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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!