and there), who I would admit mentate better than I do on any given day, have sometimes shown up in my screening room exhibiting systolic pressures of 80 MM.

I contact the nurses for further advisement, and a surprising majority of these patients have had the low BPs for years; for them, it's normal.

I have to clarify that I am doing the screening in the duty determination clinic area of the FDNY's Bureau of Health Services, second floor of FDNY HQ, 9 Metrotech Center, Brooklyn NY.

Edited August 3, 2009 by Richard B the EMT

[tniuqs]

Isnt a person with a closed head injury alone more likley to be hypertensive rather than hypotensive? If the patient is hypotensive, then the laws of probability dictate they are probably compromised somewhere else, what we are now being taught is to bolus 100-200 ml of fluids to maintain a radial pulse, this wil maintain adequate perfusion until we get the patient to difinitive care.

Oh I was wondering when that would come up ... ICP - MAP = CPP (thats cerebral perfusion pressure) ... so unless your popping in an ICP probe, hypertension is most likely a normal physiological response to increased ICP, remember when we restricted fluids and used D5W because it supposedly stayed intervascluar .... ah maybe your too young Phil LOL>

Listen to what the patient is telling you through V/S ... tachycardia more indicative of early (somewhat compensated shock) btw mobey I hate these franchised PHTLS or ITLS courses there just a means to an end to teach the masses, I garteentee you will agree after you get your 05 # or REMT-P in y'all jargon.

End organ perfusion LOC is a huge deal and Urine output are the BEST indicators of perfusion ... wouldnt it be funny that in the new improved "A"PHTLS and urinary cath became the new Trauma priority intervention.

In ICUs we are using tropes to YES increase BP in some head closed head injuries, GCS of 8 and dopamine of 10 mics and bada bing bada boom the GCS climbs to 15, I have seen it.

I would like to hear of the research in trauma limited to "below the head" and the treatment in war zones .. I spoke with am MD headed over there to the sand box ... his suggestion STOP the blood loss EFFECTIVELY FIRST, we are too busy trying to play around with lines, "Drills and IO was the Way To Go" quote. Central lines have far more complications in passing.

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. Asherman type drains, better than improvised 3 sided seals ... blast injuries use that condom and 10 gauge, mind you with controversy on poor intubation successes in some services that may be a scary thing to advocate.

THEN replace fluids with IOs drilled in humerus and of course blood is always best to replace blood loss, with N/S being last choice when ne is hypotensive unless one likes really messing up coags, screwing up electrolytes ( hyperchloremic metabolic acidosis) but great for making pink kool aid.

I am under the impression that Hypertonic Saline WITH Volume expanders is presently being used (1:1) ratio [its also lighter to carry] with N/S 3:1 typical replacement (as if one can tell how much blood was lost in majority of cases without CBC we are SO behind treating trauma on civy side.

Synthetic Oxygen carrying fluids have failed miserably, the BRITs tried it and filled it under "G"

A Trauma Surgeon/ Intensivist I worked with a Dr. Doug Matheson always stated if you can't reach your targets then lower your expectations.

cheers

Edited August 4, 2009 by tniuqs

[Kiwiology]

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