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Rossaint R, Bouillon B, Cerny V, Coats TJ, Duranteau J, Fernández-Mondéjar E, Filipescu D, Hunt BJ, Komadina R, Nardi G, Neugebauer EAM, Ozier Y, Riddez L, Schultz A, Vincent JL, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care 2016; 20:100. [PMID: 27072503 PMCID: PMC4828865 DOI: 10.1186/s13054-016-1265-x] [Citation(s) in RCA: 597] [Impact Index Per Article: 74.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Accepted: 03/11/2016] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Severe trauma continues to represent a global public health issue and mortality and morbidity in trauma patients remains substantial. A number of initiatives have aimed to provide guidance on the management of trauma patients. This document focuses on the management of major bleeding and coagulopathy following trauma and encourages adaptation of the guiding principles to each local situation and implementation within each institution. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004 and included representatives of six relevant European professional societies. The group used a structured, evidence-based consensus approach to address scientific queries that served as the basis for each recommendation and supporting rationale. Expert opinion and current clinical practice were also considered, particularly in areas in which randomised clinical trials have not or cannot be performed. Existing recommendations were reconsidered and revised based on new scientific evidence and observed shifts in clinical practice; new recommendations were formulated to reflect current clinical concerns and areas in which new research data have been generated. This guideline represents the fourth edition of a document first published in 2007 and updated in 2010 and 2013. RESULTS The guideline now recommends that patients be transferred directly to an appropriate trauma treatment centre and encourages use of a restricted volume replacement strategy during initial resuscitation. Best-practice use of blood products during further resuscitation continues to evolve and should be guided by a goal-directed strategy. The identification and management of patients pre-treated with anticoagulant agents continues to pose a real challenge, despite accumulating experience and awareness. The present guideline should be viewed as an educational aid to improve and standardise the care of the bleeding trauma patients across Europe and beyond. This document may also serve as a basis for local implementation. Furthermore, local quality and safety management systems need to be established to specifically assess key measures of bleeding control and outcome. CONCLUSIONS A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. The implementation of locally adapted treatment algorithms should strive to achieve measureable improvements in patient outcome.
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Affiliation(s)
- Rolf Rossaint
- />Department of Anaesthesiology, University Hospital Aachen, RWTH Aachen University, Pauwelsstrasse 30, 52074 Aachen, Germany
| | - Bertil Bouillon
- />Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Cologne-Merheim Medical Centre, Ostmerheimer Strasse 200, 51109 Cologne, Germany
| | - Vladimir Cerny
- />Department of Anaesthesiology, Perioperative Medicine and Intensive Care, J.E. Purkinje University, Masaryk Hospital, Usti nad Labem, Socialni pece 3316/12A, 40113 Usti nad Labem, Czech Republic
- />Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesiology and Intensive Care, Charles University in Prague, Faculty of Medicine in Hradec Kralove, Sokolska 581, 50005 Hradec Kralove, Czech Republic
- />Department of Anaesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, QE II Health Sciences Centre, 10 West Victoria, 1276 South Park St., Halifax, NS B3H 2Y9 Canada
| | - Timothy J. Coats
- />Emergency Medicine Academic Group, University of Leicester, University Road, Leicester, LE1 7RH UK
| | - Jacques Duranteau
- />Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud, University of Paris XI, Faculté de Médecine Paris-Sud, 78 rue du Général Leclerc, 94275 Le Kremlin-Bicêtre, Cedex France
| | - Enrique Fernández-Mondéjar
- />Servicio de Medicina Intensiva, Complejo Hospitalario Universitario de Granada, ctra de Jaén s/n, 18013 Granada, Spain
| | - Daniela Filipescu
- />Department of Cardiac Anaesthesia and Intensive Care, C. C. Iliescu Emergency Institute of Cardiovascular Diseases, Sos Fundeni 256-258, 022328 Bucharest, Romania
| | - Beverley J. Hunt
- />King’s College, Departments of Haematology, Pathology and Lupus, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Radko Komadina
- />Department of Traumatology, General and Teaching Hospital Celje, Oblakova 5, 3000 Celje, Slovenia
| | - Giuseppe Nardi
- />Shock and Trauma Centre, S. Camillo Hospital, Viale Gianicolense 87, 00152 Rome, Italy
| | - Edmund A. M. Neugebauer
- />Faculty of Health - School of Medicine, Witten/Herdecke University, Ostmerheimer Strasse 200, Building 38, 51109 Cologne, Germany
| | - Yves Ozier
- />Division of Anaesthesia, Intensive Care and Emergency Medicine, Brest University Hospital, Boulevard Tanguy Prigent, 29200 Brest, France
| | - Louis Riddez
- />Department of Surgery and Trauma, Karolinska University Hospital, 171 76 Solna, Sweden
| | - Arthur Schultz
- />Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Lorenz Boehler Trauma Centre, Donaueschingenstrasse 13, 1200 Vienna, Austria
| | - Jean-Louis Vincent
- />Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070 Brussels, Belgium
| | - Donat R. Spahn
- />Institute of Anaesthesiology, University of Zurich and University Hospital Zurich, Raemistrasse 100, 8091 Zurich, Switzerland
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Abstract
Peripartum hemorrhage is one of the most preventable causes of maternal mortality worldwide. Much effort has been directed toward creating programs that address deficits in maternity care responsible for preventable hemorrhage-related morbidity and mortality. To have a significant impact on outcomes, such programs must address both providers and processes involved in the delivery of maternity care. At the core of a successful program, are standardized care bundles integrating medical and surgical techniques for managing hemorrhage with principles of transfusion medicine and critical care. In this article, we review the components of the safety bundle for obstetric hemorrhage developed by ACOG District II Safe Motherhood Initiative.
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Affiliation(s)
- Adiel Fleischer
- Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, 270-05 76th Ave, Suite 400, New Hyde Park, NY 11040.
| | - Natalie Meirowitz
- Department of Obstetrics and Gynecology, Hofstra North Shore-LIJ School of Medicine, 270-05 76th Ave, Suite 400, New Hyde Park, NY 11040
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Olaussen A, Thaveenthiran P, Fitzgerald MC, Jennings PA, Hocking J, Mitra B. Prediction of critical haemorrhage following trauma: A narrative review. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2016. [DOI: 10.5339/jemtac.2016.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities–the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing.
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Affiliation(s)
- Alexander Olaussen
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 5Monash School of Medicine, Monash University, Australia
- 3Trauma Service, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 1Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | - Prasanthan Thaveenthiran
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 5Monash School of Medicine, Monash University, Australia
| | - Mark C. Fitzgerald
- 3Trauma Service, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Paul A. Jennings
- 1Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 6College of Health and Biomedicine, Victoria University, Melbourne, Australia
| | - Jessica Hocking
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 7Department of Epidemiology & Preventive Medicine, Monash University, Australia
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104
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Predicting blood transfusion using automated analysis of pulse oximetry signals and laboratory values. J Trauma Acute Care Surg 2016; 79:S175-80. [PMID: 26406427 DOI: 10.1097/ta.0000000000000738] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Identification of hemorrhaging trauma patients and prediction of blood transfusion needs in near real time will expedite care of the critically injured. We hypothesized that automated analysis of pulse oximetry signals in combination with laboratory values and vital signs obtained at the time of triage would predict the need for blood transfusion with accuracy greater than that of triage vital signs or pulse oximetry analysis alone. METHODS Continuous pulse oximetry signals were recorded for directly admitted trauma patients with abnormal prehospital shock index (heart rate [HR] / systolic blood pressure) of 0.62 or greater. Predictions of blood transfusion within 24 hours were compared using Delong's method for area under the receiver operating characteristic (AUROC) curves to determine the optimal combination of triage vital signs (prehospital HR + systolic blood pressure), pulse oximetry features (40 waveform features, O2 saturation, HR), and laboratory values (hematocrit, electrolytes, bicarbonate, prothrombin time, international normalization ratio, lactate) in multivariate logistic regression models. RESULTS We enrolled 1,191 patients; 339 were excluded because of incomplete data; 40 received blood within 3 hours; and 14 received massive transfusion. Triage vital signs predicted need for transfusion within 3 hours (AUROC, 0.59) and massive transfusion (AUROC, 0.70). Pulse oximetry for 15 minutes predicted transfusion more accurately than triage vital signs for both time frames (3-hour AUROC, 0.74; p = 0.004) (massive transfusion AUROC, 0.88; p < 0.001). An algorithm including triage vital signs, pulse oximetry features, and laboratory values improved accuracy of transfusion prediction (3-hour AUROC, 0.84; p < 0.001) (massive transfusion AUROC, 0.91; p < 0.001). CONCLUSION Automated analysis of triage vital signs, 15 minutes of pulse oximetry signals, and laboratory values predicted use of blood transfusion during trauma resuscitation more accurately than triage vital signs or pulse oximetry analysis alone. Results suggest automated calculations from a noninvasive vital sign monitor interfaced with a point-of-care laboratory device may support clinical decisions by recognizing patients with hemorrhage sufficient to need transfusion. LEVEL OF EVIDENCE Epidemiologic/prognostic study, level III.
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105
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A pediatric specific shock index in combination with GMS identifies children with life threatening or severe traumatic brain injury. Pediatr Surg Int 2015; 31:1041-6. [PMID: 26349487 DOI: 10.1007/s00383-015-3789-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/31/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone. METHODS We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children. RESULTS Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6%); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44%), and elevated SIPA or abnormal GMS in 206 (53%). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers. CONCLUSION Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.
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106
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Utility of shock index calculation in hemorrhagic trauma. Am J Emerg Med 2015; 33:978. [DOI: 10.1016/j.ajem.2015.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Accepted: 04/01/2015] [Indexed: 11/20/2022] Open
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Olaussen A, Peterson EL, Mitra B, O'Reilly G, Jennings PA, Fitzgerald M. Massive transfusion prediction with inclusion of the pre-hospital Shock Index. Injury 2015; 46:822-6. [PMID: 25555919 DOI: 10.1016/j.injury.2014.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/07/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND Detecting occult bleeding can be challenging and may delay resuscitation. The Shock Index (SI) defined as heart rate divided by systolic blood pressure has attracted attention. Prediction models using combinations of pre-hospital SI (phSI) and the trauma centre SI (tcSI) values may be effective in identifying patients requiring massive blood transfusions (MT). AIM To explore whether combinations of the phSI and the tcSI augment MT prediction. METHODS The scores were retrospectively developed using all major trauma patients that presented to The Alfred Hospital between 2006 and 2012. The first PH and TC observations were used. To avoid exclusion of the 'sickest' patients, the SI was imputed to 2 where SBP was missing, but HR was present. We developed 4 models. (i) 'Dichotomised', defined as positive when both phSI and tcSI were ≥1. (ii) 'Formulaic', defined by logistic regression analysis. (iii) 'Combination', defined pragmatically based on the logistic regression. (iv) 'Trending', defined as: tcSI minus phSI. RESULTS There were 6990 major trauma patients and 360 (5.2%) received MT. There were 1371 cases with either phSI or tcSI missing and were thus excluded from the analysis. The 'Dichotomised' had higher positive predictive value than the tcSI with a further 5 per 100 patients identified. The 'Formulaic' model, defined as: log Odds (MT)=2.16×tcSI+0.89×phSI-5.42, and the 'Combination' model, defined as: phSI×0.5+tcSI, performed equally (AUROC 0.83 versus 0.83, χ(2)=0.86, p=0.35). The 'Formulaic' performed marginally, but statistically significantly, more accurate than the tcSI alone (AUROC 0.83 versus 0.82, χ(2)=6.89, p<0.01). An 'Upward Trending' SI was observed in 1758 patients, revealing a 4.6-fold univariate association with MT (OR 4.55; 95%CI 2.64-7.83), and an AUROC of 0.79 (95%CI 0.74-0.83). The 'Downward Trending' SI was protective against MT (OR 0.44; 95%CI 0.34-0.57). CONCLUSION The initial pre-hospital SI is associated with MT. However, this relationship did not clinically augment MT decision when combined with the in-hospital SI. The simplicity of the SI makes it a favourable option to explore further. Computer-assisted technology in data capturing, analysis and prognostication presents avenues for further research.
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Affiliation(s)
- Alexander Olaussen
- Monash University, Clayton, Victoria, Australia; Monash University, Department of Community Emergency Health and Paramedic Practice, Australia; Trauma Service, The Alfred Hospital, Australia; Emergency & Trauma Centre, The Alfred Hospital, Australia; National Trauma Research Institute, The Alfred Hospital, Australia.
| | | | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia; National Trauma Research Institute, The Alfred Hospital, Australia
| | - Gerard O'Reilly
- Trauma Service, The Alfred Hospital, Australia; Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia
| | - Paul A Jennings
- Monash University, Department of Community Emergency Health and Paramedic Practice, Australia; Ambulance Victoria, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- Trauma Service, The Alfred Hospital, Australia; National Trauma Research Institute, The Alfred Hospital, Australia
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108
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Pasquier P, Dubost C, Malgras B, Kearns K, Mérat S. The shock index for pre-hospital identification of trauma patients with early acute coagulopathy and massive bleeding. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:152. [PMID: 25887371 PMCID: PMC4376331 DOI: 10.1186/s13054-015-0839-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Pierre Pasquier
- Intensive Care Unit, Bégin Military Teaching Hospital, 69 avenue de Paris, 96160, Saint-Mandé, France.
| | - Clément Dubost
- Intensive Care Unit, Bégin Military Teaching Hospital, 69 avenue de Paris, 96160, Saint-Mandé, France.
| | - Brice Malgras
- Department of Surgery, Val-de-Grâce Military Teaching Hospital, 74 boulevard de Port Royal, 75005, Paris, France.
| | - Kevin Kearns
- Intensive Care Unit, Bégin Military Teaching Hospital, 69 avenue de Paris, 96160, Saint-Mandé, France.
| | - Stéphane Mérat
- Intensive Care Unit, Bégin Military Teaching Hospital, 69 avenue de Paris, 96160, Saint-Mandé, France.
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109
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Galvagno SM, Hu P, Yang S, Gao C, Hanna D, Shackelford S, Mackenzie C. Accuracy of continuous noninvasive hemoglobin monitoring for the prediction of blood transfusions in trauma patients. J Clin Monit Comput 2015; 29:815-21. [PMID: 25753142 DOI: 10.1007/s10877-015-9671-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 02/23/2015] [Indexed: 11/27/2022]
Abstract
Early detection of hemorrhagic shock is required to facilitate prompt coordination of blood component therapy delivery to the bedside and to expedite performance of lifesaving interventions. Standard physical findings and vital signs are difficult to measure during the acute resuscitation stage, and these measures are often inaccurate until patients deteriorate to a state of decompensated shock. The aim of this study is to examine a severely injured trauma patient population to determine whether a noninvasive SpHb monitor can predict the need for urgent blood transfusion (universal donor or additional urgent blood transfusion) during the first 12 h of trauma patient resuscitation. We hypothesize that trends in continuous SpHb, combined with easily derived patient-specific factors, can identify the immediate need for transfusion in trauma patients. Subjects were enrolled if directly admitted to the trauma center, >17 years of age, and with a shock index (heart rate/systolic blood pressure) >0.62. Upon admission, a Masimo Radical-7 co-oximeter sensor (Masimo Corporation, Irvine, CA) was applied, providing measurement of continuous non-invasive hemoglobin (SpHb) levels. Blood was drawn and hemoglobin concentration analyzed and conventional pulse oximetry photopletysmograph signals were continuously recorded. Demographic information and both prehospital and admission vital signs were collected. The primary outcome was transfusion of at least one unit of packed red blood cells within 24 h of admission. Eight regression models (C1-C8) were evaluated for the prediction of blood use by comparing area under receiver operating curve (AUROC) at different time intervals after admission. 711 subjects had continuous vital signs waveforms available, to include heart rate (HR), SpHb and SpO2 trends. When SpHb was monitored for 15 min, SpHb did not increase AUROC for prediction of transfusion. The highest ROC was recorded for model C8 (age, sex, prehospital shock index, admission HR, SpHb and SpO2) for the prediction of blood products within the first 3 h of admission. When data from 15 min of continuous monitoring were analyzed, significant improvement in AUROC occurred as more variables were added to the model; however, the addition of SpHb to any of the models did not improve AUROC significantly for prediction of blood use within the first 3 h of admission in comparison to analysis of conventional oximetry features. The results demonstrate that SpHb monitoring, accompanied by continuous vital signs data and adjusted for age and sex, has good accuracy for the prediction of need for transfusion; however, as an independent variable, SpHb did not enhance predictive models in comparison to use of features extracted from conventional pulse oximetry. Nor was shock index better than conventional oximetry at discriminating hemorrhaging and prediction of casualties receiving blood. In this population of trauma patients, noninvasive SpHb monitoring, including both trends and absolute values, did not enhance the ability to predict the need for blood transfusion.
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Affiliation(s)
- Samuel M Galvagno
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA.
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Peter Hu
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shiming Yang
- Department of Biomedical Engineering, University of Maryland, Baltimore County (UMBC), Baltimore, MD, USA
| | - Cheng Gao
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - David Hanna
- University of Maryland School of Medicine, Baltimore, USA
| | - Stacy Shackelford
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
- Center for Sustainment in Trauma and Readiness Skills (Baltimore-CSTARS), United States Air Force, Baltimore, MD, USA
| | - Colin Mackenzie
- Department of Anesthesiology, University of Maryland School of Medicine, 22 South Greene Street, T1R83, Baltimore, MD, 21201, USA
- Program in Trauma, R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
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Yang S, Njoku M, Mackenzie CF. 'Big data' approaches to trauma outcome prediction and autonomous resuscitation. Br J Hosp Med (Lond) 2015; 75:637-41. [PMID: 25383434 DOI: 10.12968/hmed.2014.75.11.637] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Massive clinical digital data routinely collected by high throughput biomedical devices provide opportunities and challenges for optimal use. This article discusses how such data are used in learning prediction models at level 1 trauma centres to support decision making in trauma patients.
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Affiliation(s)
- Shiming Yang
- Data Analyst, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA
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111
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Ilancheran A, Rahman F, Mitra B. Indications for blood transfusion following trauma - a pilot study. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2015. [DOI: 10.5339/jemtac.2015.4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: Indications for blood transfusion during trauma resuscitation remain poorly understood. This study aimed to objectively determine the range of factors that lead to initiation of blood transfusion during trauma resuscitation. Design and method: This was a prospective, observational pilot study. A questionnaire was distributed to all clinicians following any transfusion of packed red blood cells during trauma resuscitation. The questionnaire focused on the clinicians’ opinion regarding the indication for red cell transfusion. Results: Complete data on 37 individual episodes of transfusion initiation in the Emergency Department were collected. The most commonly used pre-hospital factors that influenced initiation of transfusion was a pre-hospital systolic blood pressure (SBP) of < 100 mm Hg (65%), pre-hospital tachycardia (38%) or estimated blood loss of >1 L (30%) by paramedics. On arrival to hospital, the activation of a massive transfusion protocol was the commonest indication for transfusion, followed by a positive FAST examination (43%), low systolic blood pressure (35%), tachycardia (32%) or pallor (35%). Blood tests to guide initiation of transfusion were less commonly used with 9 (24%) patients transfused for a low haemoglobin level and 6 (16%) patients transfused for coagulopathy. Conclusions: A combination of objective pre- and in-hospital vital signs, together with subjective indicators such as pallor and estimation of blood loss guided initiation of transfusion following injury.
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Affiliation(s)
- Arun Ilancheran
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Fatima Rahman
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Monash University, Australia
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112
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Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg 2015; 50:331-4. [PMID: 25638631 DOI: 10.1016/j.jpedsurg.2014.08.009] [Citation(s) in RCA: 133] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2014] [Accepted: 08/13/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Shock index (SI) (heart rate/systolic blood pressure)>0.9 predicts mortality in adult trauma patients. We hypothesized that age adjusted SI could more accurately predict outcomes in children. METHODS Retrospective review of children age 4-16 years admitted to two trauma centers between 1/07 and 6/13 following blunt trauma with an injury severity score (ISS)>15 was performed. We evaluated the ability of SI>0.9 at emergency department presentation and elevated shock index, pediatric age adjusted (SIPA) to predict outcomes. SIPA was defined by maximum normal HR and minimum normal SBP by age. Cutoffs included SI>1.22 (age 4-6), >1.0 (7-12), and >0.9 (13-16). RESULTS Among 543 children, 50% of children had an SI>0.9 but this fell to 28% using age adjusted SI (SIPA). SIPA demonstrated improved discrimination of severe injury relative to SI: ISS>30: 37% vs 26%; blood transfusion within the first 24 hours: 27% vs 20%; Grade III liver/spleen laceration requiring blood transfusion: 41% vs 26%; and in-hospital mortality: 11% vs 7%. CONCLUSION A pediatric specific shock index (SIPA) more accurately identifies children who are most severely injured, have intraabdominal injury requiring transfusion, and are at highest risk of death when compared to shock index unadjusted for age.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - James T Ross
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA.
| | - Suhong Tong
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, CO USA.
| | - Denis D Bensard
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO USA; Department of Surgery, Denver Health Medical Center, Denver, CO USA.
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113
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Toccaceli A, Giampaoletti A, Dignani L, Lucertini C, Petrucci C, Lancia L. The role of shock index as a predictor of multiple-trauma patients' pathways. Nurs Crit Care 2015; 21:e12-9. [PMID: 25641362 DOI: 10.1111/nicc.12152] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2014] [Revised: 11/04/2014] [Accepted: 12/08/2014] [Indexed: 11/29/2022]
Abstract
OBJECTIVES This research was conducted with the aim of investigating the accuracy of the shock index (SI) in distinguishing which multiple-trauma patients should be admitted to an intensive care unit (ICU) after treatment in an emergency room (ER). BACKGROUND The SI is an easily obtained indicator, as it corresponds to an arithmetic ratio between the two parameters that are always measured during the first-aid treatment of multiple-trauma patients: heart rate (HR) and systolic blood pressure (SBP). There are many studies examining the SI in the multiple-trauma patients as a possible predictor of the destination unit. The SI is evaluated both at the trauma scene (pre-hospital SI-pH) and in the emergency room (SI-ER). DESIGN AND METHODS An observational study with a retrospective approach was conducted on 158 adult patients with multiple trauma. RESULTS The mean SI-pH and SI-ER values were higher in ICU patients than in-patients discharged or admitted to a normal ward, but the difference between these two patient groups was significant only for the SI-ER. Analysis of the receiver operating characteristic (ROC) curves confirmed that only the SI-ER is significant as a reliable indicator for ICU admission with a best cut-off of 1·05. However, a threshold value of 0·75 was still able to establish the correct type of destination for multiple-trauma patients, with a sensitivity of 57·3% and a specificity of 62·5%. CONCLUSIONS This research showed that the SI-pH and SI-ER values are correlated, but only the SI-ER has shown statistical significance in terms of distinguishing the type of destination of multiple-trauma patient (ICU, ordinary ward or discharge) after initial treatment in the ER. RELEVANCE TO CLINICAL PRACTICE The results of this study suggest the possibility of using SI in multiple-trauma patients as a triage indicator to assess the patients' care complexity and to guide the choice of proper clinical paths.
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Affiliation(s)
- Andrea Toccaceli
- Department of Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Andrea Giampaoletti
- Nursing Critical Care, Faculty of Medicine and Surgery of Ancona, Ancona, Italy
| | - Lucia Dignani
- Department of Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Carla Lucertini
- Department of Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Cristina Petrucci
- Department of Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
| | - Loreto Lancia
- Department of Health, Life and Environmental Sciences, University of L'Aquila, L'Aquila, Italy
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Mitra B, Nash JL, Cameron PA, Fitzgerald MC, Moloney J, Velmahos GC. Potentially avoidable blood transfusion during trauma resuscitation. Injury 2015; 46:10-4. [PMID: 25280387 DOI: 10.1016/j.injury.2014.08.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2014] [Revised: 08/21/2014] [Accepted: 08/30/2014] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Red blood cell (RBC) transfusion is often essential during trauma resuscitation but is associated with high cost and potential adverse outcomes. This study aimed to determine the incidence of potentially avoidable RBC transfusions (PAT) among adult major trauma patients. MATERIALS AND METHODS A retrospective review of data collected by <name blinded> Registry on patients presenting between Jan 2006 and Dec 2011 was conducted. Eligible patients received at least 1 unit of RBC in the first 24h following presentation to the Emergency Department (ED). Episodes of PAT were determined according to haemodynamic stability and post-transfusion haemoglobin levels. RESULTS There were 621 patients included, of whom 224 (36.1%; 95% CI: 32.3-40.0) received PAT. Of them, 132 (58.9%) were haemodynamically stable on arrival and did not require a surgical procedure. Patients with PAT had significantly lower injury severity scores (30 vs 34, p<0.01), higher presenting systolic blood pressure (129 vs 112mm Hg, p<0.01) and a lower frequency of a shock index ≥1 (24.1 vs 65.0%, p<0.01), compared to those without PAT. They also had a significantly lower mortality (13.4 vs 21.7%, p<0.01). CONCLUSIONS PAT after trauma was common and often delivered to haemodynamically stable patients who did not require surgical procedures. Clinical decision pathways for trauma resuscitation should aim to limit PAT.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Deparment of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Emergency Medicine, Hamad Medical Corporation, Doha, Qatar.
