Permissive hypotension
Permissive hypotension or hypotensive resuscitation
It is becoming common in
Pathophysiology
Following injury, the otherwise healthy individual has a natural ability to clot off bleeding. The higher the pressure in your vessels, the harder it is for the bleeding to stop, since the fluid essentially "pushes" the clot out and consequently the bleeding resumes. In more technical terms: hypotension facilitates in vivo coagulation. This is especially true in patients who still have active bleeding. Attempts to normalize blood pressure in case of uncontrolled bleeding as in patients with penetrating trauma, may result in increased blood loss and worse outcomes. In this context, restriction of fluid resuscitation may actually improve outcomes. This concept has been supported by animal studies that have demonstrated aggressive fluid resuscitation increases the volume of hemorrhaging fluid to a significant level as well as increased mortality.[15][16]
Another issue with aggressive fluid resuscitation is the potential for
The
It is important to remember that permissive hypotension is a temporary measure to improve outcomes until the source of bleeding is controlled. There are issues associated with prolonged permissive hypotension (> 90 min considered prolonged where detrimental effects outweigh benefits according to most recent animal studies - no human data available to date)
Contraindications
Patients with preexisting
Permissive hypotension relies on the heart's ability to pump fluid through the body efficiently. Less
Permissive hypotension may also be contraindicated in patients with
A high percentage of
Current Recommendations
- Britain: Resuscitation to maintain a palpable radial pulse (indicative of systolic blood pressure 80-90mm Hg) in ongoing hemorrhage in soldiers and to maintain only a palpable central pulse (ex. carotid), indicative of systolic blood pressure of 60mm Hg with penetrating torso trauma.[22]
- United States: US Military follows permissive hypotension. Any patient that experiences altered mental status or becomes unconscious (systolic blood pressure less than or equal to 50mmHg) is resuscitated to restore mentation or systolic blood pressure of 70mmHg.[23][24][25][26][27]
- Israel: Israeli Military also follows permissive hypotension and follows similar guidelines as the United States.[28]
References
- ISBN 978-0-07-148480-0.
- ^ a b Schweiz Med Wochenschr 2000;130:1516–24
- ^ Kowalenko T, et al. J Trauma. 1992, 33:349-53
- ^ Stahel PF, et al. Injury. 2009, 40 (4, suppl):S27-35.
- ^ Brickell WH, et al. Circ Shock. 1989, 28:321-32
- ^ Stern SA, et al. Ann Emerg Med. 1993, 22:155-63
- ^ Geeraedts, Jr LMG, et al. Injury. 2009, 40:11-20.
- ^ Shen L, et al. J Clin Invest. 1983, 71:1336-1341
- PMID 8608703.
- penetratingtorso injuries. N Engl J Med 1994;331:1105–9.
- ^ Morrison CA, et al. J Trauma. 2011, 70:652-63.
- PMID 7935634.
- PMID 12045644.
- ^ Haut ET, et al. Ann. Surg. 2011, 253:371-7
- ^ Kowalenko T, Stern S, Dronen S, Wang X. Improved outcome with hypotensive resuscitation of uncontrolled hemorrhagic shock in a swine model. J Trauma 1992;33: 349–53.
- ^ Stern SA, Dronen SC, Birrer P, Wang X. Effect of blood pressure on hemorrhage volume and survival in a near-fatal hemorrhage model incorporating a vascular injury [see comments]. Ann Emerg Med 1993;22:155–63.
- ^ Li, T, et al. Anesthesiology. 2011, 114:111-9
- ^ Kozlov AV, et al. Mol Med. 2010, 16:254-61
- ^ Garcia, Tony (1 May 2010). "Recognizing and Treating Crush Syndrome". FireEngineering.com. Retrieved 10 October 2013.
- ^ Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, et al. The role of secondary brain injury in determining outcome from a severe head injury. J Trauma 1993;34:216–22.
- ^ Chesnut RM. Avoidance of hypotension: condition sine qua non of successful severe head-injury management. J Trauma 1997;42:S4–S9.
- ^ Revel M, et al. J Trauma 2003, 54(5,suppl):S63-S67.
- ^ Butler FK, et al. Mil Med. 2000. 165(4, suppl):1-48.
- ^ Peace FJ, et al. Mil Med. 1999, 164:653-5
- ^ Champion HR. J Trauma 2003, 54(5,suppl):S7-12.
- ^ Champion HR. J Truma. 2003, 54(5,suppl):S7-12)
- ^ MacKinnon MA. Air Medical Journal. 2005, 24: 70-72.
- ^ Krauz MM. "Fluid Resuscitation for the trauma patient." Trauma, Critical Care and Surgical Emergencies: A Case and Evidence-Based Textbook. Eds. Rabinovici R, Frankel HL, Kirton OC. Pages 1-7, 2010.