Permissive Hypotension

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    Permissive Hypotension

    Resist the urge to administer a large crystalloid bolus in hypotensive trauma patients. Doing so worsens coagulopathy and acidosis. This practice should be abandoned. Normotensive trauma patients need no fluid resuscitation. The practice of permissive hypotension in trauma improves has been demonstrated to improve morbidity and mortality (selected references below).

    Hypotensive trauma patients require surgical control of hemorrhage, naturally. Blood products can be administered until this is achieved. There is no general consensus on target systolic blood pressure. However, in a recent NEJM review, David R. King recommends a target of 80mmHg. That is, the infusion of blood products should stop once the systolic blood pressure reaches 80mmHg. At this point, the patient needs surgical control of hemorrhage. You do not need to continue resuscitation with blood products to achieve normal.

    Permissive hypotension becomes a big more ambiguous in the head-injured patient where even a single episode of hypotension can worsen outcomes in mortality and morbidity. Nevertheless, in the typical blunt trauma patient presenting with hypotension without evidence of head injury, permissive hypotension is a 100 year old strategy that you can count on.

    References

    Cannon WB, Fraser J, Cowell EB. The preventive treatment of wound shock. JAMA. 1918;70(9):618–621

    Chesnut RM, Marshall LF, Klauber MR, Blunt BA, Baldwin N, Eisenberg HM, Jane JA, Marmarou A, Foulkes MA
    J Trauma. 1993 Feb; 34(2):216-22

    Chang R, Holcomb JB. Optimal Fluid Therapy for Traumatic Hemorrhagic Shock. Crit Care Clin. 2017;33(1):15-36.

    King DR. Initial Care of the Severely Injured Patient. N Engl J Med. 2019;380(8):763-770.

    Bickell WH, Wall MJ, Pepe PE, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med. 1994;331(17):1105-9.

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