Trauma Question for Rid (Dust and others)

[strippel]

medic001918 writes "With more theories coming out that support permissive hypotension...", this brings up a question.

A hospital where I work part time became a level II trauma center last year. They brought up a surgeon from one of the teaching hospitals in Philadelphia to run the program. He states ALL patients get 2 large bore IVs (18+, bilaterally if possible). Period. No excuses.

Our hospital (at my full time) has been a level II trauma center for many years. It has been perfectly acceptable to only have 1 IV. Our medical director's policy (at the time he was head of the ER) was to use common sense. If they need 2 IVs, give them 2 IVs. It was a well know rule that if you used larger than an 18, and the patient didn't warrant it, the medical director would use one on you, vein of his choosing. For years, IVs have not been a problem (or QA issue), unless the patient came in BLS, or without one. (Yes Dust, we have BLS trucks in our city. Sometimes we get busy, or a call is dispatched BLS. if you are 4 blocks from the hospital, it's kinda hard to rendezvous with ALS).

We now have a new head of trauma. He wants 2 large bore, bilateral IVs. Period. We have had crews yelled at for not having them. The problem is the new trauma doc has not sent out a memo yet (it is due later this month), nor has our current medical director (now head of the ER) changed protocols.

What happened to the idea of permissive hypotension?

[medic001918]

My guess is that like most things in medicine, not everyone subscribes to the theory. It may be your medical directors feeling that trauma patients should still be aggressively resuccitated with fluids. Our protocols are pretty generous and allow us some flexibility. Like your old medical director, if they need fluid we can give it to them. But noone is going to come on a head hunt for us if we chose to allow some degree of hypotension. The more I've read about hypotension, the more I've come to think that's the direction we should be going until we start carrying products that allow some form of oxygen carrying capacity. Putting large qualities of NS or LR on a patient does nothing for their ability to perfuse the organs with the oxygen they require.

Shane

NREMT-P

[PRPGfirerescuetech]

medic001918 writes "With more theories coming out that support permissive hypotension...", this brings up a question.

A hospital where I work part time became a level II trauma center last year. They brought up a surgeon from one of the teaching hospitals in Philadelphia to run the program. He states ALL patients get 2 large bore IVs (18+, bilaterally if possible). Period. No excuses.

Our hospital (at my full time) has been a level II trauma center for many years. It has been perfectly acceptable to only have 1 IV. Our medical director's policy (at the time he was head of the ER) was to use common sense. If they need 2 IVs, give them 2 IVs. It was a well know rule that if you used larger than an 18, and the patient didn't warrant it, the medical director would use one on you, vein of his choosing. For years, IVs have not been a problem (or QA issue), unless the patient came in BLS, or without one. (Yes Dust, we have BLS trucks in our city. Sometimes we get busy, or a call is dispatched BLS. if you are 4 blocks from the hospital, it's kinda hard to rendezvous with ALS).

We now have a new head of trauma. He wants 2 large bore, bilateral IVs. Period. We have had crews yelled at for not having them. The problem is the new trauma doc has not sent out a memo yet (it is due later this month), nor has our current medical director (now head of the ER) changed protocols.

What happened to the idea of permissive hypotension?

Did you ask him why?

[strippel]

Not me.

Our supervisors had a chat with our Medical Director. He doesn't want protocols changed until the memo appears.

As far as talking with the new trauma doc, I have not met him yet.

I do have the question into one of the other trauma surgeons, with no answer yet.

[jdish]

Do you mean stewart?

[chbare]

Strippel, all feelings about theories of trauma management aside, this looks like a case of people not communicating. You service and medical director need to deal with the surgeon directly and get everybody on the same page.

Take care,

chbare.

[AZCEP]

Two IV's is one thing, aggressively replacing fluid until the blood comes out looking like Kool-Aid, is something else entirely.

Definitely ask the question so that you can learn from those that will be supervising the care provided.

[strippel]

I understand the not communicating.

The memo is in the mail.

Talks on permissive hypotension were numerous at EMS conferences. Now, not so much.

I was just wondering if I missed any new information.

[dgmedic]

Ken Mattox has put together a great reference page over at trauma.org. No one is talking about it b/c it goes against the traditional EMS dogma....a continuation of the many dumbass things blind faith dogma will get you.

Before you talk to your medical director, head of trauma, or whatever, jog on over to trauma.org: the link is http://www.trauma.org/resus/permissivehypotension.html Ask your trauma director why, in the face of all this evidence he/she is wanting to change? Everyone that has protocols that default to that "2 large bore, 3:1" crap needs to print and pass along. 2 big IV's prepares the patient to get blood, 3:1 on the other hand prepares the patient to die. How about 2 large bore saline locks? That sounds more appropriate.

-dg

[Dustdevil]

What happened to the idea of permissive hypotension?

I think it is possible that you are jumping to an erroneous conclusion.

There is a very big difference between rapidly infusing massive amounts of fluids and simply establishing two large-bore IV's. Just because you have the access doesn't mean you actually run them wide open.

Before this becomes a pointless controversy, I would recommend you clarify if he is actually advocating aggressive fluid resuscitation, or if he is simply asking for access to be established in case they are needed later. After at all, once you have circulatory collapse, it's a little late to start looking for veins.

It should also be clarified SPECIFICALLY which "trauma" victims he is referring to. Even the permissive hypotension proponents don't say it applies to all trauma patients. Not all trauma is the same. This is one of those situations in EMS where you have to actually understand your patient, his injury, and the physiology involved, in order to determine whether permissive hypotension or fluid resuscitation is the most appropriate course of action. Of course, this would require education instead of a cookbook, which most systems don't seem to be interested in. :roll: