Fluid titrations in your service.

Melclin

Melclin

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I was hoping some of you guys could point me in the direction of websites for services that have guidelines for titrating up to permissive hypotension in truncal trauma.

I seem to remember someone mentioning once that instead of just withholding fluids all together regardless of BP (except if pt becomes pulseless), their service advocated titrating up to a SBP of 70 or something like that. I'd like links to guidelines like this to fuel discussion at my uni, and I really can't be bothered trawling through a million websites for US ambulance services.
 
I just went through ITLS (international trauma life support) where they had us titrating fluids to obtain 90 mmHg systolic, or, palpable peripheral pulses.
 
90 SBP for blunt trauma, 70 SBP for penetrating.
 
is the bleeding controlled or not?

controlled is 90 uncontrolled is the "minimum compatible with life"
 
46Young said:
90 SBP for blunt trauma, 70 SBP for penetrating.
Click to expand...

We aren't doing ITLS until next month, but an instructor mentioned this.
 
Links for service guidelines guys and/or gals. I need evidence.

The issue of controlled bleeding appears a bit of a grey area. In the literature, what is considered a controlled haemorrhage is a bit sketchy and I think the truncal guidlines are based in the idea that the bleed cannot really be confirmed to be controlled in incidences of penetrating truncal trauma. Anyway, I'm not really asking to have the debate here....unless anyone wants too (I've asked before and no one cared too:sad:) , I just need some links really.

EDIT- cheers for the ITLS pointer daedalus.
 
Last edited by a moderator:
Here you are mate!

http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmed&pubmedid=17106628

"Nevertheless, more recent findings suggest values for the lower MAP limit of autoregulation to be considerably higher than 60 mmHg [73–75]. In a critical review of the literature, Drummond [76] postulated an average lower limit of no less than 70 mmHg. Moreover, the limit seems to vary strongly across individuals. Waldemar et al. [77], for instance, reported an inter-individual range between 53 and 103 mmHg. In accordance with Duschek and Schandry’s [65] data, the doctrine of stable cerebral perfusion down to the limit of a MAP of 60 mmHg can no longer be supported by the current state of research."

70mmhg is the current standard for acceptable CPP per ATLS (and thus PHTLS). For those of you quoting protocols and independent card courses such as ITLS, you are being taught inappropriately. Systolic BP is only a small piece of the pie, the MAP, ICP, and JVD are the relevant parts that need to be looked at.

A systolic of 70mmhg is INSUFFICENT for maintaining cerebral perfusion. If you figure a BP of 70/50, your MAP is only 57 (already insufficent). Now factor a small physiological ICP level of 0-10 and its potentially reduced further. Your patients brain is not perfusing and you may as well get out your watering can, as they will become a vegetable if this level is sustained.

80mmhg perhaps for pentrating trauma, but honestly, unless you planning on throwing in an ICP bolt, I wouldn't recommend you allow an unknown ICP level to cause your MAP to bottom out.
 
Further to Fligh-LP's post, it is difficult to give a single golden number of what is/isn't acceptable. I aim for the lowest BP I can whilst maintaining normal mentation (assuming no TBI) which should (theoretically) allow adequate perfusion to vital organs such as brain, kidneys and gut. If I can avoid fluid administration I will, but obviously at some point some may be required.

I have no hard data for this, it is merely the conclusion that I have come to from my reading of the research.
 
Cheers for the link flight. Yeah I agree with you smash, where as the prevailing point of view with some of my tutors is fluids + truncal trauma = DONT because of Bickell, Pepe, et al NEJM 1994 end of story.

Fluid resus has been a pet topic of mine for a little while now, I did my major essay on it for trauma management this semester and it feels like alot of my tutors aren't quite down with the current thinking on permissive hypotension. Cheers guys.
 
Flight-LP said:
80mmhg perhaps for pentrating trauma, but honestly, unless you planning on throwing in an ICP bolt, I wouldn't recommend you allow an unknown ICP level to cause your MAP to bottom out.
Click to expand...

Sorry, I meant CPP, not MAP.
 
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