| | - Jessica L Nash
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Peter A Cameron
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia; Deparment of Epidemiology & Preventive Medicine, Monash University, Melbourne, Australia; Emergency Medicine, Hamad Medical Corporation, Doha, Qatar; National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Mark C Fitzgerald
- National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia; Trauma Service, The Alfred Hospital, Melbourne, Australia
| | - John Moloney
- Anaesthesia & Perioperative Medicine, The Alfred Hospital, Melbourne, Australia
| | - George C Velmahos
- Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, USA; Harvard Medical School, Boston, USA
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Nathan HL, El Ayadi A, Hezelgrave NL, Seed P, Butrick E, Miller S, Briley A, Bewley S, Shennan AH. Shock index: an effective predictor of outcome in postpartum haemorrhage? BJOG 2014; 122:268-75. [DOI: 10.1111/1471-0528.13206] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/16/2014] [Indexed: 11/29/2022]
Affiliation(s)
- HL Nathan
- Women's Health Academic Centre; King's College London; London UK
| | - A El Ayadi
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - NL Hezelgrave
- Women's Health Academic Centre; King's College London; London UK
| | - P Seed
- Women's Health Academic Centre; King's College London; London UK
| | - E Butrick
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - S Miller
- Safe Motherhood Programs; University of California; San Francisco CA USA
| | - A Briley
- Women's Health Academic Centre; King's College London; London UK
| | - S Bewley
- Women's Health Academic Centre; King's College London; London UK
| | - AH Shennan
- Women's Health Academic Centre; King's College London; London UK
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Correlation of computed tomography angiography parameters and shock index to assess the transportation risk in aortic dissection patients. Radiol Med 2014; 120:386-92. [PMID: 25348137 DOI: 10.1007/s11547-014-0463-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Accepted: 05/30/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic dissection (AD) is a serious, life-threatening disease. It is currently crucial for AD patients to be transferred to a specialised hospital in a safe and timely manner. For this reason, the search for clinical and imaging changes related to transportation risk is becoming increasingly important. PURPOSE The transportation risks of AD patients were assessed by studying the correlation between computed tomography angiography (CTA) parameters and shock index. MATERIALS AND METHODS Thirty-six cases of AD confirmed with 64-slice volumetric CT (VCT) (18 cases of Stanford type A and 18 cases of type B) were divided into a high-risk group (14 cases, six Stanford type A and eight type B) and a low-risk group (22 cases, 12 Stanford type A and 10 type B) according to the modified Early Warning Score. The shock index (ratio of heart rate to systolic blood pressure) and measured CTA parameters were compared between the high-risk group and the low-risk group, and the correlation between the measured CTA parameters and shock index was analysed. RESULTS The shock index and ratio of false/true lumen were compared between Stanford type A and type B, and no statistically significant differences were found. The shock index and ratio of false/true lumen were compared between the high-risk group and low-risk group, revealing a statistically significant difference (p < 0.05). Moreover, a significant linear correlation was found between the ratio of false/true lumen and the shock index (r = 0.691; p = 0.001). CONCLUSION The higher the shock index and the ratio of false/true lumen are, the greater the transportation risk for AD patients. The shock index and the ratio of false/true lumen proved to be essential clinical and radiological indices for assessing the transportation risk of AD patients.
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Driessen A, Schäfer N, Albrecht V, Schenk M, Fröhlich M, Stürmer EK, Maegele M. Infrastructure and clinical practice for the detection and management of trauma-associated haemorrhage and coagulopathy. Eur J Trauma Emerg Surg 2014; 41:413-20. [PMID: 26037989 DOI: 10.1007/s00068-014-0455-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/06/2014] [Indexed: 01/02/2023]
Abstract
PURPOSE Early detection and management of post-traumatic haemorrhage and coagulopathy have been associated with improved outcomes, but local infrastructures, logistics and clinical strategies may differ. METHODS To assess local differences in infrastructure, logistics and clinical management of trauma-associated haemorrhage and coagulopathy, we have conducted a web-based survey amongst the delegates to the 15th European Congress of Trauma and Emergency Surgery (ECTES) and the 2nd World Trauma (WT) Congress held in Frankfurt, Germany, 25-27 May 2014. RESULTS 446/1,540 delegates completed the questionnaire yielding a response rate of 29%. The majority specified to work as consultants/senior physicians (47.3%) in general (36.1%) or trauma/orthopaedic surgery (44.5%) of level I (70%) or level II (19%) trauma centres. Clinical assessment (>80%) and standard coagulation assays (74.6%) are the most frequently used strategies for early detection and monitoring of bleeding trauma patients with coagulopathy. Only 30% of the respondents declared to use extended coagulation assays to better characterise the bleeding and coagulopathy prompted by more individualised treatment concepts. Most trauma centres (69%) have implemented local protocols based on international and national guidelines using conventional blood products, e.g. packed red blood cell concentrates (93.3%), fresh frozen plasma concentrates (93.3%) and platelet concentrates (83%), and antifibrinolytics (100%). 89% considered the continuous intake of anticoagulants including "new oral anticoagulants" and platelet inhibitors as an increasing threat to bleeding trauma patients. CONCLUSIONS This study confirms differences in infrastructure, logistics and clinical practice for the detection and management of trauma-haemorrhage and trauma-associated coagulopathy amongst international centres. Ongoing work will focus on geographical differences.
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Affiliation(s)
- A Driessen
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University (Campus Cologne-Merheim), Ostmerheimerstr 200, 51109, Cologne, Germany,
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Akasaki Y, Sugimori H, Momii K, Akahoshi T, Matsuura S, Iwamoto Y, Maehara Y, Hashizume M. A simple predictive formula for the blood requirement in patients with high-energy blunt injuries transferred within one hour post-trauma. Acute Med Surg 2014; 2:82-91. [PMID: 29123699 DOI: 10.1002/ams2.74] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/29/2014] [Indexed: 11/08/2022] Open
Abstract
Aims To recognize patients who require massive transfusion at the early stage of blunt trauma, we retrospectively investigated patients with high-energy blunt injuries transferred within 1 h post-trauma. Methods Between August 2007 and July 2011, 233 trauma patients were: (i) injured by a high-energy blunt mechanism with Injury Severity Score ≥9; (ii) not dead on arrival; (iii) older than 9 years; and (iv) at our center within 1 h after injury. The findings for 113 of those patients were analyzed, including those produced by ultrasonography, computed tomography, and arterial blood gas analyses. Results Of 113 patients, 33 underwent massive transfusion (≥6 units) within 8 h of arrival. A logistic regression analysis revealed that an arterial lactate level ≥28 mg/dL (P < 0.001; odds ratio, 105.11; 95% confidence interval, 12.58-2,718.84) and a flat ratio of the inferior vena cava on computed tomography ≥3 (P < 0.001; odds ratio, 32.50; 95% confidence interval, 4.44-714.44) were significant independent predictors for a massive transfusion within 8 h. In a receiver operating curve analysis, the area under the curve of the need for massive transfusion was 0.956, with a sensitivity of 0.94 and a specificity of 0.90. A linear predictive formula for the probability (P) of receiving a massive transfusion was generated as P = 2 × lactate (mg/dL) + 15 × the flat ratio of inferior vena cava - 103. Using another 52 trauma patients, the formula was validated. Conclusions An elevated level of arterial lactate and the flat ratio of inferior vena cava were significant predictors for identifying the patients who would require a massive transfusion in the early stage after high-energy blunt trauma.
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Affiliation(s)
- Yukio Akasaki
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Hiroshi Sugimori
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Kenta Momii
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Tomohiko Akahoshi
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Suguru Matsuura
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery Graduate School of Medical Sciences Kyushu University Fukuoka Japan
| | - Yoshihiko Maehara
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
| | - Makoto Hashizume
- Emergency and Critical Care Center Kyushu University Hospital Fukuoka Japan
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Trentzsch H, Nienaber U, Behnke M, Lefering R, Piltz S. Female sex protects from organ failure and sepsis after major trauma haemorrhage. Injury 2014; 45 Suppl 3:S20-8. [PMID: 25284229 DOI: 10.1016/j.injury.2014.08.013] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Biological sex is considered a risk factor for adverse outcome after major trauma. We hypothesized that female sex is protective against organ failure, sepsis and mortality in patients with traumatic haemorrhage. PATIENTS AND METHODS We selected patients from TraumaRegister DGU(®) (TR-DGU) with primary admission for blunt trauma with an injury severity score ≥ 16 and an ICU stay ≥ 3 days that presented with relevant bleeding in the years 2007-2012. Relevant bleeding was defined as Abbreviated Injury Scale (AIS) ≥ 3 with an estimated blood loss exceeding 20%, any femoral shaft fracture, any pelvic clamp as surrogate for unstable pelvic fracture or the presence of at least one criteria of haemorrhagic shock: shock index of 0.8-1.4; base excess of -2.0 to -10.0 mmol/L; body temperature ≤ 34°C; transfusion of ≥ 4 units of packed red blood cells; application of recombinant activated factor VII; any embolization during trauma room phase and pre-hospital resuscitation volume ≥ 3000 ml or any catecholamine use during pre-hospital care in the absence of cardiopulmonary resuscitation. A total of 7560 males and 2774 females were selected and analyzed for sex differences. RESULTS Higher rates of multiple organ failure (24.4 vs. 21.3%, Odds ratio [OR] 1.19 (95% confidence interval [95%CI] 1.07-1.33), p=0.001*) and sepsis (16.5 vs. 11.3%, OR 1.55 (95%CI 1.35-1.77), p<0.001*) were observed in males. Organ function of lung, cardio-circulatory system, liver and kidney were better in females, however, there was no difference in mortality. Stratification by age group revealed that in particular age-group 16-44 years was related to improved organ function which may indicate effects of sex hormones in females at reproductive age. Increased rates of sepsis in males were observed throughout virtually all age groups starting at 16 years of age, except in age group 54-64 years. This may suggest suppressive effect of testosterone on immune function. CONCLUSIONS Our study supports the hypothesis that female sex is associated with improved organ function following traumatic injury and haemorrhagic shock, in particular in age groups that are at reproductive age. However, further studies are warranted before sex steroids can be deployed as therapeutic intervention in critically ill trauma patients.
