Hemodilution in trauma

[ccfems540]

I need some help. My medical director is from the school that every trauma patient with a blood pressure of less than 100 systolic should receive fluid unlimited fluid boluses until their pressure is stable(100 systolic). I have read that a systolic pressure of 88 systolic is adequate for perfusion but I can not find any literature that backs me up. Does anyone have information on hemodilution or related material?

 

[KEVD18]

Paging R/r911. R/r911, your presence is requested.

 

[fma08]

Interesting article I found. Something to look at while we wait ^_^.

http://www.ijccm.org/article.asp?is...e=10;issue=4;spage=241;epage=249;aulast=Rudra

 

[Ridryder911]

Yeah, read the current literature as well ATLS standards.

I know of at least two I participated in....

VF, Allen MK, Mattox KL. Immediate versus delayed fluid resuscitation for hypotensive patients with …
WH Bickell, MJ Wall Jr - N Engl J Med, 1994

Wall MJ Pepe PE Immediate versus delayed fluid resuscitation for hypotensive patients

R/r 911

 

[Ridryder911]

The key is maintain cerebral and coronary perfusion levels, all below 90 systolic. As you will read increasing critical closing pressures may actually cause more damage as you increase pressure, you increase the likelihood of increasing bleeding.

(a damned if you & damned if you don't situation)

The key point is studies have revealed that the body "shuts" down to preserve homeostasis of protecting itself. Aggressive fluid therapy (>2 liters) usually only causes hemodilation as well creating cellular problems and so forth... What many used to call irreversible shock.

R/r 911

 

[knxemt1983]

I just got out of medic school, and they beat it into our heads that once we reacha systolic pressure of 90 we should just maintain that because anything more, as Rid said, can cause more damage whether it because of an internal/external bleed, or any other cause. As far as I know a pressure of 90 is usually good enough for us in the pre-hospital setting

 

[mycrofft]

Unlimited is illogical ulness there is built in limit of time

Magical simplified thinking. Also, of which fluid does this person compose this IV tidal wave?
Ask the person this question: what if this pt has renal failure or CHF as well as the charismatic wound?

 

[boingo]

Unless you have the ability to stop the hemmorhage, i.e. tourniquet for femoral artery bleed, pouring salt water into the patient does nothing to improve their outcome. Salt water doesn't carry oxygen. It doesn't carry clotting factors. Increasing blood pressure with volume expansion using salt water increases bleeding and decreases the bodies ability to form clots. Unless it is from an IV warmer it can promote hypothermia. Unless your patient has altered mental status, fluid boluses should not be given. The magic number of 90 is pure BS. Treat the patient, not the number.

 

[Katie]

As far as I know a pressure of 90 is usually good enough for us in the pre-hospital setting

some people naturally have pressures this low too. main thing they tell us is to look at the pt and treat accordingly. the whole "treat the pt not the monitor/tool/etc."

 

[Ridryder911]

Enclosed is a link of a PowerPoint of Dr. Pepp'e. He and some other well known physicians were the authors of the MAST trouser studies, as well as Houston's Medical Director at one time and now is Dallas EMS medical director and I believe co-founder of NEMSP, and is active as Emergency Medicine and EMS Physician professor.

I got to know and work with Dr. Bickell at Tulsa when I did Trauma Studies. An outstanding scientist, physician, and statistician. I got to see and read some of the shock studies as they were being published and the shock and awe of the findings. It is hard to change ideas, and methods as seen here by the original posts... even that is has been declared over 10 years ago..

http://www.facs.org/education/gs2004/gs03pepe.pdf


R/r 911

 

[MSDeltaFlt]

The key is maintain cerebral and coronary perfusion levels, all below 90 systolic. As you will read increasing critical closing pressures may actually cause more damage as you increase pressure, you increase the likelihood of increasing bleeding.

(a damned if you & damned if you don't situation)

The key point is studies have revealed that the body "shuts" down to preserve homeostasis of protecting itself. Aggressive fluid therapy (>2 liters) usually only causes hemodilation as well creating cellular problems and so forth... What many used to call irreversible shock.

R/r 911

OK. Question. What about the hypotensive hemorrhagic traumata patient with coexisting signs and symptoms of TBI with regards to MAP and suspected ICP? Even transient decreases in CPP are dangerous. Talk about a Catch 22.

Curious and with respect.

 

[Ridryder911]

True, a very catch 22 but I personally treat the shock syndrome first. As well, as you know they are describing the brain is not being hydrated enough; where before we were concerned about the amount of fluids on TBI.

What I have seen as you have too, it is a doomed situation and one attempts to ..."just keep them alive"... Do you go aggressive with the brain or vascular as in shock? Personally, I go back to the vessels ability to perfuse to the brain.. again, a double edge sword.

Kinda like a patient that has Frank CHF and also has symptomatic response (as in shock) from rectal bleeding.. Yes, I have had a patient with such.

 

[TsmithFF10]

Mental Status, Mental Status, Mental Status...

 

[TsmithFF10]

Kinda like a patient that has Frank CHF and also has symptomatic response (as in shock) from rectal bleeding.. Yes, I have had a patient with such.

Sounds like a tough one, what was your treatment?

 

[Ridryder911]

Complicated issue, but gave a small fluid bolus to replace some of the fluid and performed PEEP per BVM (way before CPAP was invented for prehospital).

Airway is essential of course, but if there is no circulating volume then it useless as well. We was able to raise blood pressure up and when the patient was given RBC/Blood had to carefully make sure that patient did not fill up with more fluid. (It is not unusual to give Lasix between blood administration units.) Once a pressure of systolic of 60 > we gave diuretics and diuretic (tx of choice then)


R/r 911

 

[TsmithFF10]

Complicated issue, but gave a small fluid bolus to replace some of the fluid and performed PEEP per BVM (way before CPAP was invented for prehospital).

Airway is essential of course, but if there is no circulating volume then it useless as well. We was able to raise blood pressure up and when the patient was given RBC/Blood had to carefully make sure that patient did not fill up with more fluid. (It is not unusual to give Lasix between blood administration units.) Once a pressure of systolic of 60 > we gave diuretics and diuretic (tx of choice then)


R/r 911

That's so interesting, I'm curious as to what their mental status was through the whole treatment. Thanks again for the response.

 

[Zippo1969]

As far as the "hypotensive hemorrhagic trauma patient with coexisting signs and symptoms of TBI with regards to MAP and suspected ICP" question -

what s/s are you referring to? Specifically, are they showing s/s of herniation, or just LOC changes? For now I'll assume the worst

The 'double edged sword' here is a sharp one, but here's how I see it:

In the cases I've worked like this, the idea (unfortunately) is to maintain the body first. Reasoning behind this is simply if one's ICP is so high as to produce lateralizing s/s, they will need enough pressure to overcome that imbalance so as to maintain any sort of CPP. Also if they're that bad, neurogenic shock should not be ruled out, and must be treated as well...

hmmm...what's our ETA?:unsure: