Journal Club : Permissive hypotension in trauma - does the evidence support the hype?

Todd Fraser on 08-05-2011

Did I just give away my position on this arguement? This month we see the release of an interim analysis by a group from Texas, USA, led by the indefatiguable Ken Mattox. In this study, 90 patients have so far been randomised to either a low (maintain MAP >50mmHg) or high (MAP >65mmHg) pressure resuscitation during operative treatment for trauma. Short term mortality was significantly lower in the 'hypotensive' group, but 30 day mortality was unchanged. Transfusion and coagulopathy-related death was significantly lower. The authors suggest that this strategy is therefore "safe" for use in "trauma patients". This might be stretching things a little. Importantly, there was no significant difference systolic or diastolic blood pressure, nor heart rate, between the two groups, despite the intentions of the protocol. It also remains unclear why despite a higher rate of survival to 24 hours, patients eventually died at similar rates. Finally, it should be noted that the proportion of blunt trauma in the study was less than 7%. Despite lively debate in public fora, little evidence base exists for this strategy.

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Jo Butler wrote 06-12-2011 06:59:49 pm
I agree Todd. I hear this argument a lot - don't pop the clot.

As far as I know this is largely based around American trauma practice, and the evidence base is mostly penetrating trauma in young males within a short distance of a major trauma centre. This doesn't seem to apply to a great majority of traumas in my practice...

While I understand the theory, I'm reluctant to embrace it until theres a slightly stronger evidence base

Alex McKenzie wrote 06-13-2011 09:50:36 am
This is a link to a terrific vodcast I found - http://bit.ly/kgtFfp by Rick Dutton, a US trauma anaesthetist

Alex McKenzie wrote 06-13-2011 09:59:56 am
Yeah, I think its a long stretch to apply these studies to long-range retrieval type work, but I think the principle is avoiding over resuscitation. I've done a bit of prehospital work as a registrar and we're taught to resus until the patient has a radial pulse and no more. I guess its horses for courses though and in some groups might need to aim higher (your example of brain trauma is a good one).

We didn't stock blood on the service I was on and had to go get some from the local hospital. The new paradigm that Dr Dutton talks about with 1:1:1 resuscitation is a problem - we simply don't have access to that.

Is anyone using Tranexamic Acid pre-hospital?

Oliver Arkell wrote 06-21-2011 10:13:38 am
Isn't the point that you use the least amount of resuscitation possible? If they have a radial pulse you're doing well. If they can talk / follow commands their brain is taken care of.

Over resuscitation just leads to so many problems down the track - delayed surgical intervention, ARDS, abdominal compartment syndrome. We seem to spend weeks getting rid of it all again...