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Affiliation(s)
- H Trentzsch
- Institute for Emergency Medicine and Management in Medicine (INM), University Hospital of Munich, Campus Innenstadt, Munich, Germany.
| | - U Nienaber
- Academy for Trauma Surgery (AUC), Munich, Germany
| | - M Behnke
- Department of Surgery, University Hospital of Munich, Campus Großhadern, Munich, Germany
| | - R Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Campus Cologne-Merhein, Cologne, Germany
| | - S Piltz
- Department of Surgery, University Hospital of Munich, Campus Großhadern, Munich, Germany
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121
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Automated prediction of early blood transfusion and mortality in trauma patients. J Trauma Acute Care Surg 2014; 76:1379-85. [PMID: 24854304 DOI: 10.1097/ta.0000000000000235] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prediction of blood transfusion needs and mortality for trauma patients in near real time is an unrealized goal. We hypothesized that analysis of pulse oximeter signals could predict blood transfusion and mortality as accurately as conventional vital signs (VSs). METHODS Continuous VS data were recorded for direct admission trauma patients with abnormal prehospital shock index (SI = heart rate [HR] / systolic blood pressure) greater than 0.62. Predictions of transfusion during the first 24 hours and in-hospital mortality using logistical regression models were compared with DeLong's method for areas under receiver operating characteristic curves (AUROCs) to determine the optimal combinations of prehospital SI and HR, continuous photoplethysmographic (PPG), oxygen saturation (SpO2), and HR-related features. RESULTS We enrolled 556 patients; 37 received blood within 24 hours; 7 received more than 4 U of red blood cells in less than 4 hours or "massive transfusion" (MT); and 9 died. The first 15 minutes of VS signals, including prehospital HR plus continuous PPG, and SpO2 HR signal analysis best predicted transfusion at 1 hour to 3 hours, MT, and mortality (AUROC, 0.83; p < 0.03) and no differently (p = 0.32) from a model including blood pressure. Predictions of transfusion based on the first 15 minutes of data were no different using 30 minutes to 60 minutes of data collection. SI plus PPG and SpO2 signal analysis (AUROC, 0.82) predicted 1-hour to 3-hour transfusion, MT, and mortality no differently from pulse oximeter signals alone. CONCLUSION Pulse oximeter features collected in the first 15 minutes of our trauma patient resuscitation cohort, without user input, predicted early MT and mortality in the critical first hours of care better than the currently used VS such as combinations of HR and systolic blood pressure or prehospital SI alone. LEVEL OF EVIDENCE Therapeutic/prognostic study, level II.
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Schweigkofler U, Hoffmann R. [Preclinical treatment of multiple trauma : what is important?]. Chirurg 2014; 84:739-44. [PMID: 23942888 DOI: 10.1007/s00104-013-2475-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Multiple trauma is still the most common cause of death in the age group below 40 years but rarely occurs in prehospital emergencies in Germany. Therefore, personal experience of emergency physicians in prehospital treatment of multiple trauma is often limited. Priority-based therapy according to standardized algorithms and advances in clinical and intensive care have reduced hospital mortality down to 13 %. Time factors, treatment and transport by Helicopter Emergency Medical Services seem to have had a significant impact on the outcome. The current German multiple trauma S3 guidelines provide algorithms for preclinical treatment. The underlying scientific evidence in this respect is, however, low.
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Affiliation(s)
- U Schweigkofler
- Notfall- und Rettungszentrum, Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389, Frankfurt, Deutschland,
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Glasgow SM, Allard S, Rackham R, Doughty H. Going for gold: blood planning for the London 2012 Olympic Games. Transfus Med 2014; 24:145-53. [PMID: 24750387 DOI: 10.1111/tme.12116] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 02/04/2014] [Accepted: 02/20/2014] [Indexed: 11/29/2022]
Abstract
The Olympics is one of the largest sporting events in the world. Major events may be complicated by disruption of normal activity and major incidents. Health care and transfusion planners should be prepared for both. Previously, transfusion contingency planning has focused on seasonal blood shortages and pandemic influenzas. This article is the first published account of transfusion contingency planning for a major event. We describe the issues encountered and the lessons identified during transfusion planning for the London 2012 Olympics. Planning was started 18 months in advance and was led by a project team reporting to the Executive. Planning was based on three periods of Gamestime. The requirements were planned with key stakeholders using normal processes enhanced by service developments. Demand planning was based on literature review together with computer modelling. The aim was blood-stock sufficiency complimented by a high readiness donor panel to minimise waste. Plans were widely communicated and table-top exercised. Full transfusion services were maintained during both Games with all demands met. The new service improvements and high readiness donors worked well. Emergency command and control have been upgraded. Red cell concentrate (RCC) stock aged but wastage was not significantly increased. The key to success was: early planning, stakeholder engagement, service developments, integration of transfusion service planning within the wider health care community and conduct within an assurance framework.
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Affiliation(s)
- S M Glasgow
- Trauma Sciences, Blizard Institute, Barts and the London School of Medicine & Dentistry, Queen Mary University of London, London, UK
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Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care Surg 2014; 76:1111-5. [PMID: 24662879 DOI: 10.1097/ta.0000000000000160] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Heart rate and systolic blood pressure are unreliable in geriatric trauma patients. Shock index (SI) (heart rate/systolic blood pressure) is a simple marker of worse outcomes after injury. The aim of this study was to assess the utility of SI in predicting outcomes. We hypothesized that SI predicts mortality in geriatric trauma patients. METHODS We performed a 4-year (2007-2010) retrospective analysis using the National Trauma Data Bank. Patients 65 years or older were included. Transferred patients, patients dead on arrival, missing vitals on presentation, and patients with burns and traumatic brain injury were excluded. A cutoff value of SI greater than or equal to 1 (sensitivity, 81%; specificity, 79%) was used to define hemodynamic instability. The primary outcome measure was mortality. Secondary outcome measures were need for blood transfusion, need for exploratory laparotomy, and development of in-hospital complications. Multiple logistic regressions were performed. RESULTS A total of 485,595 geriatric patients were reviewed, of whom 217,190 were included. The mean (SD) age was 77.7 (7.1) years, 60% were males, median Glasgow Coma Scale (GCS) score was 14 (range, 3-15), median Injury Severity Score (ISS) was 9 (range, 4-18), and mean (SD) SI was 0.58 (0.18). Three percent (n = 6,585) had an SI greater than or equal to 1. Patients with SI greater than or equal to 1 were more likely to require blood product requirement (p = 0.001), require an exploratory laparotomy (p = 0.01), and have in-hospital complications (p = 0.02). The overall mortality rate was 4.1% (n = 8,952). SI greater than or equal to 1 was the strongest predictor for mortality (odds ratio, 3.1; 95% confidence interval, 2.6-3.3; p = 0.001) in geriatric trauma patients. Systolic blood pressure (p = 0.09) and heart rate (p = 0.2) were not predictive of mortality. CONCLUSION SI is an accurate and specific predictor of morbidity and mortality in geriatric trauma patients. SI is superior to heart rate and systolic blood pressure for predicting mortality in geriatric trauma patients. Geriatric trauma patients with SI greater than or equal to 1 should be transferred to a Level 1 trauma center. LEVEL OF EVIDENCE Prognostic/epidemiologic study, level III.
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Vassallo J, Horne S, Ball S, Smith JE. Usefulness of the Shock Index as a secondary triage tool. J ROY ARMY MED CORPS 2014; 161:53-7. [DOI: 10.1136/jramc-2013-000178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Olaussen A, Blackburn T, Mitra B, Fitzgerald M. Review article: Shock Index for prediction of critical bleeding post-trauma: A systematic review. Emerg Med Australas 2014; 26:223-8. [DOI: 10.1111/1742-6723.12232] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Alexander Olaussen
- Department of Community Emergency Health and Paramedic Practice; Monash University; Melbourne Victoria Australia
- Trauma Service; The Alfred Hospital; Melbourne Victoria Australia
| | | | - Biswadev Mitra
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Victoria Australia
- National Trauma Research Institute; Melbourne Victoria Australia
| | - Mark Fitzgerald
- Trauma Service; The Alfred Hospital; Melbourne Victoria Australia
- National Trauma Research Institute; Melbourne Victoria Australia
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Mitra B, Fitzgerald M, Chan J. The utility of a shock index ≥ 1 as an indication for pre-hospital oxygen carrier administration in major trauma. Injury 2014; 45:61-5. [PMID: 23391451 DOI: 10.1016/j.injury.2013.01.010] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 01/03/2013] [Accepted: 01/04/2013] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND AIMS The use of intravenous oxygen carriers (packed red blood cells (PRBC), whole blood and synthetic haemoglobins (HBOCs) for selected pre-hospital trauma resuscitation cases has been reported, despite a lack of validated clinical indications. The aim of this study was to retrospectively identify a sub-group of adult major trauma patients most likely to benefit from pre-hospital oxygen carrier administration and determine the predictive relationship between pre-hospital shock index (SI) [pulse rate/systolic blood pressure] and haemorrhagic shock, blood transfusion and mortality. METHODS A retrospective review of adult major trauma patients recorded in The Alfred Trauma Registry was conducted. Patients were included if they received at least 1L of pre-hospital crystalloid and spent over 30 min in transit. The association of shock index and transfusion was determined. Patients were further sub-grouped by mode of transport to determine the population of trauma patients who could be included into prospective studies of intravenous oxygen carriers. RESULTS There were 1149 patients included of whom 311 (21.9%) received an acute blood transfusion. The SI correlated well with transfusion practice. A SI ≥ 1.0, calculated after at least 1L of crystalloid transfusion, identified patients with a high specificity (93.5%; 95% CI: 91.8-94.8) for receiving a blood transfusion within 4h of hospital arrival. While patients transported by helicopter had higher injury severity and blood transfusion requirement, there were no difference in physiological variables and outcomes when compared to patients transported by road car. CONCLUSIONS A shock index ≥ 1.0 is an easily calculated variable that may identify patients for inclusion into trials for pre-hospital oxygen carriers. Shocked patients have high mortality rates whether transported by road car or by helicopter. The efficacy of pre-hospital intravenous oxygen carriers should be trialled using a shock index ≥ 1.0 despite fluid resuscitation as the clinical trigger for administration.
