Slow and Low

8/17/2019 Slow and Low

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Nick Rathert, MDAlbany Medical Center, Albany, NY

Associate Medical Director, Albany Fire DepartmentAssociate Medical Director, Schenectady Fire Department

Associate Chief- Division of Prehospital and OperationalMedicine


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No financial or other personal conflicts of interest

to disclose


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At the completion of this presentation theaudience is expected to:

Understand the concepts that have driven the

permissive hypotension movement Understand the difference between management

goals in the medical vs trauma patient

Understand the limitations of the data supporting

permissive hypotension Understand the continuing discussion in permissive

hypotension as a strategy


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Physiologic decrease blood flow resulting ininsufficient delivery of metabolites to andinadequate removal of byproducts from tissues

or organs Hypotension is not the same as shock


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AKA- Controlled resuscitation, Damage controlresuscitation, Hypotensive resuscitation

Strategy of withholding or limiting IV fluids to keep

pressure at a subnormal level Goal of providing just enough pressure to maintain

end organ perfusion


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Normal saline is notnormal Hyperchloremic

acidosis

May reduce bodytemperature

Dilution of Hgb andclotting factors

Lethal Triad Acidosis Hypothermia

Coagulopathy


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Less than half ofcrystalloid infusedremains intravascular

Lungs

Skin

Bowel


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Pressures above 80 mmHg have been shown todislodge newly formed clots in animal models


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Multipleobservational andanimal model studies

demonstrate areduction in mortalityin hypotensive vsnormotensiveresuscitation


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BROWN, 2012, TRAUMA AND ACUTE CARE SURGERY

1216 Sever trauma patients analyzed

Patients that received >500ml crystalloid

Longer prehospital times

Higher INR

Higher 24 hour resuscitation requirements

Higher rate of Acute Traumatic Coagulopathy

Patients without hypotension that received >500 mlcrystalloid

Doubled rate of in-hospital 30 day mortality

HOWEVER Patients with hypotension

Mortality was inversely proportional to fluid volume >2000ml

**2% increase in survival for every 1mmHG increase in BP


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Damage Control Resuscitation (DCR)

Limits [crystalloid] volume They don’t have a saline deficiency

Order, ratio and total blood product volumes are still unclear Avoids “pressure head”

Don’t blow the new clot off the injury

Addresses trauma induced coagulopathy and

iatrogenic hemodilution Its already being utilized so don’t dilute it

Some programs are leading with plasma or platelets


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Damage control surgery

Limited surgery to control bleeding andcontamination

Get In, Get Done, Get Out Delayed definitive repair

Make it pretty when the patient is stable


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Medical vs Trauma

Mechanisms drivingshock state

Timing Mechanisms of repair

Age

Peds

Elderly

Blunt vs Penetrating

TBI vs Non-TBI


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Increased volume in arigid container =increased pressure

Cerebral PerfusionPressure

MAP- ICP=CPP

Each episode of

hypotension doublesmortality


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If normotensive andmentating Apply Diesel

Continue to reassess

Talking and radialpulse

If hypotensive,confused and/oranxious 500 ml bolus adults

Assess response

10ml/kg for children


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Blood or artificialcolloidal fluid inpreshospital setting

US as tool forassessing response

Real-timetelementoring for

austere damagecontrol surgery bynonsurgeons


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Scoop and Run

Mast Pants (1970s)

ATLS = 2 large bore

IV and 2L NS (70s-90s)

Fluid = Bad (5-10years ago)

My favorite


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Thank You!

Slow and Low

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