Nick Rathert, MD

Albany Medical Center, Albany, NY

Associate Medical Director, Albany Fire Department
Associate Medical Director, Schenectady Fire Department
Associate Chief- Division of Prehospital and Operational
Medicine

No financial or other personal conflicts of interest

to disclose

At the completion of this presentation the

audience 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

Physiologic decrease blood flow resulting in

insufficient delivery of metabolites to and
inadequate removal of byproducts from tissues
or organs
Hypotension is not the same as shock

AKA- Controlled resuscitation, Damage control

resuscitation, 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

Normal saline is not

normal

Hyperchloremic
acidosis
May reduce body
temperature
Dilution of Hgb and
clotting factors

Lethal Triad

Acidosis
Hypothermia
Coagulopathy

Less than half of

crystalloid infused
remains intravascular

Lungs
Skin
Bowel

Pressures above 80 mmHg have been shown to

dislodge newly formed clots in animal models

Multiple
observational and
animal model studies
demonstrate a
reduction in mortality
in hypotensive vs
normotensive
resuscitation

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 ml

crystalloid
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

Damage Control Resuscitation (DCR)

Limits [crystalloid] volume

They dont have a saline deficiency
Order, ratio and total blood product volumes are still unclear

Avoids pressure head

Dont blow the new clot off the injury

Addresses trauma induced coagulopathy and

iatrogenic hemodilution
Its already being utilized so dont dilute it
Some programs are leading with plasma or platelets

Damage control surgery

Limited surgery to control bleeding and

contamination
Get In, Get Done, Get Out

Delayed definitive repair

Make it pretty when the patient is stable

Medical vs Trauma

Age

Mechanisms driving
shock state
Timing
Mechanisms of repair
Peds
Elderly

Blunt vs Penetrating
TBI vs Non-TBI

Increased volume in a
rigid container =
increased pressure
Cerebral Perfusion
Pressure

MAP- ICP=CPP

Each episode of
hypotension doubles
mortality

If normotensive and
mentating

Apply Diesel
Continue to reassess
Talking and radial
pulse

If hypotensive,
confused and/or
anxious

500 ml bolus adults

Assess response

10ml/kg for children

Blood or artificial
colloidal fluid in
preshospital setting
US as tool for
assessing response
Real-time
telementoring for
austere damage
control surgery by
nonsurgeons

Scoop and Run

Mast Pants (1970s)
ATLS = 2 large bore
IV and 2L NS (70s90s)
Fluid = Bad (5-10
years ago)
My favorite

Thank You!