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Affiliation(s)
- Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia; Transfusion Research Unit, Department of Epidemiology & Preventive Medicine, Monash University, Victoria, Australia; National Trauma Research Institute, Melbourne, Victoria, Australia.
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Charbit J, Millet I, Lakhal K, Brault-Noble G, Guillon F, Taourel P, Capdevila X. A haemoperitoneum does not indicate active bleeding in the peritoneum in 50% of hypotensive blunt trauma patients: a study of 110 severe trauma patients. Injury 2014; 45:88-94. [PMID: 22769979 DOI: 10.1016/j.injury.2012.05.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2012] [Revised: 04/05/2012] [Accepted: 05/15/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND We hypothesised that in blunt trauma patients with haemodynamic instability and haemoperitoneum on hospital admission, the haemorrhagic source may not be confined to the peritoneum. The purpose of this study was to describe the incidence and location of bleeding source in this population. METHODS The charts of trauma patients admitted consecutively between January 2005 and January 2010 to our level I Regional Trauma Centre were reviewed retrospectively. All hypotensive patients presenting a haemoperitoneum on admission were included. Hypotension was defined by a systolic blood pressure ≤ 90 mmHg. The haemoperitoneum was quantified on CT images or from operative reports as moderate (Federle score<3 or between 200 and 500 ml) or large (Federle score ≥ 3 or >500 ml). Active bleeding (AB) was defined as injury requiring a surgical or radiologic haemostatic procedure, regardless of origin (peritoneal (PAB) or extraperitoneal (EPAB)). RESULTS Of 1079 patients admitted for severe trauma, 110 patients met the inclusion criteria. Seventy-eight (71%) were male, mean age 35.3 (SD 19) years and mean ISS 36.5 (SD 20.5). Among the 91 patients who had AB, 37 patients (41%) had PAB, 34 (37%) had EPAB and 20 had both (22%). Forty-eight (53%) of them had moderate haemoperitoneum and 43 (47%) had large haemoperitoneum. A large haemoperitoneum had positive predictive value for PAB of 88% (95% CI 75-95%) and negative predictive value of 65% (95% CI 49-79%). The corresponding values in the subgroup of patients with EPAB were 65% (95% CI 38-86%) and 76% (95% CI 59-88%). CONCLUSION Haemoperitoneum was associated with PAB in only 52% of hypotensive blunt trauma patients and 63% of bleeding patients. In contrast, 59% of bleeding patients had at least one EPAB. The screening of a haemoperitoneum as a marker of active haemorrhagic source may be confusing and lead to misdiagnosis and inappropriate strategy. Clinician should exclude carefully the presence of any EPAB explaining haemorrhagic shock, before to decide haemostatic treatment.
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Affiliation(s)
- J Charbit
- Department of Anesthesiology and Critical Care, Lapeyronie University Hospital, Montpellier, F-34295 Cedex 5, France.
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Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery? J Anesth 2013; 28:381-9. [PMID: 24141883 DOI: 10.1007/s00540-013-1727-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2013] [Accepted: 10/02/2013] [Indexed: 10/26/2022]
Abstract
PURPOSE Early operative control of hemorrhage is the key to saving the lives of severe trauma patients. We investigated whether emergency room (ER) stay time [time from the ER to the operating room (OR)] is associated with trauma severity and unexpected trauma death [Trauma and Injury Severity Score (TRISS) method-based probability of survival (Ps) ≥0.5 but died] of injured patients needing emergency trauma surgery. METHODS We performed a retrospective review of all trauma patients requiring emergency surgery and all patients with pelvic fractures requiring transcatheter arterial embolization at our hospital from January 2002 to December 2012. We analyzed the relationships among injury severity on ER admission [Injury Severity Score (ISS); Revised Trauma Score (RTS); Ps; Shock Index (SI); American Society of Anesthesiologists Physical Status (ASA-PS)]; mortality rate; unexpected trauma death rate; and ER stay time. RESULTS ER stay times were significantly shorter for patients with life-threatening conditions [RTS <6.0 (p < 0.01), Ps <0.5 (p < 0.001), SI ≥1.0 (p < 0.01), and ASA-PS ≥4E (p < 0.001)]. In particular, ER stay time was inversely related to injury severity up to 120 min. The risk of unexpected trauma death significantly increased as ER stay time increased over 90 min (p < 0.01). CONCLUSIONS Our results suggest that all medical staff should work together effectively on high-risk patients in the ER, bringing them immediately to the OR according to their level of risk. If injured patients need emergency trauma surgery, ER stay times should be kept as short as possible to reduce unexpected trauma death.
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131
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Peterson KL, Hardy BT, Hall K. Assessment of shock index in healthy dogs and dogs in hemorrhagic shock. J Vet Emerg Crit Care (San Antonio) 2013; 23:545-50. [PMID: 24034472 DOI: 10.1111/vec.12090] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2012] [Accepted: 07/30/2013] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To compare the shock index (SI) in a population of healthy dogs to a population of dogs with confirmed hemorrhagic shock. DESIGN Retrospective analysis of data collected prospectively from 2 previous studies. SETTING University teaching hospital. ANIMALS Seventy-eight healthy control dogs enrolled in a study to establish a reference interval for a tissue oxygen monitor; 38 dogs with confirmed hemorrhagic shock enrolled in a study to evaluate the tissue oxygen monitor in hemorrhagic shock. The heart rate and systolic blood pressure obtained during the respective studies were used to calculate the SI. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Shock index was significantly higher in the hemorrhage group (median 1.37, range 0.78-4.35) than the control group (median 0.91, range 0.57-1.53); 92% of the dogs in hemorrhagic shock had an SI of >0.91. Compared with controls, dogs in hemorrhagic shock had significantly lower body temperatures (median 38.3°C, range 35.6-39.9°C versus median 38.7°C, range 37.5-39.9°C), higher heart rates (median 150/min, range 120-220/min versus median 110/min range 80-150/min), lower systolic blood pressures (mean 112 mm Hg, SD ±35.8 mm Hg versus mean 125 mm Hg, SD ±21.5 mm Hg), higher lactate concentrations (median 0.51 mmol/L, range 0.078-1.41 mmol/L versus median 0.11 mmol/L, range 0.033-0.33 mmol/L), and lower hemoglobin concentrations (median 81 g/L, range 56-183 g/L versus median 162.5 g/L, range 133-198 g/L). CONCLUSIONS Shock index is a simple and easy calculation that can be used as an additional triage tool and should prompt further investigation for hemorrhage if the values are >0.9.
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Affiliation(s)
- Katherine L Peterson
- Department of Veterinary Clinical Sciences, University of Minnesota, College of Veterinary Medicine, St Paul, MN, 55108
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Mutschler M, Nienaber U, Münzberg M, Wölfl C, Schoechl H, Paffrath T, Bouillon B, Maegele M. The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Crit Care 2013; 17:R172. [PMID: 23938104 PMCID: PMC4057268 DOI: 10.1186/cc12851] [Citation(s) in RCA: 179] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2013] [Accepted: 07/24/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Isolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters. METHODS Between 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock. RESULTS Worsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick's values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock. CONCLUSION SI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.
