Hypotensive in the Field but Normotensive in the ED: Erroneous Field BP or Sick Trauma Patient?
ABSTRACT & COMMENTARY
Source: Chan L, et al. The significance of out-of-hospital hypotension in blunt trauma patients. Acad Emerg Med 1997;4:785-788.
The objective of this study was to determine whether blunt trauma patients who were initially hypotensive in the field but normotensive on arrival to the ED had a greater degree of blood loss and injury severity, and a higher mortality. Hypotension in the field was defined as any BP obtained that was less than 90 mmHg systolic. This group of patients was compared to a group whose systolic BP was greater than 90 mmHg in the field and on arrival to the ED. There were 52 patients in each group. The patients who were hypotensive in the field had a higher mortality, more frequent ICU admissions, more pelvic and femur fractures, and a higher Injury Severity Score than those patients who were normotensive in the field. Although not statistically significant, there was a trend toward a higher incidence of ED transfusions and intraabdominal injuries in the group that was hypotensive in the field. Chan and associates conclude that blunt trauma patients who are hypotensive in the field but normotensive on arrival to the ED are generally more severely injured.
COMMENT BY GLENN C. FREAS, MD, JD, FACEP
This study confirms what most emergency physicians would expect. The results raise a couple of questions and bring up a practical point in our systematic approach to blunt trauma patients who are "hemodynamically stable" in the ED.
Chan et al admit to some limitations in this study. They looked at only admitted patients. Specifically, they did not include patients who were hypotensive in the field, normotensive on arrival to the ED, and discharged after their work-up in the ED. We do not know how many of those patients were excluded from the study, and that has important implications for the significance of the results. Chan et al also acknowledge that the only BP that was studied in the ED was the initial reading. We do not know how many patients became hypotensive in the ED or how quickly they may have deteriorated. Finally, we do not know how much intravenous fluid patients received in the prehospital setting. Despite these latter two points, it is certainly important that we realize that this subset of patients has the potential to be more severely injured despite an initial reassuring BP on the arrival to the ED.
This has practical implications regarding how we workup these patients. If we suspect intra-abdominal injury and the patient who was hypotensive in the field is hemodynamically stable in the ED, do we send them for an abdominal CT scan (as many would do)? The increased incidence of intra-abdominal injury and ED transfusions was not statistically significant in this study. But is it more prudent to do a bedside study, like ultrasound or peritoneal lavage, to workup intra-abdominal injury? Although these tests are not organ-specific, they certainly yield quick and valuable information in patients whose hypotension may return while in the CT scan suite. Obviously, each case is different depending on the clinical findings and suspicions as well as the capabilities of the ED and hospital. If I have a patient who was unstable in the field, is stable in the ED, has clinical evidence of intra-abdominal injury, and does not have a pelvic fracture or femur fracture to explain hypotension in the field, I am going to be more than a little nervous sending them any great distance to the CT scan area. The use of bedside ultrasound to detect free fluid seems like a prudent approach in this patient. If I did not have that modality readily available, I would have to carefully judge the likelihood that my patient will remain stable throughout the scanning process.
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