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Tue Jun 28 04:59:17 BST 2005

I understand what you are saying - still the question remains is how to deal
with the polytraumatised patient with a low BP and bleeding in the belly and
a head injury.

How do you deal with this type of patient? Permissive hypotension or cyclic
hyperresuscitation? (Is there middle ground?)

Dean

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of John Holmes
Sent: 28 June 2005 03:01 AM
To: trauma-list at trauma.org
Subject: RE: [ccm-l] Out of Date Teachings, Formerly, Trendelenberg
position,REVISE ATLS

.............. It could be that if one gives less fluid initially, the brain

wouldn't swell as
much and hence a BP of less than 90 could easily tolerate the hypotension 
...............

This is dangerous supposition.  The clinical evidence to date is that 
hypotension in the resus phase is a strong prognostic indicator of bad 
outcomes in acute traumatic head injury.  Even if your hypothesis were 
correct, a lot of work needs to be done to demonstrate clinical safety in 
such an approach.  Remember -  there are several mechanisms of cerebral 
oedema, not just crystalloid overload.  As well, raised ICP is not just a 
function of cerebral oedema - an expanding SOL per se may cause raised ICP 
and reduced CPF.

John

Dr John L Holmes
Director Emergency Medicine,  Mater Adult Hospital,  Brisbane,  Australia

<br><br><br>&gt;From: &quot;Dean Lutrin&quot; 
&lt;deanlutrin at gmail.com&gt;<br>&gt;Reply-To: Trauma &amp; Critical Care 
mailing list &lt;trauma-list at trauma.org&gt;<br>&gt;To: &quot;'Trauma &amp; 
Critical Care mailing list'&quot; 
&lt;trauma-list at trauma.org&gt;<br>&gt;Subject: RE: [ccm-l] Out of Date 
Teachings, Formerly, Trendelenberg position,REVISE ATLS<br>&gt;Date: Mon, 27

Jun 2005 15:24:59 +0200 &gt; &gt;Hello &gt; &gt;All the reports 
about keeping the BP above 90 in head injury are with 
the &gt;consideration that a significant amount of fluid has been given 
so there is &gt;even more cerebral oedema so one needs to try harder to 
maintain CPP. It &gt;could be that if one gives less fluid initially, the

brain wouldn't swell as<br>&gt;much and hence a BP of less than 90 could 
easily tolerate the hypotension.<br>&gt;<br>&gt;Something I have thought 
about as well<br>&gt;<br>&gt;Dean Lutrin<br>&gt;JHB, 
SA<br>&gt;<br>&gt;-----Original Message-----<br>&gt;From: 
trauma-list-bounces at trauma.org 
[mailto:trauma-list-bounces at trauma.org]<br>&gt;On Behalf Of Gabriela 
Jimenez<br>&gt;Sent: 27 June 2005 08:16 AM<br>&gt;To: Trauma &amp; Critical 
Care mailing list<br>&gt;Subject: Re: [ccm-l] Out of Date Teachings, 
Formerly, Trendelenberg<br>&gt;position,REVISE ATLS<br>&gt;<br>&gt;Hi 
everyone!<br>&gt;I have some doubts about permissive hipotension in a 
patient with<br>&gt;hemorragic shock and a severe brain injury too, when the

guidelines of &gt;management of severe TBI in children recommends not to 
keep the &gt;patient hipotensive, 'cause the secondary insults increased 
the &gt;morbidity and mortality, and in adults they talk about keeping 
a &gt;systolic blood pressure &gt; 90 mmHg. Or in a patient with a 
hemorragic &gt;shock &amp; traumatic acute spinal cord injury, when the 
guidelines for &gt;the management of acute cervical spine and spinal 
cord injuries &gt;recommends to keep a systolic blood pressure &gt; 90 
mmHg and correct &gt;hipotension as soon as possible. &gt; WHAT THEN?

What should I do? &gt;I read the discussion about permissive hipotension 
that is in &gt;trauma.org but I think no one talked about what to do in 
such &gt;settings. &gt;Please, I'd appreciate any help. 
Thanks! &gt; &gt;Dra Jimenez &gt;Pediatric Surgery Resident at 
Hospital Nacional de Niños, Costa Rica &gt; &gt;2005/6/26, 
flysurg at aol.com &lt;flysurg at aol.com&gt;: &gt; &gt; Ken, &gt; 
&gt; &gt; &gt; I agree wholeheartedly and have asked for each of these to

be discussed at &gt;the next ATLS Sub-Committee meeting. &gt; 
&gt; &gt; &gt; Steve Smith &gt; &gt; &gt; &gt; -----Original 
Message----- &gt; &gt; From: KMATTOX at aol.com &gt; &gt; To: 
ThompsDR at mail.amc.edu; dchalfin at applied-decision.com &gt; &gt; Cc: 
trauma-list at trauma.org; ccm-l at ccm-l.org &gt; &gt; Sent: Sun, 26 Jun 2005 
15:10:47 EDT &gt; &gt; Subject: Re: [ccm-l] Out of Date Teachings, 
Formerly, Trendelenberg &gt;position, REVISE ATLS &gt; &gt; &gt; 
&gt; In a message dated 6/24/2005 12:27:11 P.M. Central Standard 
Time, &gt; &gt; ThompsDR at mail.amc.edu writes: &gt; &gt; &gt; &gt; 
Probably need to update ATLS then. &gt; &gt; Dan &gt; &gt; &gt; 
&gt; I would totally agree that both ATLS and ACLS need to be updated STAT 
in a &gt; &gt; number of areas. Just as a start the areas of 
pericardiocentesis, use &gt;of &gt; &gt; steroids in spinal cord 
injury, and aggressive fluid resuscitation need &gt;to be &gt; &gt; 
revised. &gt; &gt; &gt; &gt; k &gt; &gt; -- &gt; &gt; 
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;trauma-list 
: TRAUMA.ORG<br>&gt;To change your settings or unsubscribe 
visit:<br>&gt;http://www.trauma.org/traumalist.html<br>ll the reports about 
keeping the BP above 90 in head injury are with the
consideration that a significant amount of fluid has been given so there is
even more cerebral oedema so one needs to try harder to maintain CPP. It
could be that if one gives less fluid initially, the brain wouldn't swell as
much and hence a BP of less than 90 could easily tolerate the hypotension.

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[ccm-l] Out of Date Teachings, Formerly, Trendelenberg position, REVISE ATLS