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DeMuro JP, Simmons S, Jax J, Gianelli SM. Application of the shock index to the prediction of need for hemostasis intervention. Am J Emerg Med 2013; 31:1260-3. [DOI: 10.1016/j.ajem.2013.05.027] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2013] [Revised: 04/26/2013] [Accepted: 05/20/2013] [Indexed: 11/27/2022] Open
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Porter AE, Rozanski EA, Sharp CR, Dixon KL, Price LL, Shaw SP. Evaluation of the shock index in dogs presenting as emergencies. J Vet Emerg Crit Care (San Antonio) 2013; 23:538-44. [PMID: 23855723 DOI: 10.1111/vec.12076] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2011] [Accepted: 06/09/2013] [Indexed: 12/01/2022]
Abstract
OBJECTIVES To (1) determine a reference interval for shock index (SI) [defined as heart rate (HR)/systolic blood pressure (SBP)], in a group of healthy dogs, and (2) compare SI in healthy dogs with dogs presenting to the emergency room (ER) deemed to be in or not in a state of shock. DESIGN Prospective study. ANIMALS Sixty-eight clinically normal dogs, 18 dogs that were presented to the ER deemed to be in shock and 19 dogs presenting to the ER not deemed to be in shock. SETTING University teaching hospital. INTERVENTIONS Peripheral or central venous blood sampling. MEASUREMENTS AND MAIN RESULTS Heart rate and SBP were recorded on simulated presentation (healthy dogs), and emergency presentations for both dogs deemed to be in shock and dogs not deemed in shock. Dogs in shock had a median SI of 1.37 (0.87-3.13), which was significantly higher than both other groups; dogs not deemed in shock had median SI 0.73 (0.56-1.20), P < 0.0001 and healthy dogs had median SI 0.78 (0.37-1.30) P < 0.0001), respectively. Receiver operator characteristic curve analysis suggested a SI cut-off of 1.0, yielding an area under the receiver operator characteristic (AUROC) of 0.89 (Specificity (Sp) 89, Sensitivity (Sn) 90) when comparing dogs deemed in shock with healthy dogs, and 0.92 (Sp 95, Sn 89) when comparing dogs in shock with to dogs not deemed in shock. CONCLUSIONS The SI is an easy and noninvasive patient parameter that is higher in dogs that are deemed to be in shock than both healthy dogs and dogs presented as emergencies but not deemed to be in a state of shock. The measurement of SI may have some benefit in clinical assessment of emergency patients.
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Affiliation(s)
- Adam E Porter
- Department of Clinical Sciences, Cummings School of Veterinary Medicine, Tufts University, North Grafton, MA, 01536
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135
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The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality. J Trauma Acute Care Surg 2013; 74:1432-7. [DOI: 10.1097/ta.0b013e31829246c7] [Citation(s) in RCA: 120] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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136
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Bruijns SR, Guly HR, Bouamra O, Lecky F, Wallis LA. The value of the difference between ED and prehospital vital signs in predicting outcome in trauma. Emerg Med J 2013; 31:579-582. [PMID: 23616498 DOI: 10.1136/emermed-2012-202271] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 04/01/2013] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Traditional vital signs are seen as an important part of trauma assessment, despite their poor predictive value in this regard. OBJECTIVE This study evaluated whether the difference between systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and shock index (SI) taken in the emergency department (ED) and prehospital can predict 48 h mortality postadmission following trauma. METHODS Retrospective cohort was obtained from the Trauma Audit and Research Network. Subjects were excluded if head or spinal injuries, prehospital intubation or CPR were present. Main outcome was 48 h mortality. The difference (delta, Δ) between ED and prehospital values were used as study variables (ie, ΔSI=SI-ED minus SI-prehospital). Accuracy was assessed using area under receiver operator characteristic curve (AUROC). AUROC coordinates were used to identify 95% specificity cut points and described further using sensitivity and likelihood ratios (LRs). RESULTS Significant AUROC statistics were revealed for ΔSBP (0.57) and ΔRR (0.56) for the full sample, ΔSBP (0.62) and ΔSI (0.65) for moderate, and ΔRR (0.6) for severe injury. Best LRs were 3.4 and 2.4 for ΔRR and ΔSI, respectively, but sensitivities were low (<=26%). Cut point values for ΔSBP, ΔRR and ΔSI were 37 mm Hg, 8 breaths/min and 0.2, respectively. DISCUSSION ΔSBP and ΔRR performed best overall, but ΔSI performed best in the moderate injury group, suggesting earlier identification with ΔSI. Use of Δ values result in good rule-in of 48 h mortality and may supplement trauma treatment decisions.
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Affiliation(s)
- Stevan R Bruijns
- Division of Emergency Medicine, University of Cape Town, Karl Bremer Hospital, Mike Pienaar Blvd, Bellville, South Africa.,Emergency Department, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Henry R Guly
- Emergency Department, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK
| | - Omar Bouamra
- Trauma Audit and Research Network, Health Sciences Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Salford Royal Hospital, Salford, UK
| | - Fiona Lecky
- Emergency Department, Derriford Hospital, Plymouth Hospitals NHS Trust, Plymouth, UK.,Emergency Medicine Research in Sheffield (EMRiS), Health Services Research, School of Health and Related Research, University of Sheffield, Regent's Court, Salford, UK
| | - Lee A Wallis
- Division of Emergency Medicine, University of Cape Town, Karl Bremer Hospital, Mike Pienaar Blvd, Bellville, South Africa
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Redefining massive transfusion when every second counts. J Trauma Acute Care Surg 2013; 74:396-400; discussion 400-2. [PMID: 23354230 DOI: 10.1097/ta.0b013e31827a3639] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The massive transfusion (MT) concept (>10-U packed red blood cells per 24 hours) is retrospective, arbitrary, and prone to survivor bias. Accounting for rate and timing is a more accurate conceptual framework. We redefined MT as a critical administration threshold (CAT) of 3 U/h, which is clinically pertinent and reflects hemorrhagic shock. The purpose of this study was to compare the traditional form of MT to a CAT definition in predicting mortality. METHODS Patients receiving transfusion in the first 24 hours were included. Precise transfusion times for each unit, in minutes, were calculated from time of injury. MT and CAT were compared to determine risk of death. Univariate and multivariate analyses were used to examine inpatient mortality. RESULTS A total of 169 patients(70%, >10 New Injury Severity Score [NISS]) were studied; 46% were CAT+; 22% met the MT criteria. With logistic regression, a CAT of 3 U/h (CAT+) was more predictive of death compared with 2, 4, 5, or 6 U/h. CAT was met once (CAT 1), twice (CAT 2) or more than 3 times (CAT 3) in 21%, 14%, and 11%, respectively. Increasing CAT was associated with increased mortality. CAT identified 75% of all deaths; MT only identified 33% and failed to identify 42% of CAT+ deaths. CAT (relative risk [RR] 3.58; 95% confidence interval [CI] 1.80-7.15) had a stronger association with mortality compared with MT(RR, 1.82; 95% confidence interval, 1.02-3.26). CONCLUSION The traditional definition of MT is inadequate to reflect illness severity. Using CATs allows prospective identification of critically ill trauma patients and eliminates survivor bias. CAT may serve as an activation trigger for transfusion protocols, allowing early identification of patients with critical transfusion requirements. Clinical trials involving transfusion strategies should consider CAT as an instrument for evaluating outcomes. LEVEL OF EVIDENCE Diagnostic/prognostic study, level II.
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Rappaport LD, Deakyne S, Carcillo JA, McFann K, Sills MR. Age- and sex-specific normal values for shock index in National Health and Nutrition Examination Survey 1999-2008 for ages 8 years and older. Am J Emerg Med 2013; 31:838-42. [PMID: 23478110 DOI: 10.1016/j.ajem.2013.01.014] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 01/07/2013] [Accepted: 01/15/2013] [Indexed: 11/29/2022] Open
Abstract
PURPOSE Shock index (SI), the ratio of heart rate to systolic blood pressure, has found to outperform conventional vital signs as a predictor of shock. Although age-specific vital sign norms are recommended in screening for shock, there are no reported age- or sex-specific norms for SI. Our primary goal was to report age- and sex-specific SI normal values for a nationally representative population 10 years and older by 5-year age groups. A secondary goal was to report SI normal values for children ages 8 to 19 years by 1-year age groups. BASIC PROCEDURES Weighted data from the National Health and Nutrition Examination Survey 1999-2008 data sets were used to generate age- and sex-specific percentile curves of SI for subjects 8 years and older. MAIN FINDINGS The primary analysis included 33906 subjects (101837 weighted) 10 years and older. The secondary analysis included 13393 subjects (37983 weighted) 8 to 19 years old. Normalized SI values for each percentile decreased with increasing age and were higher for females across all ages. The most commonly cited SI threshold of 0.9 exceeded the 97th percentile for males younger than 25 years and for females younger than 40 years. CONCLUSIONS This first report of age- and sex-specific normal values for SI indicates that SI norms vary by age and sex. Just as age-specific vital sign norms are recommended in screening for shock, our findings suggest that age- and sex-specific SI norms may be more effective in screening for shock than a single-value threshold.
