Präklinische Volumentherapie beim Trauma

Does increased prehospital replacement volume lead to a poor clinical course and an increased mortality? A matched-pair analysis of 1896 patients of the Trauma Registry of the German Society for Trauma Surgery who were managed by an emergency doctor at the accident site

INTRODUCTION

Severe bleeding after trauma frequently leads to a poor outcome. Prehospital fluid replacement therapy is regarded as an important primary treatment option. Our study aimed to assess the influence of prehospital fluid replacement therapy on the post-traumatic course of severely injured patients in a retrospective analysis of matched pairs.

PATIENTS AND METHODS

The data of 51,425 patients of the Trauma Registry of the German Society for Trauma Surgery were analysed. The following patients were included: Injury Severity Score ≥ 16 points, primary admission, age ≥ 16 years, no isolated brain injury, transfusion of at least one unit of packed red blood cells (pRBC), systolic blood pressure ≥ 60 mmHg at the accident site. The patients were divided into two groups according to the following matched-pair criteria (low-volume: 0-1500 ml prehospital volume replaced; high-volume: ≥ 1501 ml prehospital volume): intubation at the accident site (yes/no), time from injury to hospital ± 10 min., means of rescue (emergency helicopter, MICU), Abbreviated Injury Scale (body regions), injury year, systolic blood pressure and age (years). All patients were managed by an emergency doctor at the accident site.

RESULTS

A total of 948 patients in each group met the inclusion criteria. Increasing replacement volume was associated with an increased need for transfusion (pRBCs: low-volume: 7 units, high-volume: 8.3 units; p<0.001) and a reduced ability to coagulate (prothrombin ratio (PR): low-volume: 68%, high-volume: 61.5%; p<0.001). Patients in shock (systolic BP<90 mmHg) upon admission to the hospital were equally in both groups (25.6%; p=0.98). Significantly higher lethality was observed in cases of increasing volume (low-volume: 22.7%, high-volume: 27.6%; p<0.01).

CONCLUSIONS

Excessive prehospital fluid replacement leads to an increased mortality rate. The results of this study support the concept of restrained volume replacement in the prehospital treatment of patients with severe trauma.

[Extended medical quality management exemplified by the tracer diagnosis multiple trauma. Pilot study in the air rescue service]

BACKGROUND

Adequate prehospital and inhospital primary care is a decisive factor in the successful treatment of multiple trauma patients. For optimization of treatment algorithms the implementation of a medical quality management is of utmost importance. The aim of this study was to extend quality management by including data on process quality.

METHODS

A retrospective study of primary rescue missions of the Helicopter Emergency Medical Service (HEMS) Christoph 22 in Ulm over a period of 2.5 years was performed. In a detailed analysis of filter criteria, in which relevant deviations from the recommendations (not fulfilled in  > 10% of the cases) occurred, process data was included (vital data, measurements and events).

RESULTS

In the study population (n = 298, males 71.8%, mean age 39.8 ± 21.8 years) 2 filter criteria were identified in which relevant deviations where observed: time management where prehospital treatment time  ≤ 60 min in 36% of the cases was not fulfilled and circulatory management where the systolic blood pressure, detected with Riva-Rocci method (RR(sys))  ≥ 120 mmHg on hospital admission in patients with severe head trauma was not fulfilled in 45% of the cases. In patients with deviations in time management, prehospital treatment time was prolonged (75.6 ± 18.3 min versus 50.5 ± 6.7 min; p < 0.01) caused by a prolonged on scene attendance time (34.1 ± 22.1 min versus 20.6 ± 9.2 min; p < 0.01) and transport time (17.3 ± 9.4 min versus 13.3 ± 4.8 min; p < 0.01). In entrapment trauma prehospital treatment time was expanded (44% versus 10%; p < 0.01). Patients in whom circulatory management deviations were observed were more often in shock on arrival at the scene (RR(sys)  ≤ 90 mmHg: 60% versus 30%; p < 0.01), more often hypoxemic [pulse oximeter oxygen saturation (S(p)O(2)) ≤ 90%: 36% versus 19%; p < 0.05] and more often sustained a trauma to the chest as well as to chest and abdomen/pelvis (69% versus 52% and 42% versus 28%, respectively; p < 0.05). Furthermore, the infusion volume of colloids was higher (1241 ± 810 ml versus 753 ± 359 ml; p < 0.05) and the combined usage of small volume resuscitation and catecholamines was more often necessary (42% versus 25%; p < 0.05).

CONCLUSIONS

Including process data of prehospital mission data recording facilitates an extended medical quality management.

[Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume replacement - an analysis of 604 patients from the trauma registry of the DGU]

BACKGROUND

Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries.

PATIENTS AND METHODS

All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml).

RESULTS

Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions.

CONCLUSION

In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.