Levophed Assisted Transfusion

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 crap-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.


Original author: Tyler Christifulli

The Art of Taking It Off...


I would have never imagined that I would be writing about taking off personal protective equipment (PPE) and certinely didn't think I would be learning about a fella referred to as the 'tiger king',  but here we are in 2020 and I am writing about taking off PPE. I was going to do this as a vlog but really didn’t want to waste the PPE.

This is going to be a quick overview of doffing PPE with the use of illustrations, because I am a visual leaner and I wanted to get this out quickly (I draw faster than I write). Hopefully we are pretty good with putting on the PPE, but honestly how much time was spent on taking it off, PPE that is.

As the PPE requirements change at a rapid rate, this is not going to be an all-inclusive review, just the basics of doffing gloves, goggles, mask and gowns. 

Special thanks to Courtney Graham for allowing me to use the amazing drawing of Sam. 


The sequence for putting on donning PPE should be: 

 Gloves > Gown > Mask > Eye Protection or Face Shield > Gloves 

1️⃣: ???????????? or ???? ???????? 

2️⃣: ????

3️⃣: ????




Notice that you will be double gloving. Your second pair of gloves should be pulled over the wrist area of your gown. 


Now we will move on to taking it off…… 

Doffing PPE is much more difficult than it seems, as the risk of inadvertent personnel contamination is high. While doffing PPE it is important to be slow and methodical. Many instituations have facilitated the use of check lists as well as observers to ensure inadevertent contamination does not occur.  

For taking off or doffing PPE the sequence will be: 

Gloves > Gown > Gloves > Eye Protection or Face Shield > Mask  

1️⃣: ????

2️⃣: ????

3️⃣: ????

4️⃣: ????

5️⃣: ????


This is Sam. Sam will show you the propper way of doffing your PPE. 


As you remove your first pair of gloves, remember they are contaminated. 

Remove your first glove by grabbing your palm area and begin to pull them off. After they are removed, remove the opposite side by sliding your fingers under the glove and between the gown and peel them off. 


Remove your gown by grabbing the front of the gown and pull it away from your body. As you are pulling the gown forward, turning it inside out into a bundle. 

Remove your second pair of gloves as described above. 

Eye Protection or Face Shield: 

Remove goggles or face shield by grabbing the back of the strap. If you are using eye protection, do not grab the front of the glasses, grab the sides. 


When removing your mask, do not touch the front of the mask, untie the ties or pull the rear band to remove your mask. 

When this is completed, wash your hands! 

Be safe out there and remember there are no emergenices in a pandemic! 


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