FiremanMike
Just a dude
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Holy crap people, forget I said anything..
Neurogenic Shock With Internal/External Hemmorhage
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zzyzx
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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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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.
zzyzx
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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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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?
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.
Aidey
Community Leader Emeritus
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Also see: Anaphylaxis.
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I didn't attempt to lambaste you, I simply challenged you to justify the practice you were advocating.
I would be very interested in learning about those. Can you link to one of them?
zzyzx
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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?
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?
mycrofft
Still crazy but elsewhere
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Hahaha you have unleashed the EMTLIFE Gates of Torrential Wisdom.....
Good question by the way!!:beerchug:
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.
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.
OP
OP
AeroClinician
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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?
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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mycrofft
Still crazy but elsewhere
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In this case, probably wouldn't. If it were say rebar protruding from the abdomen, maybe.
MLFD AEMT CC
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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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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?
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
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Always the thing to keep in mind. Keep it simple and all that
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.
mycrofft
Still crazy but elsewhere
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+1……………….