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Fri Feb 3 10:17:36 GMT 2006

I agree with many of those who have posted regarding the need for rapid 
evacuation for surgical control of heamorrhage, and of the perils of 
fluid (+/- vasopressor) therapy to raise the MAP.

However, I think it is worth exploring the assumption that all shock in 
this setting is hypovolaemic. I'm sure that many people will be familiar 
with the article by Mahoney et al (1) that found that traumatic brain 
injury may be associted with isolated hypotension i.e. with no later 
evidence found of haemorrhage.

I do not presume to understand the operational setting in which 
paramedics work in Australia. But, if we factor in a long transfer time, 
a mechanism of injury consistent with isolated head injury, and a survey 
that is negative for other injuries (hard to be certain I fully 
appreciate), might it not be reasonable, to treat the hypotension?

On a seperate note: in the north-west UK, I have seen almost exlusively  
noradrenaline used on neuro-ICU for the management of MAP, both in 
traumatic and non-traumatic neuro patients (other conditions aside).
Per-operatively either noradrenaline or pure pressors such as 
meteraminol are used. Most of these patients at this stage have quite 
marked vasodilation, and dobutamine (an ino-dilator) would not be my choice.

1) Isolated brain injury as a cause of hypotension in the blunt trauma 
patient. Mahoney EJ, Biffl WL, Harrington DT, Cioffi WG. J Trauma. 2003 
Dec;55(6):1065-9.

regards

Tom Hurst
Anaesthesia SpR, UK

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