# Neurogenic Shock With Internal/External Hemmorhage



## AeroClinician (Oct 25, 2013)

Trauma pt., fell 4 stories off of the roof of a house onto an adjacent wall with resulting evisceration of intestines + Bleeding, Neurogenic shock is suspected with HR:58 B/P:86/52 Sp02 86%.

What do you do? Give fluid bolus right? Then Dopamine as well? Wouldn't that make the hemorrhage worse?

Please let me know.

BTW this is a fictional pt. , I did not have this in real life.


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## Carlos Danger (Oct 25, 2013)

Why would you want to give fluid or dopamine?


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## AeroClinician (Oct 25, 2013)

Halothane said:


> Why would you want to give fluid or dopamine?



Umm, because the pt. is in hemorrhagic and neurogenic shock.

Pt. is bleeding from the abdomen, Approx. 1 liter is found on the ground.

What would you do?


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## Akulahawk (Oct 25, 2013)

Me? Considering that the MAP isn't too horrible (60.3) I'm going to start a line... but keep this patient dry. I'd probably look more at providing oxygenation and ensuring the patient is breathing effectively than running lots of fluids or pressors because I don't think I'd be doing that patient any favors by popping clots...


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## Carlos Danger (Oct 25, 2013)

Firehazmedic said:


> Umm, because the pt. is in hemorrhagic and neurogenic shock.
> 
> Pt. is bleeding from the abdomen, Approx. 1 liter is found on the ground.
> 
> What would you do?




Well, I wouldn't speed up his blood loss by needlessly raising his BP......


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## epipusher (Oct 25, 2013)

Halothane said:


> Well, I wouldn't speed up his blood loss by needlessly raising his BP......



I agree,titrate to 90 if anything.


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## AeroClinician (Oct 25, 2013)

Ah, ok. So if anything the lowered heart rate is beneficial because the pt. wont bleed out as quickly as without the neurogenic shock.


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## Tigger (Oct 25, 2013)

Do you think dopamine is indicated in cases of hypovolemic shock? 

Why or why not?


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## AeroClinician (Oct 25, 2013)

Tigger said:


> Do you think dopamine is indicated in cases of hypovolemic shock?
> 
> Why or why not?



No, hypovolemia is a contraindication to dopamine.

I was throwing that in there because dopamine is given for neurogenic shock.


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## FiremanMike (Oct 25, 2013)

Get MAP to 65mmHg with fluid and (if available/necessary) push dose pressors so the kidneys are perfusing and get him to a trauma surgeon.


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## chaz90 (Oct 25, 2013)

Firehazmedic said:


> No, hypovolemia is a contraindication to dopamine.
> 
> I was throwing that in there because dopamine is given for neurogenic shock.



What takes precedence in this case though? Neurogenic shock can be difficult to diagnose in the field, and it certainly isn't present in isolation in this scenario. Again, the MAP is OK for this patient, and I'd give fairly minimal fluids. I wouldn't even think of touching Dopamine.


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## VFlutter (Oct 25, 2013)

Are you within ~15min of a level one trauma center? If not, it does not really matter. Even if you are down the street it really doesn't matter.

Spinal precautions, permissive hypotension, cover exposed organs and rapid transport. 

This guy would most likely end up paralyzed, trached, and encephalopathic until either the septicemia or organ dysfunction ends it.



FiremanMike said:


> Get MAP to 65mmHg with fluid and (if  available/necessary) push dose pressors so the kidneys are perfusing and  get him to a trauma surgeon.



I think kidney perfusion is the least of this patient's problems.


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## AeroClinician (Oct 25, 2013)

Ok, if your giving fluids titrated to a permissive hypotensive status, and then the MAP drops more than the fluids will reverse. Are vasopressors at that point, advantageous?


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## FiremanMike (Oct 25, 2013)

Chase said:


> I think kidney perfusion is the least of this patient's problems.



