Permissive hypotension in adult trauma: A systematic review of outcomes across clinical settings, injury type, and resuscitation strategies.

BACKGROUND: Hemorrhage is a leading cause of preventable trauma death, and aggressive crystalloid resuscitation may worsen coagulopathy. Permissive hypotension has emerged as a key damage-control strategy. This systematic review aims to evaluate outcomes associated with permissive hypotension in adult trauma patients.

METHODS: A systematic review of five databases was conducted from January 1, 2000, to October 18, 2025. Studies assessing hypotensive resuscitation in adult trauma patients based on care setting, injury type, and fluid volume were included. Outcomes of interest included mortality, and complications.

RESULTS: 11 studies met the inclusion criteria and analyzed a total of 4529 patients. Permissive hypotension was only associated with decreased mortality within hospital settings (6.3% vs 16.3%, P = .045), while showing no difference in the prehospital settings. In hospital settings, permissive hypotension was also associated with decreased rates of complications such as acute respiratory syndrome (12.2% vs. 30.5%, p = .006), multiple organ failure (12.2% vs. 29.3%, p = .027), and disseminated intravascular coagulation (2.4% vs. 17.1%, p < .039). Compared to standard resuscitation, permissive hypotension was associated with decreased 24-h mortality (3.2% vs. 17.7%; adjusted OR = 0.17; 95% CI 0.03-0.92) in patients with blunt injuries.

CONCLUSION: Permissive hypotension is an effective strategy in hemorrhagic shock in blunt trauma, demonstrating reduced complication and mortality rates compared to conventional resuscitation. Resuscitation should be individualized, with fluid volumes guided by patient hemodynamics and injury characteristics.