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Life Flight Newsletter

Permissive Hypotension in the Trauma Patient

Submitted by Kyle Scarbrough, E.M.T.-P., Flight Paramedic and Rudy Cabrera, R.N., E.M.T.-P., Flight Nurse

On October 27, 2012, at 0150, a 32-year-old male was run over by a vehicle. Police officers on scene witnessed the accident and activated EMS promptly. EMS arrived at 0201, performed an initial assessment and then proceeded with spinal precautions by back-boarding the patient. EMS immediately recognized that the patient had suffered substantial trauma and would require treatment at a Level I trauma center.

Life Flight Trauma TransportEMS opted for air medical transport as they were 45 minutes from the Level I hospital by ground. The patient was then secured on the stretcher and loaded in the ambulance where secondary assessment was performed, clothing was removed, high-flow oxygen was applied, vital signs acquired and IV access initiated.

The EMS physical exam revealed intact patient airway, clear and equal lung sounds, intact chest wall, abrasions to the abdomen and left flank, as well as multiple abrasions to the right and left legs. The left ankle was found to be deformed and externally rotated. Vital signs showed the patient to be hypotensive and tachycardic, prompting paramedics to initiate a fluid bolus. The crew administered 200 mL of normal saline and stopped the bolus to maintain a systolic blood pressure of 90 mmHg.

The air medical flight crew arrived at the patient’s side at 0222, 32 minutes after the initial insult. At 0224, the patient was tachycardic at 136 BP 80/p, a respiratory rate of 18, oxygen saturation of 98 percent on a non-rebreather at 15 LPM.

The flight crew received the report from the paramedics on scene and performed their initial assessment to find the same. The patient was transferred to the flight stretcher and loaded into the aircraft. The helicopter departed for the trauma center at 0227, five minutes after arriving. In flight, the crew members performed an ultrasound extended focused assessment with sonography for trauma (eFAST) exam, while the nurse initiated a second IV. The paramedic identified free fluid in the RUQ (Morrison’s pouch).

With the positive eFAST exam and the persistent tachycardia, the patient met criteria for blood administration (see chart, page 5). The crew then initiated one unit of fresh frozen plasma (FFP) with a pressure infusing bag running through a blood warming system. Through the second IV, one unit of packed red blood cells (PRBCs) was initiated in the same manner. At 0241 the flight crew landed at the trauma center with the patient receiving a total of two units of FFP and two units of PRBCs.

At 0245 the patient was transferred to the Emergency department bed and the report was given to the awaiting trauma team with vitals 90/palpated, heart rate 102 and sats 100 percent. The total time from insult to arrival at the Level I trauma center was 55 minutes.

The Emergency department staff performed a primary assessment to find the patient to be hemodynamically stable and confirmed the paramedics’ positive eFAST exam. X-rays at the bedside revealed multiple rib fractures, a left hip dislocation and fracture to the ankle. Both hip and ankle were reduced at the bedside and treated accordingly. A CT exam showed rightsided rib fractures with adjacent pulmonary contusion, pneumothorax and hemothorax with associated sub Q emphysema, grade 2 liver laceration, and intraperitoneal air was found with suspicion of diaphragm injury. The patient was then transported to the operating room where an exploratory laparotomy was performed. In surgery, a right 5-cm hemidiaphragm laceration was repaired and closed and a right chest tube was inserted.

The patient was admitted to the ICU, not intubated, for monitoring and recovery, where he was treated with antibiotics, pain management and further evaluation of his injuries. Rehab began three days into his ICU stay and he was transferred to a step-down unit on Nov. 4. The patient was discharged home on Nov. 14 with orders to follow up with the trauma clinic and scheduled rehab services.


Discussion

This case study demonstrates an excellent job done by Dickinson Central Fire Station No. 1, who chose to follow what is quickly becoming a new standard protocol in emergency medicine: maintaining a permissive hypotensive state is considered ideal for this type of trauma in order to avoid damage-control resuscitation.

After checking the airway, emergency medicine protocol directs us to look at a patient’s circulation. In this case, vital signs showed the patient to be hypotensive and tachycardic, and the crew members chose to administer just enough crystalloids – in this case normal saline – to raise the patient’s blood pressure to 90 mmHg systolic, a hypotensive measurement. Although traditional fluid resuscitation strategies recommend raising the blood pressure to a “normal” range in order to address traumatic shock, studies are increasingly showing that this is not always the best practice. In this case, a pressure of 90 mmHg systolic with good mentation was ideal.

The reasoning behind this is that the patient is losing all of blood’s essential components, such as plasma, water, red and white blood cells, electrolytes, clotting factors, glucose, etc. Because normal saline cannot replace all of these components, infusing a large amount of crystalloids will dilute the circulating blood, which alters the effectiveness of the body’s compensatory mechanisms, including clotting factors.

The patient’s systolic blood pressure remained high enough to keep the patient stable until Life Flight arrived on the scene. In-air, the patient met two of four criteria for blood administration with a positive eFAST exam and persistent tachycardia (see point system, below). Each Life Flight helicopter carries 2 units of packed red blood cells and 2 units of liquid plasma, so the crew administered both units of each while transporting the patient to the Level I trauma center for further treatment.

Life Flight’s Protocol for the Administration of Blood Products In-Air

Life Flight patients who need blood products administered in-air rely on the fast action of the program’s flight nurses. When a patient presents with any two of the following, they receive blood products.

 

TRANSFUSION PROTOCOL FOR ADULTS 12 AND OLDER

Transfusion Scoring System:
Two or more points = positive prediction for Massive Trauma

 
Heart Rate > 120 bpm  1 point
Systolic Blood Pressure ≤ 90  1 point
Penetrating Injury  1 point
Positive FAST (intra-abdominal fluid by ultrasonography exam)  1 point

TRANSFUSION PROTOCOL FOR PEDIATRICS 1-11 YEARS

Transfusion Scoring System:
Two or more points = positive prediction for Massive Trauma

 
Heart Rate > 120 bpm  1 point
Hypotension defined as systolic blood pressure
< 70 mmHg + child’s age in yrs x 2
  1 point
Penetrating Injury  1 point
Positive FAST (intra-abdominal fluid by ultrasonography exam)  1 point

If the patient doesn’t meet the criteria but the flight nurse feels the patient needs blood products, the nurse then calls the hotline in the emergency center to ask the attending physician for orders. For transfer patients, the sending or receiving physician can give the orders for the administration of blood products.