This is true, but fluid resuscitation in hypovolemia should be guided towards a map of 65 and no more so as not to encourage more blood loss.  65 being the point where the kidneys are perfused, which people way smarter than me decided should be the threshold..


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## Akulahawk (Oct 25, 2013)

Firehazmedic said:


> Ok, if your giving fluids titrated to a permissive hypotensive status, and then the MAP drops more than the fluids will reverse. Are vasopressors at that point, advantageous?


Considering that such a patient is probably bleeding and therefore losing fluid, would I give much consideration to pressors in the field? 

In the words of Al Borland: I don't think so, Tim. 

Consider the rate of blood _loss_ if you're having to pour crystalloid in through a large cath or two and the MAP is _still dropping_... You're just turning what blood that is still in there into Kool Aid and greatly diluting any remaining clotting cascade components... In other words, that equals minimal to no ability to clot which equals continued unstoppable hemorrhage. 

Might it be a good idea to use vasoconstrictors at some point? Yes. Under some very controlled conditions. The field isn't exactly all that well controlled, we don't have FFP, platelets, whole blood, PRBCs, etc so we can't exactly improve the ability of the patient to form clots...


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## FiremanMike (Oct 25, 2013)

Akulahawk said:


> Considering that such a patient is probably bleeding and therefore losing fluid, would I give much consideration to pressors in the field?
> 
> In the words of Al Borland: I don't think so, Tim.
> 
> ...



Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP.  Just enough bump in MAP to get you to definitive care..


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## Akulahawk (Oct 25, 2013)

FiremanMike said:


> This is true, but fluid resuscitation in hypovolemia should be guided towards a map of 65 and no more so as not to encourage more blood loss.  65 being the point where the kidneys are perfused, which people way smarter than me decided should be the threshold..


With as much damage as the hypothetical patient in this post has sustained, I quite suspect that renal perfusion would be the least of the issues to deal with. If he survives, dialysis is still a possibility _if_ the kidneys completely shut down. Kidneys we can do without if necessary. Most of my fluid titration in the field would be diesel to engine titration... to get the patient to a Trauma Center. Even then, with that much damage, I'd be amazed if the patient survived more than a few days.


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## Carlos Danger (Oct 25, 2013)

FiremanMike said:


> Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP.  Just enough bump in MAP to get you to definitive care..



I think someone has been spending a little too much time on EMCrit


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## FiremanMike (Oct 25, 2013)

Halothane said:


> I think someone has been spending a little too much time on EMCrit



I was actually a fan from practice before listening to that particular podcast, but after listening to it, I'm that much more a fan..


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## FiremanMike (Oct 25, 2013)

Akulahawk said:


> With as much damage as the hypothetical patient in this post has sustained, I quite suspect that renal perfusion would be the least of the issues to deal with. If he survives, dialysis is still a possibility _if_ the kidneys completely shut down. Kidneys we can do without if necessary. Most of my fluid titration in the field would be diesel to engine titration... to get the patient to a Trauma Center. Even then, with that much damage, I'd be amazed if the patient survived more than a few days.



Everyone needs a target goal for fluid resuscitation.  Some people choose 90 systolic, I choose a map of 65 for my stated reason.


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## Akulahawk (Oct 25, 2013)

FiremanMike said:


> Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP.  Just enough bump in MAP to get you to definitive care..


Remember, the "container" isn't full because it's leaking... Increasing the pressure inside could very easily pop some newly established clots. In regards to using Epi, I'd think it would be more prudent NOT to stomp on the gas and make the heart beat faster... so perhaps a pure vasoconstrictor might be good to use in a controlled manner to get the bleeding peripheral blood vessels to constrict and further slow blood loss. 

If you can manage to fill the container some without a clot blowout, then perhaps pressors might slowly be introduced to further _slowly_ bring the MAP up to where kidney perfusion is occurring. 

