Permissive Hypotension Resuscitation In Patients With Severe Trauma

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Oct 11, 2022

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Patients with unmanageable hemorrhagic shock are typically treated with damage control resuscitation (DCR) and damage control surgery (DCS). Permissive Hypotension is an element of DCR.

In a patient with hemorrhagic blood loss, permissive hypotension is the maintenance of blood pressure lower than physiological levels.

During early fluid resuscitation, this method is utilized to maintain appropriate vasoconstriction and organ perfusion and to prevent undesirable coagulopathy.

This activity describes the examination and management of permissive hypotension and emphasizes its role in enhancing clinical outcomes in critically ill patients. This article provides further information about this Resuscitation exercise.

Understanding Permissive Hypotension Resuscitation

COPYRIGHT_SPINE: Published on https://spinal-injury.net/permissive-hypotension/ by Dr. Bill Butcher on 2022-10-13T12:44:14.898Z

A person lying on the stretcher carried to the ambulance

In the first twenty-four hours after injury, hemorrhagic shock is the leading cause of death among trauma patients. Optimal fluid resuscitation procedures have been studied for nearly a century, with some controlled trials being conducted more recently.

Hypotensive resuscitation, also known as permissive hypotension, is a resuscitation method that employs restricted fluids and blood products in the initial phases of treatment for hemorrhagic shock.

Permissive hypotension for uncontrolled hemorrhage is the first main component of damage control resuscitation that aims to prevent excessive fluid delivery in actively exsanguinating trauma patients.

Prevention of clot disruption, hemodilution, hypothermia, and metabolic acidosis are potential benefits. However, it is essential to understand that permissive hypotension is neither a treatment nor a replacement for hemostasis regulation.

Maintain a blood pressure lower than usual until operational control of the bleeding can be achieved. In prehospital and hospital settings, forceful fluid resuscitation is associated with more problems than hypotensive resuscitation, as revealed by randomized controlled trials studying restricted fluid resuscitation.

There is still a need for a large, multicenter trial that can examine the benefit of hypotensive resuscitation in blunt and penetrating trauma patients, given that the populations studied in each randomized controlled trial are slightly different, as are the timing of intervention and targeted vitals.

The Discovery Of Permissive Hypotension

A person in the stretcher assisted by medical team

Permissive hypotension in actively hemorrhaging trauma patients is not a novel concept. The concept extends back to the early 20th century, when a group of Medical Corps captains reported their management of wounded during World War I.

Despite multiple animal studies conducted in the 1950s and 1960s, these recommendations were mostly ignored over the majority of the 20th century. Theoretically, permissive hypotension maintains a delicate equilibrium between organ perfusion and rebleeding risk.

Permissive hypotension is neither a treatment nor a substitute for surgery or definitive hemorrhage control, and it currently only applies to trauma patients actively exsanguinating in the prehospital or emergency department setting while awaiting resuscitation with blood products and emergency damage control surgery.

According to the permissive hypotension approach, strong measures to restore normal physiology should only be done after the bleeding has been managed.

The Benefits Of Permissive Hypotension

In previous decades, it was widely known that patients with active hemorrhage and hypotension due to trauma should receive substantial fluid infusions to replenish lost volume. However, this perspective is shifting. Before implementing permissive hypotension in trauma patients, its viability and safety must be demonstrated.

However, the number of deaths owing to coagulopathy bleeding in the first 24 hours after injury was much lower in the hypotensive group, and there were no deaths due to bleeding after surgical correction of the hemorrhage.

This indicates that early permissive hypotension is a significant contributor to the early death of trauma victims. As this was an interim study of a clinical trial including only 90 participants, the relevance of these results may shift.

In addition, significantly fewer blood products were utilized in the hypotensive group, with no deleterious impact on mortality or morbidity. Again, this demonstrates the opportunity to reduce expenditures and allocate resources to other patients.

Conclusion

For individuals with hemorrhagic damage, permissive hypotension may offer a survival benefit over traditional resuscitation. It may also decrease blood loss and blood product consumption. The majority of studies, however, were underpowered, highlighting the necessity for high-quality, adequately powered trials.

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