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Shock Management
Published in Ian Greaves, Keith Porter, Jeff Garner, Trauma Care Manual, 2021
Ian Greaves, Keith Porter, Jeff Garner
The aim of permissive hypotension is to keep the blood pressure low enough to avoid exacerbating haemorrhage by hydrostatic clot disruption whilst maintaining adequate end organ perfusion.24 This strategy is appropriate for the trauma patient with uncontrolled haemorrhage. In practical terms this means targeting systolic blood pressures of around 80 mmHg (this roughly equates to a palpable radial pulse) until definitive haemostasis is achieved (either via surgery or interventional radiology). If the radial pulse is lost or absent boluses of 250 mL of blood products (see following section) should be given until it returns. However, retrospective studies looking at national trauma registries25, 26 indicate that a systolic blood pressure (SBP) on admission of <110 mmHg is associated with worsening outcomes. Thus, an SBP of 110 mmHg may indicate a ‘lower limit of normal’ and perhaps the upper limit of a pressure range target for resuscitation, this is certainly pertinent to the elderly trauma patient. The recent Trauma Haemostasis and Oxygenation Research Network position paper on the role of hypotensive resuscitation as part of remote damage control resuscitation states a target SBP of 100 mmHg should be used and the pressure should never fall below 90 mmHg. An upper limit for active resuscitation should be 110 mmHg.27
Damage Control
Published in Kenneth D Boffard, Manual of Definitive Surgical Trauma Care: Incorporating Definitive Anaesthetic Trauma Care, 2019
Permissive hypotension is a strategy to reduce blood loss by limiting systolic pressure to the minimum necessary to maintain perfusion of vital organs. In massively bleeding patients, raising blood pressure to normal levels before achieving surgical haemostasis has been shown to enhance bleeding by displacing clots formed during the body's attempt at primary haemostasis (‘popping the clot’). The strategy is not new, and was reported during the World War I, when it was stated that ‘if the pressure is raised before the surgeon is ready to check any bleeding that may take place, blood that is sorely needed may be lost’. Although safe limits of blood pressure in terms of preservation of organ perfusion are unknown, a systolic blood pressure of 80 mm Hg, and in case of concomitant severe brain trauma, a mean arterial pressure (MAP) of over 80 mm Hg are recommended. While there is no hard evidence for these limits, it is very clear that such low pressures should be maintained for the shortest possible time in order to limit vital organ ischaemia. The importance of early surgical haemostasis and the need for the DCR concept being applied must be emphasized.
Shock and blood transfusion
Published in Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie, Bailey & Love's Short Practice of Surgery, 2018
Professor Sir Norman Williams, Professor P. Ronan O’Connell, Professor Andrew W. McCaskie
These concepts have been combined into a new paradigm for the management of trauma patients with active haemorrhage called damage control resuscitation (DCR). The four central strategies of DCR are:Anticipate and treat acute traumatic coagulopathy.Permissive hypotension until haemorrhage control.Limit crystalloid and colloid infusion to avoid dilutional coagulopathy.Damage control surgery to control haemorrhage and preserve physiology.
Complications associated with the current sequential pharmacological management of early postnatal hypotension in extremely premature infants
Published in Baylor University Medical Center Proceedings, 2019
Rita P. Verma, Shaeequa Dasnadi, Yuan Zhao, Hegang H. Chen
A lack of equipoise among physicians and parents limits the feasibility of prospective controlled trials in EPH of ELBW neonates. Currently, neonatologists do not have a scientific evidence-backed pathophysiological definition of hypotension in preterm infants for initiating medicinal therapy. For these reasons, there is skepticism about the validity of studies on EPH and their clinical applicability, and physicians find the suggestion of “permissive hypotension” and restricted use of medications in EPH hard to implement in clinical practice. The significant adverse effects of the current pharmacological management of EPH in ELBW infants, as identified in our study, underscore the need for additional information on this critical morbidity. Investigating the pathophysiological effects of maternal diabetes mellitus and hypertension on fetal blood pressure might provide information that could help in understanding the pathogenesis and management of EPH in extremely premature neonates in the future.
Current strategies for hemostatic control in acute trauma hemorrhage and trauma-induced coagulopathy
Published in Expert Review of Hematology, 2018
Michael Caspers, Marc Maegele, Matthias Fröhlich
The current standard of care for major trauma hemorrhage is based upon the principles of DCR, and these principles have been adopted by major international guidelines (17). Achieving early hemorrhage control represents a multifaceted team approach to the initial assessment, timely use of temporary hemostatic measures and DCS/O surgery approaches all tailored to the clinical presentation and status of the patient. The German S3-DGU guideline (S3-DGU) together with the European trauma guideline (ETG) refer for adults with active bleeding to allow for “permissive hypotension” with target mean arterial pressure (MAP) of 65 mm Hg or a target systolic pressure of 80–90 mm Hg until bleeding control can be achieved (16,17). Exceptions are patients with suspected injuries to the central nervous system or underlying cardiovascular diseases (S3-DGU: Recommendation (R) 2.101, Grade of Recommendation (GoR [32],) B, R2.102, GoR 0; ETG: R13, Grade [33] 1C and R14, Grade 1B [20,21]). “Permissive hypotension” reduces hemorrhage from injured sites and promotes resuscitation strategies, which avoid blood dilution. The fluid of choice for initial volume replacement – a matter of heavy debate over the last decades and still ongoing – is currently considered isotonic crystalloid solution while NaCL0,9% as well as Ringer´s lactate and colloids should be avoided due to their adverse effects on hemostasis (ETG R16, Grade 1A [21,34–38]). There has been a substantial decline in the formerly excessive use of both pre- and early in-hospital intravenous fluid over the past as numerous studies identified liberal and uncritical fluid use as an independent risk factor for coagulopathy on admission along with impaired outcomes [39–41].
Predicting the need for massive transfusion in the prehospital setting
Published in Expert Review of Hematology, 2020
Thaddeus J Puzio, Kyle Kalkwarf, Bryan A Cotton
The practice of blood-based resuscitation gained momentum as it was incorporated into caring for severely injured patients with ‘Damage Control Resuscitation’ (DCR). This strategy allows patients to experience permissive hypotension until surgical bleeding is halted, abbreviates operative interventions to focus on hemorrhage and contamination control, and allows for definitive surgical intervention in a delayed fashion after warming and resuscitation. These patients are most often resuscitated with minimal crystalloid and blood components including: plasma, packed red blood cells, and platelets to approximate the constituents of whole blood. [7–17]