In this hypothetical case, while there probably will be kidney injury, it's far more important to ensure that the brain is still perfused. Kidneys we can do without. Brain? Not so much.


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## Carlos Danger (Oct 25, 2013)

I'm sorry, but I think the idea of using a vasopressor in a bleeding patient with a good MAP is insane.


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## Akulahawk (Oct 25, 2013)

Halothane said:


> I'm sorry, but I think the idea of using a vasopressor in a bleeding patient with a good MAP is insane.


Which is why I've been advocating ONLY for their use under very controlled conditions.


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## FiremanMike (Oct 25, 2013)

If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.


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## Carlos Danger (Oct 25, 2013)

FiremanMike said:


> If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.



Why?

Are you trying to make this hypothetical patient bleed faster?


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## Akulahawk (Oct 25, 2013)

FiremanMike said:


> If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.


Cram in a liter and at that point you KNOW the patient has a rather significant bleeding problem that likely needs a surgeon and are quickly on the way to turning the patient's remaining blood pink.


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## FiremanMike (Oct 25, 2013)

Halothane said:


> Why?
> 
> Are you trying to make this hypothetical patient bleed faster?



We're taking about 10-20mcg of epi, not 0.3-1mg.  Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes.  As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.




Akulahawk said:


> Cram in a liter and at that point you KNOW the patient has a rather significant bleeding problem that likely needs a surgeon and are quickly on the way to turning the patient's remaining blood pink.



In fairness I believe we've moved beyond this particular patient and are simply talking about fluid resuscitation in general.  This dude had a map around 60, and I'd bet a 200-300cc bolus would get me where I'm comfortable.  Beyond that, we're on the same page that mass fluid isn't an appropriate route, so our next method to perfuse vital organs in lieu of mass crystalloid replacement would be moving on to pressors.  Again, I'm not giving someone a pressor with a map of 60 just to get them to 65, but I'll probably start thinking about it if their map is 40 after some fluid...


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## Carlos Danger (Oct 25, 2013)

FiremanMike said:


> We're taking about 10-20mcg of epi, not 0.3-1mg.  Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes.  As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.
> 
> 
> 
> ...



Is there clinical evidence supportive of that practice?


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## Akulahawk (Oct 25, 2013)

FiremanMike said:


> We're taking about 10-20mcg of epi, not 0.3-1mg.  Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes.  As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.
> 
> 
> 
> ...


Are we speaking about a trauma patient with a MAP of 40 or are we now discussing the non-trauma patient? Because in the non-trauma patient with a MAP of 40, that's not responding to fluid therapy, pressors might very well be useful... however, this thread has been about fluid resus in the trauma patient until this post.


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## Carlos Danger (Oct 25, 2013)

Akulahawk said:


> Are we speaking about a trauma patient with a MAP of 40 or are we now discussing the non-trauma patient? Because in the non-trauma patient with a MAP of 40, that's not responding to fluid therapy, pressors might very well be useful... however, this thread has been about fluid resus in the trauma patient until this post.



Exactly what I am wondering. We seem to be all over the MAP (pun intended).

Vasopressors and inotropes are not indicated in uncontrolled bleeding, period. That's why we don't routinely start neo or levo or dopamine drips in traumas. 

Now, if you were losing pulses and you were 5 minutes from the trauma bay and you'd given all the IVF and blood that you have, then maybe I could see a little squirt of epi or two, but that's just a last resort done out of desperation; it's not an actual management strategy.

The military learned long ago that aiming for an arbitrary BP in bleeding trauma patients does more harm than good. There is lots of literature on it.


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## FiremanMike (Oct 25, 2013)

Halothane said:


> Is there clinical evidence supportive of that practice?



There are ongoing studies that show promise in pressor use in hemorrhagic shock.


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## FiremanMike (Oct 25, 2013)

For some reason I can't multiquote on my ipad..

Yes I would consider it in a trauma patient.  I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.

Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..


