Neurogenic Shock With Internal/External Hemmorhage

[Akulahawk]

Sounds like a beautiful scenario for 1-2cc of 1:100,000 epi IVP. Just enough bump in MAP to get you to definitive care..

Remember, the "container" isn't full because it's leaking... Increasing the pressure inside could very easily pop some newly established clots. In regards to using Epi, I'd think it would be more prudent NOT to stomp on the gas and make the heart beat faster... so perhaps a pure vasoconstrictor might be good to use in a controlled manner to get the bleeding peripheral blood vessels to constrict and further slow blood loss.

If you can manage to fill the container some without a clot blowout, then perhaps pressors might slowly be introduced to further slowly bring the MAP up to where kidney perfusion is occurring.

In this hypothetical case, while there probably will be kidney injury, it's far more important to ensure that the brain is still perfused. Kidneys we can do without. Brain? Not so much.

 

[Carlos Danger]

I'm sorry, but I think the idea of using a vasopressor in a bleeding patient with a good MAP is insane.

 

[Akulahawk]

I'm sorry, but I think the idea of using a vasopressor in a bleeding patient with a good MAP is insane.

Which is why I've been advocating ONLY for their use under very controlled conditions.

 

[FiremanMike]

If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.

 

[Carlos Danger]

If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.

Why?

Are you trying to make this hypothetical patient bleed faster?

 

[Akulahawk]

If there was confusion, the pressor wouldn't be my first choice, but if I've crammed a liter in and we're still well below 65, I'd definitely start moving that direction.

Cram in a liter and at that point you KNOW the patient has a rather significant bleeding problem that likely needs a surgeon and are quickly on the way to turning the patient's remaining blood pink.

 

[FiremanMike]

Why?

Are you trying to make this hypothetical patient bleed faster?

We're taking about 10-20mcg of epi, not 0.3-1mg. Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes. As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.

Cram in a liter and at that point you KNOW the patient has a rather significant bleeding problem that likely needs a surgeon and are quickly on the way to turning the patient's remaining blood pink.

In fairness I believe we've moved beyond this particular patient and are simply talking about fluid resuscitation in general. This dude had a map around 60, and I'd bet a 200-300cc bolus would get me where I'm comfortable. Beyond that, we're on the same page that mass fluid isn't an appropriate route, so our next method to perfuse vital organs in lieu of mass crystalloid replacement would be moving on to pressors. Again, I'm not giving someone a pressor with a map of 60 just to get them to 65, but I'll probably start thinking about it if their map is 40 after some fluid...

 

[Carlos Danger]

We're taking about 10-20mcg of epi, not 0.3-1mg. Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes. As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.




In fairness I believe we've moved beyond this particular patient and are simply talking about fluid resuscitation in general. This dude had a map around 60, and I'd bet a 200-300cc bolus would get me where I'm comfortable. Beyond that, we're on the same page that mass fluid isn't an appropriate route, so our next method to perfuse vital organs in lieu of mass crystalloid replacement would be moving on to pressors. Again, I'm not giving someone a pressor with a map of 60 just to get them to 65, but I'll probably start thinking about it if their map is 40 after some fluid...

Is there clinical evidence supportive of that practice?

 

[Akulahawk]

We're taking about 10-20mcg of epi, not 0.3-1mg. Getting blood to vital organs may potentially deliver more blood to the damaged vessels, but we're trying to buy another 5-10 minutes. As a reminder, pressors aren't my first choice, and in this particular patient it would be unlikely that it'd even come into my radar, but having extra tools in the box is always a positive.




In fairness I believe we've moved beyond this particular patient and are simply talking about fluid resuscitation in general. This dude had a map around 60, and I'd bet a 200-300cc bolus would get me where I'm comfortable. Beyond that, we're on the same page that mass fluid isn't an appropriate route, so our next method to perfuse vital organs in lieu of mass crystalloid replacement would be moving on to pressors. Again, I'm not giving someone a pressor with a map of 60 just to get them to 65, but I'll probably start thinking about it if their map is 40 after some fluid...

Are we speaking about a trauma patient with a MAP of 40 or are we now discussing the non-trauma patient? Because in the non-trauma patient with a MAP of 40, that's not responding to fluid therapy, pressors might very well be useful... however, this thread has been about fluid resus in the trauma patient until this post.

 

[Carlos Danger]

Are we speaking about a trauma patient with a MAP of 40 or are we now discussing the non-trauma patient? Because in the non-trauma patient with a MAP of 40, that's not responding to fluid therapy, pressors might very well be useful... however, this thread has been about fluid resus in the trauma patient until this post.

Exactly what I am wondering. We seem to be all over the MAP (pun intended).

