How to treat hypotension in a hanging case?

Management of Hypotension in Hanging Cases

In hanging cases with hypotension, initial treatment should focus on a restricted fluid resuscitation strategy with 0.9% sodium chloride or balanced crystalloid solution, followed by noradrenaline (norepinephrine) if target blood pressure is not achieved despite adequate fluid therapy. 1

Initial Assessment and Fluid Resuscitation

• Assume hypotension is due to hemorrhage until proven otherwise, as this is the most common cause in trauma patients 2
• Begin immediate fluid resuscitation with isotonic crystalloids (0.9% saline) to reverse hypovolemia 1
• Avoid hypotonic solutions such as Ringer's lactate, especially if there is potential head trauma from the hanging mechanism 1
• Target a systolic blood pressure of 80-90 mmHg initially if there is no evidence of traumatic brain injury 1
• If traumatic brain injury is suspected or confirmed, maintain a higher mean arterial pressure ≥80 mmHg to ensure adequate cerebral perfusion 1, 2

Vasopressor Therapy

• If fluid resuscitation fails to achieve target blood pressure, administer noradrenaline (norepinephrine) to maintain arterial pressure 1
• Consider using a passive leg raise test to determine if the patient is fluid responsive before initiating vasopressors 1
• If the passive leg raise test does not correct hypotension, focus on vascular tone and chronotropy/inotropy rather than additional fluid administration 1
• For patients with myocardial dysfunction, add dobutamine infusion 1
• In patients with bradycardia, consider dopamine as an alternative vasopressor 1

Monitoring and Titration

• Use arterial line monitoring whenever possible to accurately measure blood pressure and guide vasopressor titration 1
• Titrate vasopressors to effect rather than using fixed doses 1
• Monitor markers of tissue perfusion including lactate clearance, urine output, skin perfusion, and mental status 1
• For epinephrine administration in shock, the recommended dosing is 0.05 mcg/kg/min to 2 mcg/kg/min, titrated to achieve desired mean arterial pressure 3

Special Considerations for Hanging Cases

• Assess for potential cervical spine injury and airway compromise, which are common in hanging cases 2
• Consider early intubation if there are signs of airway compromise or declining neurological status 2
• Position the patient with 20-30° head-up tilt if no spinal injury is suspected to improve cerebral venous drainage 2
• Be vigilant for the development of coagulopathy, which is common in patients with combined traumatic injury and shock 2

Pitfalls to Avoid

• Avoid excessive fluid administration, which can lead to hemodilution without added benefit to vascular responsiveness 4
• Do not delay initiation of vasopressors if the patient remains hypotensive despite adequate fluid resuscitation 1
• Avoid rapid correction of blood pressure with bolus doses of sedatives, which may worsen hypotension 2
• Do not use permissive hypotension strategies if traumatic brain injury is suspected, as this can worsen secondary brain injury 1, 2
• Be cautious with phenylephrine in patients who are preload dependent, as it can cause reflex bradycardia 1

Algorithm for Management

1. Begin with 0.9% sodium chloride or balanced crystalloid solution 1
2. Target systolic BP 80-90 mmHg (no TBI) or MAP ≥80 mmHg (with TBI) 1, 2
3. Perform passive leg raise test to assess fluid responsiveness 1
4. If fluid responsive: continue restricted volume replacement 1
5. If not fluid responsive or if hypotension persists despite adequate fluid therapy: add norepinephrine 1
6. If myocardial dysfunction is present: add dobutamine 1
7. If bradycardia is present: consider dopamine instead of norepinephrine 1
8. Continue monitoring and titrating therapy based on clinical response and markers of tissue perfusion 1