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## VFlutter (Oct 25, 2013)

FiremanMike said:


> For some reason I can't multiquote on my ipad..
> 
> Yes I would consider it in a trauma patient.  I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.
> 
> Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..



I would rather have transient tissue hypoperfusion with controlled bleeding than uncontrolled bleeding trying to maintain a MAP ~60. Acute organ dysfunction can be managed but once a hemorrhaging trauma patient loses their ability to clot it is game over. 

I have had patients with Aortic cross clamp times over 60 mins with little sequela.


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## Akulahawk (Oct 25, 2013)

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FiremanMike said:


> There are ongoing studies that show promise in pressor use in hemorrhagic shock.


Which ones? Here's some snippets I found just with a quick google search...



> http://www.uptodate.com/contents/treatment-of-severe-hypovolemia-or-hypovolemic-shock-in-adults
> "Vasopressors (eg, norepinephrine) generally should not be administered, since they do not correct the primary problem and tend to further reduce tissue perfusion."





> http://www.annalsofintensivecare.com/content/3/1/13
> "...no clinical studies have validated any vasopressor support for the management of hemorrhagic shock."





> http://www.surgicalcriticalcare.net/Guidelines/Vasopressors%20and%20Inotropes%20in%20Shock.pdf "Vasopressors are not recommended in the initial stabilization of hemorrhagic shock. Permissive hypotension may be employed until bleeding is controlled in patients requiring emergent surgical intervention."





> http://www.jwatch.org/em200802220000001/2008/02/22/caution-about-vasopressor-use-hemorrhagic-shock "Use of vasopressors (any of the 4 studied) within 12 hours after injury, compared with no use of vasopressors, was associated with an increased mortality risk (hazard ratio, 1.81), as was use of vasopressors within 24 hours after injury (HR, 2.15). Aggressive early crystalloid resuscitation within 12 hours, compared with no use of crystalloid resuscitation, was associated with a reduction in mortality (HR, 0.59)."


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## Akulahawk (Oct 25, 2013)

FiremanMike said:


> For some reason I can't multiquote on my ipad..
> 
> Yes I would consider it in a trauma patient.  *I find it curious that Hal acknowledges it could be a consideration to buy a few minutes* while at the same time attempting to lambaste me for saying the same.
> 
> Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..


He said he can see it used as an act of desperation. If that pops any clots... it's game over that much quicker.


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## VFlutter (Oct 25, 2013)

http://emcrit.org/lectures/hemostatic-resuscitation/


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## mycrofft (Oct 25, 2013)

Firehazmedic said:


> Trauma pt., fell 4 stories off of the roof of a house onto an adjacent wall with resulting evisceration of intestines + Bleeding, Neurogenic shock is suspected with HR:58 B/P:86/52 Sp02 86%.
> 
> What do you do? Give fluid bolus right? Then Dopamine as well? Wouldn't that make the hemorrhage worse?
> 
> ...



1.  How long do you think this fictional character has to live after point of impact? (not your time on scene, but impact to expiration).
2. Are you bypassing the shock from basically the most acute abdomen you can imagine outside a war zone?
3. OK one person is trying to find a vein or any other route to administer this stuff. What is the other person doing? What is the over-all game plan and predicted time line?


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## fma08 (Oct 26, 2013)

mycrofft said:


> 1.  How long do you think this fictional character has to live after point of impact? (not your time on scene, but impact to expiration).
> 2. Are you bypassing the shock from basically the most acute abdomen you can imagine outside a war zone?
> 3. OK one person is trying to find a vein or any other route to administer this stuff. What is the other person doing? What is the over-all game plan and predicted time line?



Wise sage is wise.


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## Akulahawk (Oct 26, 2013)

Chase said:


> http://emcrit.org/lectures/hemostatic-resuscitation/


Actually, I've seen that video before. I thought it was pretty darned good when I saw it the first time, I liked it even more this time. I noticed that the speaker was advocating 1:1:1... and no crystalloids early... and heard NOT ONE THING about pressors in trauma resus.


