What is the management of a patient with abdominal trauma, normal echocardiogram (echo), normal systolic blood pressure (SBP) but low diastolic blood pressure (DBP)?

From the Guidelines

Management of a patient with abdominal trauma, normal echocardiogram, normal systolic blood pressure but low diastolic blood pressure requires a careful approach with permissive hypotension, avoiding aggressive fluid resuscitation, and focusing on identifying and treating potential hemorrhage. The widened pulse pressure (normal SBP with low DBP) suggests vasodilation or early compensated shock, which may indicate ongoing bleeding despite normal systolic readings 1. Initial management should include establishing two large-bore IV access lines (16-18 gauge) and administering isotonic crystalloid fluids such as normal saline or lactated Ringer's at a restricted volume, with a goal of maintaining a mean arterial pressure of 65 mmHg or more, as suggested by the concept of permissive hypotension 1.

Key Considerations

• Immediate diagnostic workup should include FAST (Focused Assessment with Sonography for Trauma) examination, complete blood count, coagulation studies, and cross-matching for potential blood transfusion.
• CT scan with IV contrast should be considered if the patient is hemodynamically stable.
• Close hemodynamic monitoring is essential with serial vital signs every 15 minutes, including blood pressure, heart rate, respiratory rate, oxygen saturation, and urine output (target >0.5 mL/kg/hr).
• If there are signs of deterioration or the patient fails to respond to initial fluid resuscitation, immediate surgical consultation for possible exploratory laparotomy is warranted.

Rationale

The concept of permissive hypotension is supported by recent studies, which suggest that aggressive fluid resuscitation may be detrimental in trauma patients, increasing the likelihood of secondary abdominal compartment syndrome and coagulopathy 1. A prospective randomized trial demonstrated a benefit for the initial intra-hospital hypotensive resuscitation strategy, with reduced 24-hour postoperative death and coagulopathy in the group with the lower target minimum pressure 1. However, it is essential to note that permissive hypotension may be contraindicated in certain patient populations, such as those with traumatic brain injury or spinal injuries, and should be carefully considered in elderly patients or those with chronic arterial hypertension 1.

Recommendations

• Avoid aggressive fluid resuscitation and aim for permissive hypotension.
• Monitor patients closely for signs of deterioration or failure to respond to initial fluid resuscitation.
• Consider immediate surgical consultation for possible exploratory laparotomy if necessary.
• Use isotonic crystalloid fluids at a restricted volume, with a goal of maintaining a mean arterial pressure of 65 mmHg or more.

From the FDA Drug Label

Give this solution by intravenous infusion. Insert a plastic intravenous catheter through a suitable bore needle well advanced centrally into the vein and securely fixed with adhesive tape, avoiding, if possible, a catheter tie-in technique as this promotes stasis An IV drip chamber or other suitable metering device is essential to permit an accurate estimation of the rate of flow in drops per minute After observing the response to an initial dose of 2 mL to 3 mL (from 8 mcg to 12 mcg of base) per minute, adjust the rate of flow to establish and maintain a low normal blood pressure (usually 80 mm Hg to 100 mm Hg systolic) sufficient to maintain the circulation to vital organs In previously hypertensive patients, it is recommended that the blood pressure should be raised no higher than 40 mm Hg below the preexisting systolic pressure. The average maintenance dose ranges from 0. 5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base).

The management of a patient with abdominal trauma, normal echocardiogram, normal systolic blood pressure but low diastolic blood pressure may involve the use of norepinephrine (IV) 2 to maintain a low normal blood pressure, usually between 80 mm Hg to 100 mm Hg systolic. The dose should be adjusted according to the response of the patient, with an average maintenance dose ranging from 0.5 mL to 1 mL per minute (from 2 mcg to 4 mcg of base). It is also important to suspect and correct occult blood volume depletion when present.

• Key considerations:
  • Maintain low normal blood pressure
  • Adjust dose according to patient response
  • Suspect and correct occult blood volume depletion
  • Use central venous pressure monitoring to detect and treat hypotension 2

From the Research

Evaluation and Management of Abdominal Trauma Patient

• The patient has abdominal trauma with a normal echocardiogram, normal systolic blood pressure (SBP) but low diastolic blood pressure (DBP).
• The management of such a patient should focus on hemodynamic support and fluid resuscitation, taking into account the type of injury and potential complications 3.
• Crystalloids are currently recommended for trauma resuscitation, and the amount of fluid administered should be tailored to the individual patient, with clear endpoints of resuscitation to maximize chances of survival 3.

Fluid Resuscitation Strategies

• Fluid resuscitation should be limited to the bare minimum to maintain arterial pressure and prevent dilution of coagulation factors, especially in cases of severe trauma 4.
• A target systolic arterial pressure of 80-90 mmHg is recommended until control of hemorrhage in trauma patients without brain injury 4.
• Large-volume crystalloid resuscitation (≥5L in the first 24h) is associated with increased mortality and longer time ventilated, and should be avoided 5.

Vasopressor Support and Blood Transfusion

• Early vasopressor support may be required to restore arterial pressure and prevent excessive fluid resuscitation 4.
• In cases of severe trauma, early infusion of blood products and control of bleeding can decrease trauma-induced coagulopathy 6.
• Massive transfusion protocols, which involve transfusing fresh frozen plasma, packed red blood cells, and platelets in a 1:1:1 ratio, can improve survival in severely injured patients 6.

Considerations for Resuscitation

• The use of colloids is not superior to crystalloids in treating hypovolemia in trauma patients and can have adverse effects such as renal failure, bleeding complications, and anaphylaxis 3.
• Hypertonic saline can be effective and well-tolerated in the treatment of hypovolemic shock and traumatic brain injury, with potential benefits including reduced fluid requirements and immune modulation 3.
• Permissive hypotension and damage control resuscitation strategies may be employed to balance hemodynamic and haemostatic resuscitation, but these concepts may not be appropriate for pediatric trauma patients 7.