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Pacagnella RC, Souza JP, Durocher J, Perel P, Blum J, Winikoff B, Gülmezoglu AM. A systematic review of the relationship between blood loss and clinical signs. PLoS One 2013; 8:e57594. [PMID: 23483915 PMCID: PMC3590203 DOI: 10.1371/journal.pone.0057594] [Citation(s) in RCA: 127] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2012] [Accepted: 01/24/2013] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION This systematic review examines the relationship between blood loss and clinical signs and explores its use to trigger clinical interventions in the management of obstetric haemorrhage. METHODS A systematic review of the literature was carried out using a comprehensive search strategy to identify studies presenting data on the relationship of clinical signs & symptoms and blood loss. Methodological quality was assessed using the STROBE checklist and the general guidelines of MOOSE. RESULTS 30 studies were included and five were performed in women with pregnancy-related haemorrhage (other studies were carried in non-obstetric populations). Heart rate (HR), systolic blood pressure (SBP) and shock index were the parameters most frequently studied. An association between blood loss and HR changes was observed in 22 out of 24 studies, and between blood loss and SBP was observed in 17 out of 23 studies. An association was found in all papers reporting on the relationship of shock index and blood loss. Seven studies have used Receiver Operating Characteristic Curves to determine the accuracy of clinical signs in predicting blood loss. In those studies the AUC ranged from 0.56 to 0.74 for HR, from 0.56 to 0.79 for SBP and from 0.77 to 0.84 for shock index. In some studies, HR, SBP and shock index were associated with increased mortality. CONCLUSION We found a substantial variability in the relationship between blood loss and clinical signs, making it difficult to establish specific cut-off points for clinical signs that could be used as triggers for clinical interventions. However, the shock index can be an accurate indicator of compensatory changes in the cardiovascular system due to blood loss. Considering that most of the evidence included in this systematic review is derived from studies in non-obstetric populations, further research on the use of the shock index in obstetric populations is needed.
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Affiliation(s)
| | - João Paulo Souza
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
| | - Jill Durocher
- Gynuity Health Projects, New York, New York, United States of America
| | - Pablo Perel
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Jennifer Blum
- Gynuity Health Projects, New York, New York, United States of America
| | - Beverly Winikoff
- Gynuity Health Projects, New York, New York, United States of America
| | - Ahmet Metin Gülmezoglu
- Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland
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Mutschler M, Nienaber U, Münzberg M, Fabian T, Paffrath T, Wölfl C, Bouillon B, Maegele M. Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid? Emerg Med J 2013; 31:35-40. [DOI: 10.1136/emermed-2012-202130] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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141
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Li B, Fanning C, Patel A, Parikh A. Shock index: blunt clinical predictions. Crit Care 2013; 17:468. [PMID: 24257460 PMCID: PMC4055963 DOI: 10.1186/cc13125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Shock index: a simple clinical parameter for mortality risk assessment in trauma? J Trauma Acute Care Surg 2012; 73:780-1; author reply 781. [PMID: 22929512 DOI: 10.1097/ta.0b013e31825ff540] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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143
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Utility of shock index calculation in combat casualty triage protocol? Am J Surg 2012; 204:812. [DOI: 10.1016/j.amjsurg.2011.10.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2011] [Accepted: 10/14/2011] [Indexed: 11/17/2022]
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Affiliation(s)
- Daniel Dante Yeh
- Department of Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
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Morrison JJ, Dickson EJ, Jansen JO, Midwinter MJ. Utility of admission physiology in the surgical triage of isolated ballistic battlefield torso trauma. J Emerg Trauma Shock 2012; 5:233-7. [PMID: 22988401 PMCID: PMC3440889 DOI: 10.4103/0974-2700.99690] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 09/07/2011] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND An assessment of hemodynamic stability is central to surgical decision-making in the management of battlefield ballistic torso trauma (BBTT). AIMS To analyse the utility of admission physiological parameters in characterising hemodynamic stability. SETTINGS AND DESIGN A retrospective analysis of consecutive admissions, with BBTT, to forward surgical facility in Afghanistan. MATERIALS AND METHODS The cohorts' admission physiology, need for operative intervention, and mortality data were collected retrospectively. The cohort was divided into patients requiring surgery for Life-Threatening Torso Hemorrhage (LTTH) and those not requiring immediate surgery (non-LTTH). STATISTICAL ANALYSIS Parameters were compared using two sample t tests, Mann-Whitney, Fisher's exact, and Chi-square tests. Receiver operator characteristic curves were used to identify significant parameters and determine optimum cut-off values. RESULTS A total of 103 patients with isolated BBTT were identified: 44 in the LTTH group and 59 in the non-LTTH group. The mean New Injury Severity Score ± Standard Deviation (NISS±SD) was 28±14 and 13±12, respectively. The heart rate, systolic blood pressure (SBP), pulse pressure, shock index (SI=heart rate/SBP) and base excess were analysed. SI correlated best with the need for surgical torso hemorrhage control, P<0.05. An optimal cut-off of 0.9 was identified, producing a positive and negative predictive value of 81% and 82%, respectively. CONCLUSIONS Shock index (SI) is a useful parameter for helping military surgeons triage BBTT, identifying patients requiring operative torso hemorrhage control. SI performance requires a normal physiological response to hypovolemia, and thus should always be considered in clinical context.
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Affiliation(s)
- Jonathan J Morrison
- Academic Department of Military Surgery and Trauma, Royal Centre for Defence Medicine, Birmingham Research Park, Vincent Drive, Edgbaston, Birmingham B15 2SQ, UK
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Charbit J, Mahul M, Roustan JP, Latry P, Millet I, Taourel P, Capdevila X. Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion. Am J Emerg Med 2012; 31:130-6. [PMID: 22980362 DOI: 10.1016/j.ajem.2012.06.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2012] [Accepted: 06/09/2012] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The purpose of this study was to define whether the semiquantitative analysis of hemoperitoneum increases the accuracy of early prediction of massive transfusion (MT). METHODS A retrospective review of severe trauma patients consecutively admitted to our trauma intensive care unit between January 2005 and December 2009 was conducted. Patients diagnosed with blunt abdominal trauma who had a computed tomography scan on admission were included. The hemoperitoneum size was defined using the Federle score on computed tomography as large, moderate, or minimal/none. The association between MT (≥10 U of packed red blood cells in the first 24 h) and moderate and large sizes of hemoperitoneum was assessed using a multiple logistic model. RESULTS Of the 381 patients meeting the inclusion criteria, 270 (71%) were male; the mean age was 35.5 ± 18.2 years and mean injury severity score was 23.4 ± 17. Ninety-seven (26%) had large hemoperitoneum, 107 (28%) had moderate hemoperitoneum, and 177 (46%) had minimal/no hemoperitoneum. Eighty-three patients (22%) required MT. The positive predictive value for MT of a large hemoperitoneum was 41%, 23% for a moderate hemoperitoneum, and 10% for minimal/no hemoperitoneum (P < .001). The corresponding values for hypotensive patients were 61%, 32%, and 25%, respectively (P < .001). In the multivariate analysis model, only the large size of hemoperitoneum was significantly associated with MT (OR 6.4, 95% CI 2.9-14, P < .001, r(2) = 0.47). CONCLUSION The assessment of the size of hemoperitoneum on admission substantially improves the prediction of MT in trauma patients and should be used to trigger and guide initial haemostatic resuscitation.
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Affiliation(s)
- Jonathan Charbit
- Department of Anesthesiology and Critical Care, Lapeyronie University Hospital, Montpellier, F-34295 Cedex 5, France.
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Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M. A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation 2012; 84:309-13. [PMID: 22835498 DOI: 10.1016/j.resuscitation.2012.07.012] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 05/29/2012] [Accepted: 07/09/2012] [Indexed: 10/28/2022]
Abstract
AIM The aim of this study was to validate the classification of hypovolaemic shock given by the Advanced Trauma Life Support (ATLS). METHODS Patients derived from the TraumaRegister DGU(®) database between 2002 and 2010 were analyzed. First, patients were allocated into the four classes of hypovolaemic shock by matching the combination of heart rate (HR), systolic blood pressure (SBP) and Glasgow Coma Scale (GCS) according to ATLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to the ATLS classification and the corresponding changes of the remaining two parameters were assessed within these four groups. Analyses of demographic, injury and therapy characteristics were performed as well. RESULTS 36,504 patients were identified for further analysis. Only 3411 patients (9.3%) could be adequately classified according to ATLS, whereas 33,093 did not match the combination of all three criteria given by ATLS. When patients were grouped by HR, there was only a slight reduction of SBP associated with tachycardia. The median GCS declined from 12 to 3. When grouped by SBP, GCS dropped from 13 to 3 while there was no relevant tachycardia observed in any group. Patients with a GCS=15 presented normotensive and with a HR of 88/min, whereas patients with a GCS<12 showed a slight reduced SBP of 117mmHg and HR was unaltered. CONCLUSION This study indicates that the ATLS classification of hypovolaemic shock does not seem to reflect clinical reality accurately.
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Affiliation(s)
- M Mutschler
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, Cologne, Germany.
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The shock index: a further simple tool of triage in combat casualties. Injury 2012; 43:1230. [PMID: 22244997 DOI: 10.1016/j.injury.2011.12.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2011] [Revised: 12/06/2011] [Accepted: 12/17/2011] [Indexed: 02/02/2023]
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Pasquier P, Boutonnet M, Salvadori A, de Saint Maurice G, Tourtier JP. Discrepency between heart rate and markers of hypoperfusion. J Trauma Acute Care Surg 2012; 72:801-802. [PMID: 22491577 DOI: 10.1097/ta.0b013e31824752a2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Chico-Fernández M, García-Fuentes C, Alonso-Fernández M, Toral-Vázquez D, Bermejo-Aznarez S, Alted-López E. Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones. Med Intensiva 2011; 35:546-51. [DOI: 10.1016/j.medin.2011.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 06/24/2011] [Accepted: 06/27/2011] [Indexed: 11/15/2022]
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