Vasopressors and inotropes are not indicated in uncontrolled bleeding, period. That's why we don't routinely start neo or levo or dopamine drips in traumas.

Now, if you were losing pulses and you were 5 minutes from the trauma bay and you'd given all the IVF and blood that you have, then maybe I could see a little squirt of epi or two, but that's just a last resort done out of desperation; it's not an actual management strategy.

The military learned long ago that aiming for an arbitrary BP in bleeding trauma patients does more harm than good. There is lots of literature on it.

 

[FiremanMike]

Is there clinical evidence supportive of that practice?

There are ongoing studies that show promise in pressor use in hemorrhagic shock.

 

[FiremanMike]

For some reason I can't multiquote on my ipad..

Yes I would consider it in a trauma patient. I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.

Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..

 

[VFlutter]

For some reason I can't multiquote on my ipad..

Yes I would consider it in a trauma patient. I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.

Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..

I would rather have transient tissue hypoperfusion with controlled bleeding than uncontrolled bleeding trying to maintain a MAP ~60. Acute organ dysfunction can be managed but once a hemorrhaging trauma patient loses their ability to clot it is game over.

I have had patients with Aortic cross clamp times over 60 mins with little sequela.

 

[Akulahawk]

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There are ongoing studies that show promise in pressor use in hemorrhagic shock.

Which ones? Here's some snippets I found just with a quick google search...

http://www.uptodate.com/contents/treatment-of-severe-hypovolemia-or-hypovolemic-shock-in-adults
"Vasopressors (eg, norepinephrine) generally should not be administered, since they do not correct the primary problem and tend to further reduce tissue perfusion."

http://www.annalsofintensivecare.com/content/3/1/13
"...no clinical studies have validated any vasopressor support for the management of hemorrhagic shock."

http://www.surgicalcriticalcare.net/Guidelines/Vasopressors%20and%20Inotropes%20in%20Shock.pdf "Vasopressors are not recommended in the initial stabilization of hemorrhagic shock. Permissive hypotension may be employed until bleeding is controlled in patients requiring emergent surgical intervention."

http://www.jwatch.org/em200802220000001/2008/02/22/caution-about-vasopressor-use-hemorrhagic-shock "Use of vasopressors (any of the 4 studied) within 12 hours after injury, compared with no use of vasopressors, was associated with an increased mortality risk (hazard ratio, 1.81), as was use of vasopressors within 24 hours after injury (HR, 2.15). Aggressive early crystalloid resuscitation within 12 hours, compared with no use of crystalloid resuscitation, was associated with a reduction in mortality (HR, 0.59)."

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[Akulahawk]

For some reason I can't multiquote on my ipad..

Yes I would consider it in a trauma patient. I find it curious that Hal acknowledges it could be a consideration to buy a few minutes while at the same time attempting to lambaste me for saying the same.

Tissue hypoperfusion is what it is regardless of cause, if we can affect an improvement of that long enough to get them to the trauma bay, I see no issue with considering all the tools we have available..

He said he can see it used as an act of desperation. If that pops any clots... it's game over that much quicker.

 

[VFlutter]

http://emcrit.org/lectures/hemostatic-resuscitation/

 

[mycrofft]

Trauma pt., fell 4 stories off of the roof of a house onto an adjacent wall with resulting evisceration of intestines + Bleeding, Neurogenic shock is suspected with HR:58 B/P:86/52 Sp02 86%.

What do you do? Give fluid bolus right? Then Dopamine as well? Wouldn't that make the hemorrhage worse?

Please let me know.

BTW this is a fictional pt. , I did not have this in real life.

1. How long do you think this fictional character has to live after point of impact? (not your time on scene, but impact to expiration).
2. Are you bypassing the shock from basically the most acute abdomen you can imagine outside a war zone?
3. OK one person is trying to find a vein or any other route to administer this stuff. What is the other person doing? What is the over-all game plan and predicted time line?

 

[fma08]

1. How long do you think this fictional character has to live after point of impact? (not your time on scene, but impact to expiration).
2. Are you bypassing the shock from basically the most acute abdomen you can imagine outside a war zone?
3. OK one person is trying to find a vein or any other route to administer this stuff. What is the other person doing? What is the over-all game plan and predicted time line?

Wise sage is wise.

 

[Akulahawk]

http://emcrit.org/lectures/hemostatic-resuscitation/

Actually, I've seen that video before. I thought it was pretty darned good when I saw it the first time, I liked it even more this time. I noticed that the speaker was advocating 1:1:1... and no crystalloids early... and heard NOT ONE THING about pressors in trauma resus.

 

[Akulahawk]

Wise sage is wise.

Agreed...