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Don't worry, in 10 or 20 years we will all be saying the exact same thing... It's the circle of life.
IV Fluids increase death rate for trauma victims
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Don't worry, in 10 or 20 years we will all be saying the exact same thing... It's the circle of life.
If it makes you feel any better, there are still providers who are not only using it, but defending the practice.
(Why I have no idea, some people are slow.)
The original idea of permissive hypotension is credited to a French Army surgeon in WWI. I forgot his name though.
In the nicest way possible, I have to ask if you read the whole study or just the abstract. I can see how one could take what the authors wrote as an abstract and think that this study provided some sort of new knowledge, but if you were looking at the full text I'm left wondering (legitimately: what did I miss?) what was so interesting.
Personally, I couldn't find much of interest. This study would be great to give plausibility to a claim that prehospital fluid administration can be harmful for reason x,y.or z. Unfortunately that claim has been plausable for quite a few years at this point, and better studies have given a much more detailed, nuanced, and interesting perspective.
Sorry, I think that this is a derivative, nearly meaningless study that provides an abbreviated review of the literature at best.
I would also suggest that outright removing prehospital cannulation/fluid administration from protocol is probably not the best move. The question of whether or not to provide fluid recussitation, how much to provide, etc. are clinical questions that should be decided on the basis of assessment of a particular patient in a particular situation. Lumping a heterogeneous group of patients together and banning a specific treatment because it may be harmful to some doesn't seem like good management of a medical system.
As a secondary issue, I have to wonder if studies like this contribute to the hesitation of many to try to pay attention to research and use evidence to help determine treatments. Searches can turn up hundreds of studies on any particular topic, many of which are of poor quality and have divergent results.
Sorting through the mountain of bad/redundant/preliminary information to find the few well done studies that establish something new can be quite a daunting task. Determining which studies are of high quality and which are not is a time consuming task that often requires reading the entirety of low-quality studies before you decide that they were, well, junk (oh, just wasted your time, so sorry, try again tomorrow...).
Sometimes I feel like I'm looking for a needle in a haystack when I'm looking for good evidence on a particular topic, and I feel like many authors are throwing more "hay" on the stack, making reading the literature a tall order.
Sorting through the mountain of bad/redundant/preliminary information to find the few well done studies that establish something new can be quite a daunting task. Determining which studies are of high quality and which are not is a time consuming task that often requires reading the entirety of low-quality studies before you decide that they were, well, junk (oh, just wasted your time, so sorry, try again tomorrow...).
Sometimes I feel like I'm looking for a needle in a haystack when I'm looking for good evidence on a particular topic, and I feel like many authors are throwing more "hay" on the stack, making reading the literature a tall order.
That is exactly the problem!!!
It seems to me many MDs are of the mind that their job is not to treat patients but to do research. Not to be outdone, the nursing researchers jump on board as well. To prove that they are equal other ancillary providers start to do the same and a publish or perish environment is created.
People of all levels feel compelled to publish something, and just like you said, there are piles and piles of garbage. What's worse is people who do not have the time to filter it all (which is becomming harder to do) either want to change practice everytime the wind blows, or suddenly give legitimacy to a practice because there is now research on it.
On the otherside, good research has trouble floating to the top because when you tell a falsehood often enough it becomes defacto truth, and the plethora of garbage discounts the findings of well done studies.
The solution is actually less people doing research and more intense reviews and replications of research before publication.
But everyone from EMS to physicians has their own trade publications promoting themselves by featuring this "research."
The herd needs to be culled.
What would be great too is every undergrad or grad student who does research should be judged on its quality, not the fact his name is on it. That way, poor research is punished instead of rewarded by getting your name in print.
There was a time in my career where sending your study to be published had to be quality, because if you sent junk once too often, whatever you sent in the future was just put in the trash.
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rhan101277
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I think there is much research that providing crystalloid is helpful, it bridges the gap until blood can get infused. Back in the day all they did was constrict by using epi drip or whatever. It really does not matter how much constricting you do when it is a volume issue. People were loosing extremities and what not from that type of thing.
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It only helps in nonprogressive shock.
According to the ACS (and I am sure a few other sources) In stage 1 blood loss, and transiently in stage 2.
It restores volume when bleeding has been controlled or is self limiting. If there is a viable circuit, it can increase CVP. However, when the circuit is open, it can do more harm than good trying to normalize numbers with a substance that doesn't carry oxygen.
I would like to see evidence that it bridges any gaps.
I could pour crystalloid into somebody and achieve BPs of anything I wanted. It doesn't mean it will help at all.
Shishkabob
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The thing I don't like about this study (besides what I already put)
The better / more progressive agencies aim to do permissive hypotension and maintaining MAP and CVP.
If you don't have an adequate MAP, nothing else matters, period. Might as well let the person bleed out on scene... same outcome.
The better / more progressive agencies aim to do permissive hypotension and maintaining MAP and CVP.
If you don't have an adequate MAP, nothing else matters, period. Might as well let the person bleed out on scene... same outcome.
medicRob
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You should really consider moving on to critical care paramedic when you get the chance.
abckidsmom
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Jugular Venous Pulsation.
Cap refil. Frank-Starling law in a closed circuit what goes out must come back. If the cap refil is delayed something is very much wrong with the circuit. Now it is just a matter of inflow or outflow from the right heart.
Except if you let them bleed out on scene you save their estate a several hundred thousand dollar healthcare bill...
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You both (Linuss & 187) should probably tone it down and get back on topic before the mods step in...
Blessed187
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It's done, I said my peace
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Now that this thread has been cleaned up, I've reopened only because I believe this is an important topic. To those of you whose posts were removed simply because they quoted an offending post, I apologize but there was no way for me to leave them and still have the thread make any sense.
Let me make one thing real clear, right here and right now...
BE POLITE
Let me make one thing real clear, right here and right now...
BE POLITE
AnthonyM83
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Haven't these studies been around for awhile? The previous PHTLS edition basically taught the same thing. IV's en-route, not on-scene, and specific guidelines for fluids and permissive hypotension....
Right, that was my point about the hypothesis already having been generated. This particular study is really nothing more than a question-poser, and the questions have already been posed, and some answers produced, as you note.
I do think sometimes a bit more specificity is called for when people say "permissive hypotension." Does this mean no fluid at all? Delayed fluid recussitation until in-hospital? Targeted fluids to some SBP/MAP/clinical assessment level? What level?
I get the impression that usually we mean "aiming for a MAP of 65 or 70", and that doesn't really strike me as "hypotensive" per se. That said, there is even dispute over what "normotension" is, and there is some evidence that, at least in blunt trauma, the hypertensive line may begin at a systolic of 110 (as opposed to the 90 that was apparently quoted in PHTLS):
http://www.ncbi.nlm.nih.gov/pubmed/19077604
http://www.ncbi.nlm.nih.gov/pubmed/17693826
My impression is that there is no great evidence for truly hypotensive recussitation in humans, although there is a lot of animal data supporting it.
medicRob
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I've gotten to the point where I actually put pieces of black tape on the monitor in the trauma sim lab when training students that covers the systolic and diastolic, having them rely on only the MAP pressure to know when fluids and drugs like levo are appropriate. So many people neglect the little number in parenthesis beside the blood pressure on the monitor. You'd be surprised at how many paramedics when asked if they can calculate MAP from a BP say no.
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