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## Akulahawk (Oct 26, 2013)

fma08 said:


> Wise sage is wise.


Agreed...


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## FiremanMike (Oct 26, 2013)

Holy crap people, forget I said anything..


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## zzyzx (Oct 26, 2013)

Let's say this patient was not in neurogenic shock but only bleeding. What would the body be doing to compensate? It would increase the heart rate and clamp down the vessels. So, since the body is prevented from doing its thing, I don't see why it would be inappropriate to run dopamine. This is a different scenario than someone who is just bleeding internally. That said, with the BP given in the original post, I would hold off on pressors and only give a fluid bolus.


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## chaz90 (Oct 26, 2013)

zzyzx said:


> Let's say this patient was not in neurogenic shock but only bleeding. What would the body be doing to compensate? It would increase the heart rate and clamp down the vessels. So, since the body is prevented from doing its thing, I don't see why it would be inappropriate to run dopamine. This is a different scenario than someone who is just bleeding internally. That said, with the BP given in the original post, I would hold off on pressors and only give a fluid bolus.



Except that would be a possibly detrimental attempt at compensation. Just because the body does something to compensate doesn't mean it's an appropriate reaction or something that helps the patient.


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## zzyzx (Oct 26, 2013)

The body trying to compensate for a large volume of blood loss is not an appropriate response in order to perfuse vital organs? Or for uncontrolled vasodilation of the lower extremities ?


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## Akulahawk (Oct 26, 2013)

zzyzx, I think most of us _know_ what the body would be doing if bleeding was the _only_ problem that it had... we'd see an increased heart rate and peripheral vasoconstriction in an attempt to maintain a certain level of perfusion. Here's the problem. This response isn't exactly helpful in patients like this and it's probably why patients crump quickly... their body's attempt to maintain perfusion can easily pop clots or prevent effective formation of clots, so the bleeding continues until volume is so depleted that cardiac output lowers and finally clots can form and not be popped off. In any event, by that time, the body's probably massively peripherally vasoconstricted anyway. Running dopamine, to me, just doesn't make sense before bleeding is stopped. If the pump isn't working well or the "container" is just too big, I can see using dopamine... but when the "container" is broken?


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## usalsfyre (Oct 26, 2013)

FiremanMike said:


> Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP.  Just enough bump in MAP to get you to definitive care..



Negative Ghostrider....

Pressors are not 100% contraindicated in hemorrhagic shock, but I wouldn't play with them until surgical control was in place. The MAP is not that bad, and I really don't give two feces about his kidneys right now, more about the fact that his ICP is probably headed through the roof.


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## Aidey (Oct 26, 2013)

chaz90 said:


> Except that would be a possibly detrimental attempt at compensation. Just because the body does something to compensate doesn't mean it's an appropriate reaction or something that helps the patient.



Also see: Anaphylaxis.


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## usalsfyre (Oct 26, 2013)

In other news, read the whole thread before responding...

I'm inspired to paraphrase the Doctor here. Paramedics tend to think of resuscitation with very linear, defined end points. In reality it's a lot more wibbly wobbly.


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## Carlos Danger (Oct 27, 2013)

FiremanMike said:


> I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.



I didn't attempt to lambaste you, I simply challenged you to justify the practice you were advocating.




FiremanMike said:


> There are ongoing studies that show promise in pressor use in hemorrhagic shock.



I would be very interested in learning about those. Can you link to one of them?


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## zzyzx (Oct 28, 2013)

Don't mean to hijack the thread, but since we all seem to agree that we would not be giving pressors with the BP and patient condition stated in the original post, let's continue this scenario...

Your patient, who's in neurogenic shock and has also lost a significant amount of blood, and may or may not continue to be bleeding internally, becomes very altered. He no longer responds to commands, just groans, and you are unable to get a blood pressure. His heart rate remains at 58. You are a 1/2 hour from the hospital. What would you like to do?


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## mycrofft (Oct 28, 2013)

FiremanMike said:


> Holy crap people, forget I said anything..



Hahaha you have unleashed the EMTLIFE Gates of Torrential Wisdom.....

Good question by the way!!:beerchug:


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## medicsb (Oct 28, 2013)

I suppose we are assuming this hypothetical patient is otherwise young and healthy.  For whatever reason, not all hypovolemic and hypotensive patients get tachycardic (J Am Coll Surg. 2003 May;196(5):679-84 and, J Trauma. 2009 Nov;67(5):1051-4).   Bradycardia, relative or otherwise, doesn't indicate neurogenic or spinal shock, though a HR lower than 60, to me, would make a neurologic shock a little more likely.  

The question of fluids and/or pressors is not one that can be easily answered as there may be no correct answer.  If hemorrhagic AND neurogenic shock are present, then I could see the earlier use of a pressor. (In hemorrhagic shock, you can use a pressor, but it is usually only done AFTER adequate fluid resuscitation and/or control of bleeding.  It is generally a last line treatment.) Anyhow, in response to hemorrhage, the sympathetic system will cause small arteries and arterioles to constrict to limit blood flow.  The smaller the lumen diameter, the faster the velocity of fluid movement (meters per second) that is needed to maintain the overall flow (volume per second).   Proximal to the constriction, a higher pressure will be needed to maintain overall flow.  If you can cause constriction without raising the pressure to much, the pressor could possibly slow bleeding if neurogenic shock is co-occuring.  I'd prefer to use something that was mostly alpha (e.g. norepi or phenylephrine) and gently give fluids to a BP of 90 systolic-ish.


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## AeroClinician (Oct 28, 2013)

Wouldn't where the Hemmorage is in the body be a factor in the decision of to use pressors or not?

Central vs Distal Hemmorhage?  

Pressors shunting blood centrally?


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## medicsb (Oct 28, 2013)

Firehazmedic said:


> Wouldn't where the Hemmorage is in the body be a factor in the decision of to use pressors or not?
> 
> Central vs Distal Hemmorhage?
> 
> Pressors shunting blood centrally?



I had to double check... It is the heart and the CNS that is least responsive to the adrenergic vasoconstriction.  Liver, kidneys, intestines, lungs, spleen, etc. all respond, however skin, muscle, and viscera of organs are most responsive.


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## Carlos Danger (Oct 28, 2013)

Firehazmedic said:


> Wouldn't where the Hemmorage is in the body be a factor in the decision of to use pressors or not?



I've never heard of that.

Why would the location of the bleed matter?


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## mycrofft (Oct 29, 2013)

Halothane said:


> I've never heard of that.
> 
> Why would the location of the bleed matter?



In this case, probably wouldn't. If it were say rebar protruding from the abdomen, maybe.


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## MLFD AEMT CC (Nov 28, 2013)

I would give fluids, but keep it at a permissive hypo-tension level (90 systolic). This way you can continue blood supply to the brain by upping the B/P and prevent diluting any platelets in the blood that would be performing clotting functions.


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## Handsome Robb (Nov 28, 2013)

My question is where did neurogenic shock come in to play? Why are we even considering it? I'm assuming the mechanism is what is bringing it into play. 

Those vitals say decompensated, nearing irreversible hemorrhagic shock. Does he have neurogenic involvement? Sure. Does that matter? No. What is going to kill him first?

Why are we even considering push dose pressors? A map of 60 isn't awesome but it's far from terrible. Extreme peripheral vasoconstriction is actually going to reduce perfusion to those tissues in exchange for what? Numbers that make you less nervous?


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## Smash (Nov 30, 2013)

Robb said:


> What is going to kill him first?



