Beware the injured child with a “normal” systolic blood pressure ▸

Consensus emergency training programmes such as the Advanced Paediatric Life Support (APLS) course teach that an abnormally low systolic blood pressure in combination with an abnormal heart rate represents decompensated hypovolaemia. The evidence for “normal” values in children and infants is, however, somewhat lacking. APLS provides “norms” for systolic blood pressure and pulse rate without confidence intervals or references. This retrospective study analysed data from 12 906 children who had suffered blunt injury and were entered onto the Trauma Audit and Research Network (TARN) database. The authors found that regardless of injury severity, injured children demonstrated a relative systolic hypertension. They concluded that systolic normotension in the injured infant or child may imply hypovolaemia and impending cardiovascular collapse.

The origin of accepted normal values has long been questioned. With no reliable alternative data, the status quo continued and many resuscitation decisions have been made on flimsy evidence. The authors of this paper have now provided some convincing evidence that systolic blood pressure is a very poor predictor of physiological status, and a “normal” blood pressure may indicate impending circulatory collapse. Hopefully, data from this study will be used to assist with future guidelines for the initial treatment of the injured child.

Is this the end of clinical resuscitation research? ▸

This letter highlights a very real concern for emergency physicians and those involved in the care of critically ill patients following the recent directive by the European Union requiring informed consent before including patients in clinical studies of emergency resuscitation. This seems to be a short sighted and worrying development. It will affect emergency medicine more than other specialties. It is only right that issues of ethics and consent are discussed and closely considered, but to instigate a directive that would effectively terminate further research seems folly in itself. …