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Podcast 82 -
Handovers,
Delegation, and
Critique w/ Cliff Getting Nerdy: Reaching the Top of
Reid a bLoG oN bLOgs Intermolecular Force the Pyramid
August 16, 2019 August 10, 2019 August 7, 2019 August 2, 2019

Levophed Assisted Transfusion

August 22, 2019 | Tyler Christifulli

There is an internal clock that begins ticking when I see a patient with a MAP below 65. That ticking gets even louder when the patient has
a known head bleed. As clinicians we have several ways to raise someones mean arterial pressure:

Fill The Tank: Fluids and blood products.

Manipulate The Pump Dynamics: Inotropes and chronotropes .

Change The Size or Compliance of The Container: Vasopressors and regional occlusion (REBOA).

The most common reflex when a clinician is attempting to increase MAP - is to open up the roller clamp on fluids. Our hope is that by
increasing venous return we will increase cardiac output.

When our MAP is low because of bleeding, the reasonable intervention would be to stop the source of bleeding - and then if
needed replace that volume (with blood). What if that source of bleeding is non-compressible? There is evidence to support permissive low
MAP's until surgery can correct the bleed. However, this permissive hypotension takes on a new face when increased intracranial pressure
is suspected.

We all remember the formula to calculate cerebral perfusion pressure (CPP). CPP is the pressure you have remaining when you subtract
the intracranial pressure from your MAP. It would only make sense that it becomes harder to put your hands in your pockets when our legs
take up more space in our jeans (even white pants at FAST19 :). Soooo if our blood pressure is low, but our ICP is consistent - we run into
an issue of getting perfusion to the brain.

Let's imagine a scenario where you have a trauma patient with a positive RUQ FAST Exam. You see the liver swimming in a pool of "free
fluid" in which you suspect to be blood knowing the mechanism of injury. You are picking this patient up from a smaller referring facility
who confirms this patient has a subarachnoid bleed. As you walk into the room you note the current MAP is 55, the patient is intubated
and poorly sedated. No blood has been administered and the patient has received 2 liters of 0.9% saline. The physician states " I was afraid
to give this guy any more sedation because of the blood pressure."

What's your next move?

While the strategies for sedation in the presence of hypotension will be covered in a future blog, we can deduce that a patient fighting the
ventilator and agitated is not helping their ICP. I believe the majority of my colleagues are going to an analgesic first (A1) approach, and
utilizing hemodynamic dose reduction in this scenario. For example, if this guy is 100 kg, I most likely will be giving 50 mg bumps of
ketamine until the patient looks comfortable. I also am completely cool with fentanyl. I believe we are finding that it's the dose and not the
drug that matters, but anyways..

The main topic I want to discuss it what we should do with the blood pressure. If we evaluate the methods discussed in the beginning of
this blog to elevate MAP, my mind processes them like this.

Manipulate The Pump Dynamics: Heart rate is typically already elevated and contraction is hyper-dynamic. It is very rare for a
hypotensive trauma patient to be bradycardic with a hypo-dynamic heart.

Fill The Tank: Yes, start a blood transfusion. It may take a few minutes to get blood in the room. Replenishing volume with balanced
crystalloids can be used with the known end-goal of blood product.

What about starting a pressor?

Change The Size or Compliance of The Container:

No, but seriously! This is the area that is of interest to me as of lately. It takes sometime for the volume to increase preload enough to
increase stroke volume. As that ticking begins to get louder, many will result to shit-loads of saline or push dose pressors to elevate the
blood pressure while waiting for blood products to increase hydrostatic pressure enough to elevate MAP. I think push dose epi is the wrong
move because of the reasons mentioned in why "manipulating the pump dynamics" is rarely the right move. So what do I do?

