13. Permissive Hypotension

My List of the 16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

13. Permissive Hypotension

In the mid 1990s and before then, you were a stud if you could swoop down on a shooting victim, toss him on a board, get him in the back of the ambulance, and take off before the mobile TV news crews arrived (even better if you were gone before the PD arrived).  Then in the three or four minutes you were in the back of the ambulance as your partner flew (we’re taking airborne on the rises) to the Level one trauma Center, you slammed in two large bore IVs and had the fluid running fast and wide.  Two 14’s was an A plus.  A 14 and a 16 was good.  Two 16’s was border line.  Anything less was not worthy of the patch on your shoulder.  You were a god if the 1000 liter bags had less than 100 cc by the time you hit the trauma room.

It really sucked if your victim had bad veins.  A 20?  That was all you could get?  A 20?  But in most cases your shooting victims were young strong males with bulging pipes, who just happened to be on the wrong street corner doing nothing at the wrong time.

I remember one time I put a 14 in a man’s AC and the fluid ran like Niagara Falls.  I noticed then the cot was soaking wet under his upper arm.  He had another huge bullet hole there that had completely taken out the vein. The fluid entered the AC, run upstream for four inches and then ran right out tinged with pink.  Pink was often the color on the sheets after we’d unloaded the patient.  And back then, we didn’t just run the fluid when the BP was low.  We ran the fluid regardless of the BP.  We were medics and aggressive and taught to stay ahead of the game.  We ran fluid in anticipation of the BP dropping.

Many medics started the day by hanging and prespiking two 1000 cc bags of fluid.  One of Saline; one of Ringers.  Some medics hung the bags, but just taped the drip sets unspiked to them.  I usually just laid two bags on the bench seat, ready to open and spike.  A few medics may have just left the fluid in the cabinets until needed.  I guess it all depended on what degree of spark you were.

Of course we know better today. Aggresive fluid resucitation in absence of controlled bleeding can damage the body’s ability to clot off the bleed, create hypothermia, and impair the delievery of oxygen. While there is still some discussion about just how much fluids trauma patients should get prehospitally, permissive hypotension seems to rule the day.  Our regional protocols calls for blood pressure to be titrated to 100 systolic.  I know some would argue that blood pressure limit should be much lower – just enough to produce a pulse and no more.

Here is a link to Trauma.org that has a good editorial and summary of the permissive hypotension debate:

Permissive Hypotension



16 Most Significant EMS Treatment Changes in My 20 Years as a Paramedic

14.Expanded Medication Routes, Less IV Emphasis
15. Narrower Use of Narcan
16. Increased Standing Orders

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