Lessons in Transport - Hypotensive Resuscitation

Lessons in Transport - Hypotensive Resuscitation

Permissive Hypotensionis also known as hypotensive resuscitation or low volume resuscitation

What is it?

A resuscitation strategy in the critically ill trauma patient (primarily applicable to penetrating trauma but also adapted to blunt trauma) where we allow the systolic BP to remain as low as necessary to avoid exsanguination while still maintaining critical end organ perfusion. (typically defined as appropriate mental status & or the presence of a radial pulse)

The Thought Process:"Don't pop the clot"...

By allowing lower blood pressures we avoid the potential disruption of an unstable fresh clot and thus worsening bleeding caused by higher BP's. 

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Lessons in Transport - The Lethal Triad

Lessons in Transport - The Lethal Triad

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - TXA has Arrived!!

Lessons in Transport - TXA has Arrived!!

To successfully resuscitate the critically ill trauma patient we must have an understanding of and a respect for the LETHAL TRIAD of TRAUMA...

Bleeding causes acidosis, coagulopathy, and hypothermia... 

Acidosis and hypothermia causes more coagulopathy which causes more bleeding... and so begins a deadly cycle

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Lessons in Transport - Therapeutic Hypothermia Part 3

Lessons in Transport - Therapeutic Hypothermia Part 3

Common Issues in Therapeutic Hypothermia

1) Bradycardia: may occur during induced hypothermia (even to as low as 35 bpm) and except in rare cases, is NOT a reason to discontinue hypothermia.

  • If bradycardia is severe, associated with persistent hypotension, and is not responsive to fluid and vasopressor therapy, a decision in conjunction with medical control to discontinue hypothermia may be made.

2) Dysrhythmias: generally does not occur unless temperatures fall < 30*C and hypothermia related ventricular fibrillation is rare unless temperature is < 28*C.

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Lessons in Transport - To Cool or Not to Cool?

Lessons in Transport - To Cool or Not to Cool?

To COOL or NOT To COOL that is the question...

(Read each of the following scenarios & honestly ask yourself if this is a patient suitable for therapeutic hypothermia)

Scenario 1: 67 yo male scene STEMI, witnessed Vfib arrest with ROSC, GCS 3T, stable vitals

Scenario 2: 24 yo female MVC, ejected, hypotensive for EMS, 10 minute cardiac arrest with ROSC, GCS 3T

Scenario 3: 2 yo female cardiac arrest suspected choking, ROSC after removing food from her airway. GCS 4T (1T2)

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Lessons in Transport - Post-Intubation Checklists

Lessons in Transport - Post-Intubation Checklists

Post-Intubation Checklists

Making a checklist can help cognitively unload you in high stakes and high pressure situations.  Post-intubation consider the following important points:

Protecting the Tube

  • Continuous wave form ETCO2... each and every time

  • Secure Endotracheal Tube at the appropriate depth (See LIT week 6)

  • Analgesia and Sedation

  • Restraints... Do you know where the soft restraints are stored?

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