Posted by Matthew Mac Partlin on Monday, September 10, 2012

Trauma is a diaphenous beast, simultaneously simple and complex. The priciples that underpin it are apparently straight-forward enough and yet some of the concepts and management strategies generate intense controversy and debate. If you read much trauma literature, there are a couple of names that recur routinely; one of those is London-based Trauma and Vascular surgeon, Dr. Karim Brohi, who is the driving force behind the website.

Scott Weingart (EM has recorded a podcast with Karim to discuss a lecture that Karim gave as part of the Masters of Trauma Sciences program that he has set up, where he tackles the topic of permissive hypotension in trauma.

They discuss the background to its development, the morbidity and mortality associates of haemorrhagic shock, the evidence behind permissive hypotension and its application, including penetrating versus blunt trauma and fluid resus in the presence of traumatic brain injury.

Importantly, they emphasize that permissive hypotension is not a treatment end-point. Rather it is a least worse intervention strategy that is employed while transfering a patient with an uncontrolled active haemorrhage to a place of definitive care; i.e. the operating theatre or interventional radiology suite.

It's worth thinking about how all of this might affect decision processes for a motorsport event. For instance, one could argue that where the event is located 5 minutes from a major trauma centre, perhaps the best strategy for a shocked trauma patient is to support the airway and ventilation, protect the cervical spine and defer attempts at IV access in preference for a short scene time and rapid transport to the site of definitive care. There are of course other options to delaying transport because of difficult IV access given the availability and ease of insertion of a IO trocar.

Additionally, there has already been the European Society of Intensive Care Medicine consensus statement recommendations (See this earlier post: Fluid type in volume resuscitation) that essentially suggest that in the absence of blood products, crystalloids should be the only resuscitation fluid used in critically ill trauma patients. So you could ditch colloids and starches from your Thomas pack, keeping things simple and relatively cheaper. If you were to follow through on Dr. Brohi's approach, depending on your proximity to the most appropriate hospital, you might not even carry much volume; perhaps just a single 1000ml bag, thereby decreasing the weight and clutter of your pack; which segues nicely into the previous post on the Clinical Logistics interview between Drs Minh Le Cong, Scott Weingart and James French on the PHARM site.

The discussion and presentation on Permissive Hypotension in Trauma between Drs Scott Weingart and Karim Brohi is here.