Permissive hypotension

[Melclin]

I'm sure some of us here operate under a protocols/guidelines that recommend permissive hypotension/fluid restrictive resuscitation/hypotensive resuscitation of some sort.

e.g. 250ml boluses targeting radial pulse or good mentation.

If you do, could you post a link to you guidelines online or PM for an email address for a pdf.

 

[Summit]

I thought we'd moved past the disproven notion that palpable radial pulses have a tight correlation to a minimum systolic. I hope any permissive hypotension protocol aims at using auscultated, auto, and/or invasive bp measurement rather than inferring from palpable distal pulses.

 

[Akulahawk]

Sacramento County shock protocol simply advises NS titration to a SBP of 90-100 mmHg. We're not authorized to use A-lines, so... it's going to be either an autocuff or manual - and that manual can be palpated, though auscultated is MUCH preferred of the manual methods. No mention of peripheral pulses is made.

 

[Melclin]

I thought we'd moved past the disproven notion that palpable radial pulses have a tight correlation to a minimum systolic. I hope any permissive hypotension protocol aims at using auscultated, auto, and/or invasive bp measurement rather than inferring from palpable distal pulses.

Its not about correlating to a specific blood pressure.

Its quite the opposite. The idea is that chasing the same specific number in all patients is a flawed idea as the number alone may not necessarily mean a blood pressure associated with a minimum level of acceptable perfusion state. I seem to be hearing a lot about how useless BP is in trauma resus lately, with one commentator arguing that the BP cuff be struck from the trauma bay altogether in favour of better measures of resus (I assume this was probably hyperbole).

My understanding is the the presence of a peripheral pulse is thought to more closely resemble a reasonable perfusion state for that individual regardless of blood pressure.

 

[Rialaigh]

I'm sure some of us here operate under a protocols/guidelines that recommend permissive hypotension/fluid restrictive resuscitation/hypotensive resuscitation of some sort.

e.g. 250ml boluses targeting radial pulse or good mentation.

If you do, could you post a link to you guidelines online or PM for an email address for a pdf.

The answer completely depends on what is causing the hypotension. The question needs to be much more specific to garner any reliable answer.

 

[Carlos Danger]

I'm sure some of us here operate under a protocols/guidelines that recommend permissive hypotension/fluid restrictive resuscitation/hypotensive resuscitation of some sort.

e.g. 250ml boluses targeting radial pulse or good mentation.

If you do, could you post a link to you guidelines online or PM for an email address for a pdf.

The answer completely depends on what is causing the hypotension. The question needs to be much more specific to garner any reliable answer.

What question?

 

[Rialaigh]

What question?

My bad :wacko: I misread his whole post last night and didn't realize he was asking for protocols but thought it was more of a discussion of permissive hypotension in general. :blush:

 

[Carlos Danger]

My bad :wacko: I misread his whole post last night and didn't realize he was asking for protocols but thought it was more of a discussion of permissive hypotension in general. :blush:

I just thought I had missed something?

 

[Melclin]

The answer completely depends on what is causing the hypotension. The question needs to be much more specific to garner any reliable answer.

Reading of the question aside... talking about haemorrhagic shock mostly in the setting of trauma patients. Was not aware that kind of terminology was in use for any other disease process for which people would have guidelines.

 

[Medic496]

Fluids

While no protocol exist, it is approved to give a 250 bolus/challenge for DKA, Sepsis, and Pneumonia who have S/S of dehydration or would benefit from the Tx. Documentation must paint a picture of pt. condition, justification for treatment, and documented effects of treatment. Through QA/QI we educate if there is an adverse effect on pt. care.

 

[Handsome Robb]

We can give up to 2L of NS targeting >90 mmHg SBP.

With that said trendelenburg is still included in that same protocol so take it for what it's worth.

 

[VFlutter]

From my understanding the concept of permissive hypotension is most relative to the bleeding trauma patient. The idea being that you want to maintain the lowest blood pressure possible to prevent clot washout, coagulopathy, and hemodiluton of existing blood volume while still maintaing end organ perfusion.

 

[STXmedic]

From my understanding the concept of permissive hypotension is most relative to the bleeding trauma patient. The idea being that you want to maintain the lowest blood pressure possible to prevent clot washout, coagulopathy, and hemodiluton of existing blood volume while still maintaing end organ perfusion.

This.

I've never heard of permissive hypotension used in any other context.

250mLs to a septic patient? To what avail?

 

[Rialaigh]

Reading of the question aside... talking about haemorrhagic shock mostly in the setting of trauma patients. Was not aware that kind of terminology was in use for any other disease process for which people would have guidelines.

In the setting of trauma patients around here I like to think their are 4 types (to simplify).

hemodynamically stable with bleeding controlled - These patients get a couple of IV's with a bag hanging at KVO.

Hemodynamically stable with bleeding uncontrolled - A couple of IV's with a bag hanging KVO or medium paced depending on bleeding.

Hemodynamically unstable with bleeding controlled - These patients get fluids wide open until mental status improves or systolic is ~90 (depending upon mental status, radial pulses, skin color, breathing status, etc..etc..).

Hemodynamically unstable with bleeding uncontrolled (True "Oh :censored::censored::censored::censored:" trauma) - 2 IV's, two bags of fluid wide open (or pressure bagged) and haul *** to a trauma center, this doesn't change until the patient dies or this status changes to one of the other 3.


If the patient has a suspected internal bleed and has a systolic BP of 80-90 with decent mental status I'm fine not running fluids until mental status deteriorates, then you open the fluids enough to keep mental status okay (or in the unconscious trauma patient you keep systolic 80-90). If you can titrate fluids to keep a patient's BP around 90 systolic and not have your fluids wide open I would consider this patient hemodynamically stable.


In true oh :censored::censored::censored::censored: trauma your not trying to keep a BP of 90...your trying to keep a BP of anything higher than 0.....If you have time to titrate your fluids to BP the guy probably isn't bleeding out on your stretcher in the next 15 minutes (the average time it takes me to get to the ER).



And I may be completely wrong but those are my thoughts Someone please educate me


As far as permissive hypotension in settings other than trauma I have seen it used quite extensively with CHF patients, elderly with no signs of dehydration, etc....

 

[the_negro_puppy]

in QAS for uncontrolled haemorrhages we give sufficient fluids to maintain radial pulse. If there is a traumatic head injury we aim for 100-1200mmhg systolic

 

[Tigger]

We can give up to 2L of NS targeting >90 mmHg SBP.

With that said trendelenburg is still included in that same protocol so take it for what it's worth.

This is our protocol. I had testing with our medical director the other day where there was some talk of permissive hypotension. His point is that everyone is so focused on getting the patient to a number (even a lower one) that they forget that dumping four liters in someone who has a pressure of 70 is still a bad idea, even if they're pressure doesn't improve.

Two liters and then call in if you're still concerned.

 

[Handsome Robb]

in QAS for uncontrolled haemorrhages we give sufficient fluids to maintain radial pulse. If there is a traumatic head injury we aim for 100-1200mmhg systolic

1200 mmHg!? Holy hypertension batman!

 

[sir.shocksalot]

250mLs to a septic patient? To what avail?

To any adult patient for that matter. That's such a trivial amount of fluid in pretty much any condition that requires fluid administration. Your septic patients may be 4-8 L fluid depleted. Serious burns can need equal amounts of fluid in a short time span. OCEMT is that a protocol just for EMTs or EMT-Is?