Permissive Hypotension in Bleeding Trauma Patients: Helpful or Not and When?

Abstract

T rauma remains the leading cause of mortality among persons 1 to 44 years old in the United States 1 and accounts for almost 9% of total mortality worldwide. 2 In 2008 a total of 663000 injury-related deaths occurred in Europe (6.9% of total deaths). 2 Uncontrolled bleeding and exsanguination are the leading cause of preventable death after trauma 3 and require early detection of potential bleeding sources and prompt action to minimize blood loss, restore tissue perfusion, and achieve a stable hemodynamic status. Permissive Hypotension in CNE Continuing Nursing EducationCover Severity of hemorrhage and rate of bleeding are fundamental factors in the outcomes of trauma. Intravenous administration of fluid is the basic treatment to maintain blood pressure until bleeding is controlled. The main guideline, used almost worldwide, Advanced Trauma Life Support, established by the American College of Surgeons in 1976, calls for aggressive administration of intravenous fluids, primarily crystalloid solutions. Several other guidelines, such as Prehospital Trauma Life Support, Trauma Evaluation and Management, and Advanced Trauma Operative Management, are applied according to a patient's current condition. However, the ideal strategy remains unclear. With permissive hypotension, also known as hypotensive resuscitation, fluid administration is less aggressive. The available models of permissive hypotension are based on hypotheses in hypovolemic physiology and restricted clinical trials in animals. Before these models can be used in patients, randomized, controlled clinical trials are necessary. (Critical Care Nurse. 2013;33[6]:18-25)

Independent early predictors of mortality in polytrauma patients: a prospective, observational, longitudinal study

“…In the present study, each 1000 mL of crystalloid infused was associated with an increase of 1.6% in the probability of mortality. This finding contradicts recent findings regarding fluids and trauma resuscitation 16 and reaffirms classic findings suggesting that a lower volume of fluid reposition is associated with a decrease in the rate of mortality in this population 11 , 15 , 45 - 47 . Whereas other studies have aimed to show that the administration of fluids, regardless of type, may be a surrogate indicator for sickness and mortality 48 , our analysis suggested a clear relationship between crystalloid volume infused and mortality, as the GEE model was adjusted for both ISS and TBI presence.…”

“…CRYSTAL appeared to be a silent mortality indicator during resuscitation following severe trauma. The infusion of a large amount of crystalloids during the first 24 hours is common and, because of the hemodynamic instability of trauma victims, caution is required regarding the volume of fluids infused 15 , 45 to avoid a large accumulated water volume, which is a known indicator of morbidity and mortality 46 , 47 . In the present study, each 1000 mL of crystalloid infused was associated with an increase of 1.6% in the probability of mortality.…”

Ambulance Nurses’ Competence and Perception of Competence in Prehospital Trauma Care

“…In addition, it took a long time to stop the bleeding from the bilateral open fractures in the legs, based on the severity of the situation. Early detection of bleeding is a prerequisite for rapid action, so that blood loss is minimized, and the patient's vital signs are stabilized [ 22 ].…”