Always the thing to keep in mind.  Keep it simple and all that



> Why are we even considering push dose pressors? A map of 60 isn't awesome but it's far from terrible. Extreme peripheral vasoconstriction is actually going to reduce perfusion to those tissues in exchange for what? Numbers that make you less nervous?



Yes.  Probably because we forget, or never realized, that pressure is not flow.  Flow is what is important and pressure is only one part of achieving flow.


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## mycrofft (Nov 30, 2013)

robb said:


> my question is where did neurogenic shock come in to play? Why are we even considering it? I'm assuming the mechanism is what is bringing it into play.
> 
> Those vitals say decompensated, nearing irreversible hemorrhagic shock. Does he have neurogenic involvement? Sure. Does that matter? No. What is going to kill him first?
> 
> Why are we even considering push dose pressors? A map of 60 isn't awesome but it's far from terrible. Extreme peripheral vasoconstriction is actually going to reduce perfusion to those tissues in exchange for what? Numbers that make you less nervous?



+1……………….


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## emspgh (Dec 11, 2013)

AeroClinician said:


> Umm, because the pt. is in hemorrhagic and neurogenic shock.
> 
> Pt. is bleeding from the abdomen, Approx. 1 liter is found on the ground.
> 
> What would you do?



 I don't recommend a full liter bolus, instead, dosed bolus' to maintain a systolic of around 100. They are correct in saying that you need to get the sats up, but that really shouldn't be an awfully difficult task. 

If the pt doesn't respond to dopamine, Atropine is not a bad choice, but let us never forget our friends epi, and nor-epi! Hopefully, if you get the heart rate up, the blood pressure will follow. 

As for fluids as a general rule, a lot of people feel it's appropriate to just automatically do a liter bolus with a shock trauma, but keep in mind, that's a way of the past. You don't want to cause any more anticoagulation issues than need be, and you don't want to dilute whatever blood is left in the person, so instead of just opening it, and ignoring it, just stick with a dose bolus of 100 at a time just keep that systolic up around 100.


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## AEMTstudent (Dec 11, 2013)

I've heard some discussions on tranexamic acid, does anyone use this in your local protocols?


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## Handsome Robb (Dec 11, 2013)

AEMTstudent said:


> I've heard some discussions on tranexamic acid, does anyone use this in your local protocols?



They're talking about adding it to ours. Our new medical director is ex-military so I'm thinking that has something to do with it. Maybe we will get blood products too! Lol



emspgh said:


> I don't recommend a full liter bolus, instead, dosed bolus' to maintain a systolic of around 100. They are correct in saying that you need to get the sats up, but that really shouldn't be an awfully difficult task.
> 
> If the pt doesn't respond to dopamine, Atropine is not a bad choice, but let us never forget our friends epi, and nor-epi! Hopefully, if you get the heart rate up, the blood pressure will follow.
> 
> As for fluids as a general rule, a lot of people feel it's appropriate to just automatically do a liter bolus with a shock trauma, but keep in mind, that's a way of the past. You don't want to cause any more anticoagulation issues than need be, and you don't want to dilute whatever blood is left in the person, so instead of just opening it, and ignoring it, just stick with a dose bolus of 100 at a time just keep that systolic up around 100.




I agree with your thoughts about fluid boluses, don't exactly agree with your target pressure but that's semantics.

I don't really agree with atropine, dopamine or epinepherine in this scenario at all.


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## CANMAN (Dec 11, 2013)

Robb said:


> They're talking about adding it to ours. Our new medical director is ex-military so I'm thinking that has something to do with it. Maybe we will get blood products too! Lol
> 
> 
> 
> ...



A 500 bolus isn't going to create any anti-coag issues and is a safe starting amount. I don't have time to titrate 100ml at a time in a patient with legit neurogenic shock. I would grab a lactate level and let that guide my fluid management, move on to pressors ie: Levo as a primary, and shoot for systolics above 90mmHG.


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