1. Permissive Hypotension By Joseph Lewis, M.D. Medical Director, Honolulu Emergency Services Division May, 2012

2. What is permissive Hypotension? It is when you allow or permit the patients blood pressure to be low.

3. Permissive Hypotension Why did the American College of Surgeons change their recommendation about fluid resuscitation to permissive hypotension in both blunt and penetrating trauma patients Because when we give more fluid then the patients need to reach a BP of 90 systolic, the patients “do worse”. That means more die and they have more bleeding complications.

4. The trauma literature shows that when you are bleeding from a non- compressible hemorrhage, a soft clot forms when your blood pressure is low and the bleeding slows down. Then your low blood pressure allows the soft clot to stay put. This soft clot slows down or stops the bleeding or hemorrhage.

5. But if you give more fluid then is needed to raise the blood pressure above 90 systolic, you do two things: 1. You increase the pressure on the clots which have formed on the damaged blood vessels to slow or stop the bleeding, so they pop off the leaks and the patient bleeds more. 2. You dilute the patients clotting factors so they can't make clots as well and they can’t stop their bleeding anymore.

6. So if you raise the blood pressure over 90 you do two things to the patient: 1. You pop clots, the patient bleeds more. 2. You dilute or thin out their clotting factors and they clot less and bleed more.

7. Does this mean we were killing them with liter boluses before? 1. No, we were doing what we thought was best at the time raising their BP over 90. 2. But now we know that if a little is good, more is not always better. 3. The good thing about being human is that we can learn from our mistakes. We can improve and do better the next time. 4. Life is a learning experience & we are learning.

8. How do I know how much fluid is to much? If the patients BP is less then 90 systolic give IV fluids in 200 ml boluses until the BP reaches 90, then TKO the line. Anything more then this is too much! Except in head injury patients, they need a BP of 100 systolic.

9. Some of the evidence…. Dr Ken Mattox Ben Taub Hospital Houston, Texas A study of over 1400 patients randomized to fluid resuscitation and no fluid resuscitation. The patients who received fluids had higher short term mortality rates (more of them died) more bleeding complications (can’t make clots)

10. Dr Spregiendach Germany Unified Trauma System 8200 patients Fluids resuscitation versus no fluid resuscitation. The patients who received no fluid resuscitation had a lower mortality rate (less of them died) lower bleeding complications (they could clot their blood) and shorter hospital stays.

11. Dr Cesar Ursic Honolulu, Hawaii Presentation at HEMSIS 2012, data from the State Trauma Registry and Queens Hospital Trauma statistics Patients who receive aggressive fluids resuscitation and arrive with higher blood pressures, bleed more and do worse. “I hate when they say ‘do worse”, that means more die and more bleeding complications.

12. Many other studies exist. The American College of Surgeons “ACS” Green Book produced by the Committee on Trauma contains the studies and the discussion. The take home message is that in blunt and penetrating trauma, patients who are hypotensive, need slow rate IV drips to maintain a BP of 90, otherwise they do worse, more will die and more will have bleeding complications (can’t clot their blood)!

13. Trauma patients with blunt or penetrating trauma who are in shock, are bleeding to death. They are not dying from a normal saline deficiency. They have a big leak which needs to be stopped in the operating room. Don’t pop their clots while raising their BP above 90. Stop diluting their clotting factors with one liter boluses. (which takes away their ability to clot their blood) Don’t delay their care for an IV start at the scene because they need Surgical Care not IV Care.

14. Our new goal is BP of 90 for blunt and penetrating trauma patients and 100 for head injury patients. Remember this about BP above 90: The trauma literature says it doesn’t work. Our Hawaii Trauma data says it doesn’t work. So lets learn from the evidence and change our ways to what works. Because we want what’s best for our patients. Use fluid boluses up to 90 systolic and help our patients do better not worse. * Remember it’s 100 for head injury patients.

15. Last Thoughts… Why 90? It seems to be the right pressure to send blood to your brain and your vital organs to keep them functioning while your laying down. Older people may need higher pressures, but that’s another In-service. If there’s head trauma and some swelling or edema of the brain it takes a little more pressure to send enough blood to the brain (100).

16. Reminder Our SO If the patients BP is less then 90 systolic give IV fluids in 200 ml blouses until the BP reaches 90, then TKO the line. Don't delay transport for an IV start. Remember that the most important thing a trauma patient needs is to get their bleeding stopped. If it is chest or abdominal bleeding we can't fix it and giving IV fluids only makes it worse.

17. Coming to an EMS Agency near you….. “Tourniquet Use”.. Starring… CAT Tourniquet ! Opening near you June 2012