Pre-hospital fluid therapy.
Hardcastle, Tim, Dr <tch at sun.ac.za>
tch at sun.ac.za
Thu Jun 14 15:43:56 BST 2007
Jose
I can't talk about level of evidence on this one - only personal and institutional experience, namely that most children who present frankly hypotensive for age, without adequate fluids (we try to use blood products early) to at least get them back to a reasonable baseline pressure (70+2Xage) have died, despite rapid assessment and rapid surgical intervention. We have seen a progressive tachycardia till the point of "no-return". The challenge with the small child is not the fact that they are hypotensive, rather the answer to whether the "are bleeding" or "have bled". The former group - permissive hypovolaemia - no problem - get them to definitive surgical care - still high mortality. The latter group - surgical intervention may do more harm than good; one would rather fully resus and investigate intensively with imaging once stable. The challenge is that the latter group is the vast majority.
So in summary, it is about the decision as to whether surgery is the management of choice or rather investigae and manage SNOM, that dictates the need for formal resuscitation to normalish values. Again this is for BLUNT trauma, not penetrating trauma.
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of JOSE SUAREZ PELAEZ
Sent: Thursday, June 14, 2007 2:33 PM
To: Trauma & Critical Care mailing list
Subject: Re: Pre-hospital fluid therapy.
Dear Dr Hardcastle,
Thank you for your comments.
It is true that when a certain hypovelemia exists, increases within specific
limits in cardiac frequency and vascular resistance constitute compensatory
mechanisms for blood pressure. We also know that hypotension is often a late
sign and that patients are always hemodynamically stable until they become
unstable.
For years our lecturers have warned about the existence of compensated
shock, occult hypoperfusion and sudden decompensation. It is curious that
two large retrospective studies found that approximately 1/3 of patients
presented relative bradycardia and had better survival. This raises various
questions.
I think that no particular age avoids:
1.. Increased intravascular pressure produces increased uncontrolled
bleeding and clot disruption.
2.. The dose-dependent damaging effects of isotonic fluid administration.
What level of evidence is there in favor of normalizing blood pressure in
children aged 6-8 years who present uncontrolled hemorrhage? What level of
evidence is there to indicate the use of 20 ml/kg isotonic boluses?
According to my review of the literature, the evidence is scarce.
It would be a pleasure to hear your opinions on this.
Thank you,
J Suárez Peláez.
----- Original Message -----
From: <tch at sun.ac.za>
To: "Trauma & Critical Care mailing list" <trauma-list at trauma.org>
Sent: Wednesday, June 13, 2007 4:58 PM
Subject: RE: Pre-hospital fluid therapy.
Jose
I do have a concern about this concept in the younger child - under age 6-8,
as their physiology IS different. The compensate by progressive tachycardia
and maintain SBP till just too late - then drop off over the waterfall and
DIE on you!
For adolescents or adults I agree completely
Tim
Dr T C Hardcastle
M.B.,Ch.B.(Stell); M.Med(Chir); FCS(SA)
Senior Surgeon / Senior Lecturer: Surgery (Trauma and ICU)
ATLS instructor and DSTC Cape Town Course Director
Intern program Coordinator: Surgery
M.Med (Emergency Medicine) Executive Committee member
Clinical Head (Director): Diana Princess of Wales Trauma Unit
Division of Surgery (General) Room 4064
Department of Surgical Sciences
Tygerberg Hospital / University of Stellenbosch
PO Box 19063
Tygerberg 7505
Western Cape
South Africa
e-mail: tch at sun.ac.za
Cell: +27824681615
Office: +27219389281 or 4911 pager 0302
-----Original Message-----
From: trauma-list-bounces at trauma.org
[mailto:trauma-list-bounces at trauma.org]On Behalf Of JOSE SUAREZ PELAEZ
Sent: Wednesday, June 13, 2007 5:25 PM
To: Trauma & Critical Care mailing list
Subject: Re: Pre-hospital fluid therapy.
Dear Dr. Mattox,
Thank you for your comments. The objective of my email was to hear different
opinions from colleagues on certain issues.
I believe that while SBP continues to be used as the main therapeutic
objective in bleeding patients, while the means/devices to measure SBP are
maintained and not replaced/complemented by other more sensitive measures
(SLCO2, NIRS, etc) to detect acceptable perfusion indicating
non-administration of fluids (to avoid greater hemorhage, re-bleeding and/or
a systemic inflammatory response due to unnecessary fluid administration),
SBP will continue to constitute the golden objective in pre-hospital
treatment and set back the day when bleeding patients are not given
excessive quantities of fluid that may result in devastating consequences,
whether immediate or not.
You and other experts have warned about the limitations of SBP as
therapeutic objective and have proposed the use of permissive hypotension.
However, quantities of isotonic fluids >750 ml may continue to be
administered. I think the didactic use of the concept permissive hypovolemia
(and not hypotension) might help to reduce excessive administration of
fluids: attempting to provide each patient with only what he/she needs,
specially in children.
There are sufficient arguments against the need to normalise BP in bleeding
patients. I think the scientific community is tending towards this
viewpoint. But how to ensure the administration of the necessary fluid to
achieve a balance between damage and benefit? As the Dutton study has shown,
this is complicated.
Perhaps, as you propose, 50 ml boluses using radial pulse and state of
consciousness as endpoints, regardless of BP, could prevent situation like
following: my nurse Toñi usually has BP of 70, in the event of an accident,
she could be hypotensive, tachycardic, anxious, etc, so, she would probably
receive excessive fluid possibly causing increased bleeding, re-bleeding,
iatrogenic respiratory distress, or even multi-organ failure and death,
after hemorhage control and a "normal" BP.
Therefore I believe we should start to use the term Permissive Hypovolemia,
not merely for semantic reasons but because of its conceptual and didactic
usefulness.
I would be grateful for any comments you may have (pro or cons)
José Suarez-Peláez
----- Original Message-----
From: <KMATTOX at aol.com>
To: <trauma-list at trauma.org>
Sent: Tuesday, June 05, 2007 12:09 PM
Subject: Re: Pre-hospital fluid therapy.
In a message dated 6/5/2007 5:27:34 A.M. Central Daylight Time,
josuarez at teleline.es writes:
José Suarez-Peláez
Dr. Jose Suarez-Pelaez has asked this group to respond to an article and a
letter to the editor in the journal, "Injury." The letter contains some
germane observations and questions. Particularly, the question of the
value
of systemic blood pressure as a measure of adequacy of resuscitation,
perfusion, etc. is right on. However, for the majority of the world,
this readily
available device is what is available, and Near Infrared Spectroscopy has
not
yet been standardized.
I would agree that in the referenced study, the inclusion criteria are two
broad and using a BP of 90/- systolic, or better 70/- as an entry criteria
for
such studies would be more appropriate.
K Mattox
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