What systolic blood pressure target is recommended for permissive hypotension during haemostatic resuscitation in adult trauma patients without traumatic brain injury?

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Blood Pressure Target for Permissive Hypotension in Haemostatic Resuscitation

Target a systolic blood pressure of 80-90 mmHg (or mean arterial pressure of 50-60 mmHg) during permissive hypotension in adult trauma patients without traumatic brain injury until major bleeding has been controlled. 1

Blood Pressure Targets by Patient Population

Patients WITHOUT Traumatic Brain Injury or Spinal Injury

  • Systolic BP target: 80-90 mmHg 1
  • Mean arterial pressure (MAP) target: 50-60 mmHg 1, 2
  • This restricted target should be maintained only until major bleeding has been surgically or interventionally controlled 1
  • Meta-analyses of randomized controlled trials demonstrate decreased mortality with this permissive hypotension strategy compared to traditional aggressive fluid resuscitation targeting normotension 1

Patients WITH Traumatic Brain Injury (GCS ≤8)

  • Mean arterial pressure target: ≥80 mmHg 1, 2
  • Permissive hypotension is absolutely contraindicated in traumatic brain injury because adequate perfusion pressure is crucial to ensure tissue oxygenation of the injured central nervous system 1
  • The same contraindication applies to spinal cord injuries 1, 3

Evidence Supporting These Specific Targets

Mortality Benefit of Permissive Hypotension

  • A randomized controlled trial comparing MAP targets of 50 mmHg versus 65 mmHg in penetrating trauma demonstrated that the lower target (MAP 50 mmHg) resulted in significantly lower 24-hour postoperative mortality and reduced severe postoperative coagulopathy 4
  • Patients resuscitated to MAP 50 mmHg received significantly fewer blood products and total intravenous fluids compared to those targeted to MAP 65 mmHg 4
  • A systematic review and meta-analysis of five randomized controlled trials (1,158 patients) found a pooled odds ratio of 0.70 (95% CI 0.53-0.92) favoring permissive hypotension for survival 5

Harm from Higher Blood Pressure Targets

  • Aggressive resuscitation techniques targeting normotension result in increased mortality, damage control laparotomy, coagulopathy, multiorgan failure, nosocomial infections, increased transfusion requirements, and prolonged ICU stays 1
  • The incidence of coagulopathy increases dramatically with crystalloid volume: >40% at 2,000 mL, >50% at 3,000 mL, and >70% at 4,000 mL 1, 3

Critical Caveats and Contraindications

Absolute Contraindications to Permissive Hypotension

  • Traumatic brain injury (especially GCS ≤8): requires MAP ≥80 mmHg 1, 2
  • Spinal cord injuries: requires MAP ≥80 mmHg 1, 3

Relative Contraindications Requiring Caution

  • Elderly patients: permissive hypotension should be carefully considered and may need modification 1
  • Chronic arterial hypertension: the strategy may be contraindicated as these patients may require higher perfusion pressures for adequate end-organ perfusion 1

Implementation Strategy

Initial Resuscitation Approach

  • Use restricted volume replacement with crystalloids initially, targeting the BP parameters above 1
  • If restricted volume replacement fails to achieve target blood pressure, initiate norepinephrine (0.01-0.5 μg/kg/min) as the first-line vasopressor 2
  • Limit total crystalloid volume to approximately 1-2 liters before transitioning to vasopressor support to avoid dilutional coagulopathy 3, 6

Monitoring During Permissive Hypotension

  • Frequently assess end-organ perfusion including mental status, capillary refill, urine output (target ≥0.5 mL/kg/hr), extremity perfusion, and lactate levels 2, 6
  • Use blood lactate to estimate and monitor the extent of bleeding and tissue hypoperfusion 2
  • If lactate is unavailable, base deficit may represent a suitable alternative 2, 3

Common Pitfalls to Avoid

  • Do not continue aggressive fluid resuscitation beyond 1-2 liters if hypotension persists without transitioning to vasopressor support, as this worsens coagulopathy without improving outcomes 3, 6
  • Do not apply permissive hypotension to patients with any evidence of head injury or spinal cord injury, even if the injury appears minor, as inadequate cerebral or spinal perfusion can worsen neurological outcomes 1
  • Do not use hypotonic solutions such as Ringer's lactate in patients with any potential head trauma, as this can worsen cerebral edema 1, 6
  • Do not delay surgical or interventional hemorrhage control while attempting to optimize blood pressure targets, as rapid bleeding control is the definitive treatment 1

References

1
Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

2
Guideline

Target Mean Arterial Pressure for Permissive Hypotension in Trauma Patients

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

3
Guideline

Management of Severe Hypotension in Spinal Cord Injury

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2025

6
Guideline

Management of Delayed Hypotension Following Electric Shock

Praxis Medical Insights: Practical Summaries of Clinical Guidelines, 2026

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Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.

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