I believe a temporary levophed assisted transfusion is entirely reasonable in this situation while waiting for blood product to catch-up with
preload requirements. Levophed begins its actions by increasing unstressed volume to stressed volume. This is like giving a fluid bolus,
but without the negative sequela of crystalloids. Squeezing the venous capacitance system will directly increase pre-load and expedite
ascension of cerebral perfusion.

I have found that this usually is only needed for the first 15 minutes of a transfusion. Parenthetically this levophed can eventually be
"weened off." The logistics of getting a blood transfusion initiated can vary depending on whether you routinely bring your blood cooler
into the hospital with you, and how quickly the hospital can get you blood. Sometimes it's easier to just have the pilot make a run to the
aircraft for the cooler (kidding.. not kidding). The levophed Bump & Drip can occur anywhere in this period.

Sometimes we don't have time to wait for the bathtub to fill up, and we need to change the compliance of the container by jumping in.
I believe that levophed has utility to be the fat kid in the swimming pool when seconds are critical to brain perfusion.

Hypotension, Hypoxia, & Hyperventilation

In May of 2019 JAMA published the Excellence in Prehospital Injury Care (EPIC) study that looked at preventing the three H's that are
known to be deleterious to positive outcomes in patients with a TBI.
The study included more than 130 EMS services and implemented special training that stressed the importance of avoiding the three H's.
This study probably included too broad of spectrum of patients to accurately detect a difference between the moderate, severe, and critical
subgroups. There is obviously not much that will change the outcome of a critical traumatic head bleed in way of intervention.

When the outcome was adjusted to evaluate the effect of this bundle on just the moderate to severe group- the moderate group doubled in
survival, and the severe group tripled. This study does not tell us anything that we did not already know, but it should increase the volume
of the ticking you hear when your TBI patient has a plummeting MAP.

How will you respond?

References are hyperlinked throughout blog.

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10 comments
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Mediocrity has become the norm. Push providers through with minimal training and poor instructors. Allow the
weakest link to set your protocols. Now for the real issues. All I hear about is the poor performance of paramedics,
Train them the right way, ventilate prior to intubation teach the right way not some abbreviated nonsense. Bad
days happen but if your having a bad day more than once or twice a year you need practice. Being aware of your
own poor practice is the first step in correcting a problem. Don’t make excuses, take pride in your practice. Make
an effort to be better than everyone else.

George Bevilacqua · a month ago · Reply

Bravo! My hero was Joanna Cassidy from the 80’s TV show 240 Robert. She flew the freakin police helicopter.
Very forward thinking for 1979. Her character’s picture is on my locker as a reminder.
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weight loss · 3 months ago · Reply

Amazing talk on RV dysfunction.

Sean Duchemin · 3 months ago · Reply

Question: What formula did you use to plot the serum concentrations over time with cumulative dosing?
Thanks!
Mike Pietersen · 4 months ago · Reply

Ok, nervous newly transplanted Atlanta paramedic here about to face southern summer head on. What do you
recommend to prevent this complete catastrophe? Worth getting an insulated lunch bag or something to store them
throughout the day? Or do you think generally as long as it is not in direct sunlight, it will survive the ambient
swelter?
Natalie Zink · 4 months ago · Reply

There is no such thing as too sick to transfer. As you mentioned, the patient would have died if you left him.
Absolutely would have taken him and given him the best chance at survival. Strong work.
Andrew · 4 months ago · Reply

Great references to The Other Guys. Another great article from FOAMfrat. Thanks

Tim Redding · 4 months ago · Reply

This is really helpful to me as a medic student just into pharma. Love the 5 half-lives rule (and that 8 is just
39 in disguise!). This is great information presented in a way I can understand, and I'll be interested in seeing how
they do it in the ICU. Hopefully better than the pharmacist explained! Had a 39 yo pt the other day w/ a BP of 50
and watched them give him every pressor possible to try to get it up, which makes it real. Thank you for the time
you put into this and for sharing it.
trainerjims · 4 months ago · Reply

I couldn't find the link to the course.

Mike · 5 months ago · Reply

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