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Mon Aug 30 23:00:31 BST 2010

What kind of rural prehospital intervals are you discussing. Military is 2-3 hours

Norman

Professor, Tulane University, Surgery
Trauma Director, Spirit of Charity Trauma Center, ILH/MCLNO
New Orleans, Louisiana
504 988 5111

-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org] On Behalf Of Stephen Richey
Sent: Monday, August 30, 2010 1:57 PM
To: Trauma-List [TRAUMA.ORG]
Subject: Re: Fluid resuscitation - rhabdomyolysis

Has anyone actually looked at permissive hypotension in the setting of
rural trauma?  All of the studies I have seen have been either in
urban areas or during military operations, both of which tend to lend
themselves to short prehospital intervals.

On Mon, Aug 30, 2010 at 10:16 AM, Miranda Voss <mvossak at yahoo.co.uk> wrote:
> Thanks all for responses.
>
> I am completely convinced by permissive hypotension in the urban/periurban setting but I have a feeling that the "country" patients are, to a certain extent, self selecting.  The patients with major injuries that would benefit from permissive hypotension as a prelude to surgical haemostasis probably don't make it to a surgeon. As time goes on, the protective effect of hypotension becomes less important than the consequences of prolonged renal hypoperfusion. The problem is that I don't know where the two lines of the graph cross and am uncertain what advice to give GPs who work at district hospital level and transfer patients to us. The traveling distances in our region are not huge (up to 200km), but a shortage of ambulances means that there is inevitably a delay of a few hours before the patient gets to us.
>
> The dilemma is particularly acute in a crush syndrome/rhabdomyolysis where we like to give 1l balanced salt solution q2h to establish a diuresis within the first 6 hours. These needs are quite contrary to those of the potentially bleeding liver or spleen.
>
> I guess a more gently forced diuresis with close observation is a possible option, but not really suitable for a patient who is spending some time in an ambulance: first of all to get to us, and then being sent on to a neurosurgeon. And perhaps you end up with a bleeding, oliguric patient anyway!
>
> My instinct is that permissive hypotension is probably not the right thing for rural transfers unless the patient will be seeing a surgeon in under two hours or so. Do the Australians have any guidelines?
>
> Miranda
> Worcester RSA.
>
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-- 
Stephen Richey

"A man's moral worth is established only at the point where he is
ready to give up his life in defense of his convictions."- Henning von
Tresckow
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Fluid resuscitation - rhabdomyolysis