Trauma Question for Rid (Dust and others)

[Ridryder 911]

There is a fine line between permissive hypotension and shock.. that is the problem. Sure, we practitioners have known for several years, making them bleed pink is not good, or even raising the blood pressure will cause the opening to get bigger... make sure that not only coronary perfusion is good but cerebral perfusion as well. Some research physicians loose sight of the latter. Again, I personally believe without a perfusion to brain, what good is it?... This has been a heated debate, between me and some of the researchers. I personally know of 2 or 3 of the early researchers, and was fortunate to review some of the literature prior to publishing in the early - mid 90's. The hate mail the physicians receive is surprising... Partly, because they still teach fluid resuscitation model in shock lecture lab, when the purposely hemorrhage the subject (dog lab) and then watch them go into symptomatic shock.. then revers with fluid therapy. Unfortunately, they usually cut the lecture short... not showing the later stages and shock syndromes (i.e DIC, End stage organ failure, etc.)

The large bore as described is for not so much fluids but ability to rapidly introduce PRBC' s, without damaging the cell walls. Yes, you can give blood through a 20g or even smaller, but not faster. If possible a fluid warmer actually helps as well.

I personally start at least 2 large bore if possible, and a third if I can (real trauma patients). As from previous posts 1 bag RL for trauma and 1 saline at keeping open with blood tubing, all have sale locke attachments, but the 3'rd is just locked off.

Yes, aggressive fluid resuscitation is foolish, for right now only the red stuff carries oxygen...

Be safe,

R/r 911

[strippel]

Thanks for the info dgmedic.

I actually was there (and a few other sites) looking before I placed the post. I just was beginning to think I was missing out on some new beneficial information.

I also understand the blood replacement needing larger IVs. That is why blood tubing is HUGE compared to regular IV tubing. The blood cells can get damaged going through small diameter.

My wife does reprofusion (where blood is processed and given back to a patient during surgery). In a small community hospital OR, one nurse couldn't understand the request for an 18g, because "we only use 22s".

[strippel]

Thanks Dust and Rid. Rid, those dog bad outcomes were what I was thinking about.

I guess I need to wait for his new protocols, and see what it says about the amounts and kinds of fluids.

At my part time, many medics are into the "get it in fast" mode because of that. Hopefully, it won't be that way here.

[ERDoc]

With all of the evidence that has been published, about the only thing that has really panned out is that large volume fluid resuscitation in pts with injury to the large arteries can be detrimental, and permissive hypotension might be the best way to treat these pts. As previously stated when you increase the pressure, you have the potential to blow off whatever clot has formed. The same has not been shown for less severe injuries such as splenic and liver lacs and things such as extremity trauma. Obviously, in the field, with blunt abd/chest trauma you have no way of knowing what is injured so, I don't think you will ever see any conclusive evidence either way, so you will end up at the mercy of your medical director and his/her beliefs.

At my hospital, the way we do it is two large bore IVs (not necessarily with fluids going). Any pt with AMS or hypotension gets one cordis by the ER and usually the trauma service will put in a second one. If they are hypotensive and do not respond to the first fluid bolus they get blood going, this is usually after CTs have been obtained and we know what their injuries are.

[Ace844]

"Strippel,"

For more info on this, there was an earlier post here on the board 'outlining' and explaining the practices and principles behind 'the hypotensive management of trauma', you can find it here::: Pre-hospital Hypotension!@ traumatic hemmhor management......

Hope this helps,

ACE844

[Spock]

Lots of good information here and all things are relative. Permissive hypotension still has its place and I routinely do it in the OR to decrease blood loss especially for orthopedic or oral/maxillary/facial procedures but I decide how low to drop the BP and tell the surgeon to go pound salt if he doesn't like it. Like Rid said, you still have to perfuse the heart and the brain. Coronary perfusion pressure (MAP - LVEDP) should be greater than 70 unless the pt has HTN or CAD in which case 80 or 90 is appropriate. Cerebral perfusion pressure (MAP - ICP or CVP) should be greater than 60 with 70 to 80 ideal for pt's with HTN. Bottom line is to keep MAP above 70 in all patients except the young and healthy.

I get irritated when I see a pt arrive with 2 large bore IV's (which will get pulled) after 6 attempts. By golly the medic was going to get 2 IV's no matter how many attempts it took! What a waste. I'm not sure why your trauma doc wants 2 IV's but he must have his reasons. Better communications is definitely needed. We prefer to have one good IV and start the rest ourselves especially since we draw labs from one of the IV's we start.

Live long and prosper.

Spock

[SingleLovingLife]

Like AZCEP, Dust, Rid and ERDoc made reference to - two large bore IV's does NOT mean you have to run them wide open. Titrate one to try to achieve the desired pressure and TKO the second...then IF you or the ER or the OR need them - they are already established. Rid mentioned blood tubing on one - in the trauma class I just completed there was a strong emphasis on this. Most everyone agrees that "pink" blood is "bad" - but it is going to be much easier to start a second line in the field BEFORE it becomes nearly impossible.

Just my 2¢.

[ffpm41]

Guess that's why they call it the "practice of medicine."

[Maciek999]

Very good lecture by Dr Karim Brohi on fluid resuscitation in trauma

http://www.medschool.ucsf.edu/sfgh_surgery..._in_trauma.aspx

Also check ppt files lectures on different trauma topics

http://www.medschool.ucsf.edu/sfgh_surgery...or_interns.aspx

[RaceMedic]

Something that is almost never brought up in these discussions and really needs to be further addressed is Kidney profusion.

the kidney's don't normally respond well to sharp changes in BP and can have some serious lasting damage from even one sharp drop or spike in pressure. they need to be profused and maintained as well as the brain and heart to have any kind of quality of life.

I worked in a dialysis center for a time while in medic school. i learned quite a bit about the kidney's and their little quarks. A little research and you will find that there are many on dialysis due to BP. Many of my PT's that were on because of BP were accually involved in traumatic events where fluid resusitation is involved. More education is needed in the full effect of BP changes.

By the way our protocols state traumas get two large bore IV's as well. They do not have to be wide open TKO is acceptable. our med director also demands we think for ourselves and use our judgement when it comes to what we do. If we feel we don't need the two IV's and can justify it ... then there are no problems

Race