Utility of Stewart's strong ion difference as a predictor of major injury after trauma in the ED

Association between ion shift index and prognosis in severe trauma patients without isolated head injury

INTRODUCTION

This study aimed to investigate the ion shift index (ISI) as a prognostic factor of severe trauma. We hypothesized that the initial ISI measured in the emergency department (ED) is associated with discharge survival in severe non-isolated head injury (IHI) patients.

MATERIALS AND METHODS

This retrospective observational study included severe trauma patients with available medical records from January 2017 to December 2018 but excluded those with IHI. Logistic regression analysis was conducted to identify the risk factors for mortality in non-IHI patients, and adjustments were performed for relevant covariates. An area under the receiver operating characteristics curve (AUROC) analysis was performed to examine the primary outcome of our study, which was mortality at hospital discharge in severe non-IHI trauma patients.

RESULTS

Of the 483 severe non-IHI trauma patients included in the study, 86 patients (17.8 %) died. The multiple logistic regression analysis demonstrated ISI (odds ratio [OR], 2.300; 95% CI, 1.183-4.470) was significantly associated with mortality in the non-IHI group. Additionally, trauma and injury severity score (TRISS; OR, 0.538; 95% CI, 0.447-0.649), lactate (OR, 1.410; 95% CI, 1.252-1.588), creatinine (OR, 1.554; 95% CI, 1.221-1.979), and activated partial thromboplastin time (aPTT; OR, 1.050; 95% CI, 1.021-1.080) were independently associated with mortality at hospital discharge. The AUROC values for TRISS, lactate, aPTT, creatinine, and ISI were as follows: 0.892 (95% CI, 0.861-0.918), 0.838 (95% CI, 0.803-0.870), 0.754 (95% CI, 0.712-0.792), 0.650 (95% CI, 0.606-0.693), and 0.848 (95% CI, 0.813-0.879), respectively. The AUROC for the multiple logistic regression model with ISI was 0.942 (95% CI, 0.917-0.962). In a model in which TRISS was omitted, the addition of ISI to other predictors significantly improved the AUROC to 0.900 (95% CI, 0.869-0.925) (p=0.039).

CONCLUSION

The initial ISI in the ED after trauma was associated with mortality in severe non-IHI trauma patients. In conjunction with other prognostic indicators, it could be used as an early prognostic marker, particularly if TRISS is unavailable.

Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis

BACKGROUND

Traumatic injury in the United States is the Number 1 cause of mortality for patients 1 year to 44 years of age. Studies suggest that early identification of major injury leads to better outcomes for patients. Imaging, such as computed tomography (CT), is routinely used to help determine the presence of major underlying injuries. We review the literature to determine whether whole-body CT (WBCT), a protocol including a noncontrast scan of the brain and neck and a contrast-enhanced scan of the chest, abdomen, and pelvis, detects more clinically significant injuries as opposed to selective scanning as determined by mortality rates.

METHODS

Scientific publications from 1980 to 2013 involving the study of the difference between pan scan and selective scan after trauma were identified. The Preferred Reporting Items for Systematic Reviews and Meta-analyses was used. Publications were categorized by level of evidence. Injury Severity Score (ISS) and pooled odds for mortality rate of patients who received WBCT scan versus those who received selective scans were compared.

RESULTS

Of the 465 publications identified, 7 were included, composing of 25,782 trauma patients who received CT scan following trauma. Of the patients, 52% (n = 13,477) received pan scan and 48% (n = 12,305) received selective scanning. Overall ISS was significantly higher for patients receiving WBCT versus those receiving selective scan (29.7 vs. 26.4, p < 0.001, respectively). Overall mortality rate was significantly lower for WBCT versus selective scanning (16.9; 95% confidence interval [CI], 16.3-17.6 vs. 20.3; 95% CI, 19.6-21.1, p < 0.0002, respectively). Pooled odds ratio for mortality rate was 0.75 (95% CI, 0.7-0.79), favoring WBCT.

CONCLUSION

Despite the WBCT group having significantly higher ISS at baseline compared with the group who received selective scanning, the WBCT group had a lower overall mortality rate and a more favorable pooled odds ratio for trauma patients. This suggests that in terms of overall mortality, WBCT scan is preferable to selective scanning in trauma patients.

LEVEL OF EVIDENCE

Systematic review and meta-analysis, level III.

Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury

BACKGROUND

Hypothermia, acidosis and coagulopathy have long been considered critical combinations after severe injury. The aim of this review was to give a clinical update on this triad in severely injured patients.

METHODS

A non-systematic literature search on hypothermia, acidosis and coagulopathy after major injury was undertaken, with a focus on clinical data from the past 5 years.

RESULTS

Hypothermia (less than 35 °C) is reported in 1·6-13·3 per cent of injured patients. The occurrence of acidosis is difficult to estimate, but usually follows other physiological disturbances. Trauma-induced coagulopathy (TIC) has both endogenous and exogenous components. Endogenous acute traumatic coagulopathy is associated with shock and hypoperfusion. Exogenous effects of dilution from fluid resuscitation and consumption through bleeding and loss of coagulation factors further add to TIC. TIC is present in 10-34 per cent of injured patients, depending on injury severity, acidosis, hypothermia and hypoperfusion. More expedient detection of coagulopathy is needed. Thromboelastography may be a useful point-of-care measurement. Management of TIC is controversial, with conflicting reports on blood component therapy in terms of both outcome and ratios of blood products to other fluids, particularly in the context of civilian trauma.

CONCLUSION

The triad of hypothermia, acidosis and coagulopathy after severe trauma appears to be fairly rare but does carry a poor prognosis. Future research should define modes of early detection and targeted therapy.

Reference values for strong ion difference--a novel tool for fetal metabolic assessment

OBJECTIVES

The aim of this pilot study was to establish reference values for strong ion difference (SID) in umbilical cord blood and investigate the feasibility of evaluating fetal metabolism according to the comprehensive approach to acid-base abnormalities, based on Stewart's physiochemical theory.

STUDY DESIGN

A prospective observational study. Women who underwent an elective cesarean section at term (n=40) were compared to women who completed a normal spontaneous delivery at term (n=40). The primary outcome was the establishment of normal values for SID in the umbilical cord vein. We also compared acid-base variables in the umbilical vein between the groups.

RESULTS

The apparent SID in the umbilical vein was 34.61+/-3.92 mequiv./L after normal delivery and 35.98+/-2.56 mequiv./L after elective cesarean section (the effective SID is 37.43+/-1.93 and 38.29+/-2.38 mequiv./L, respectively). The pH values were similar in both groups, but the pCO(2) was significantly higher and the plasma principal weak acids (albumin and phosphate) were significantly lower after cesarean sections.

CONCLUSIONS

SID enables a comprehensive approach to acid-base abnormalities in the neonate, making it a potential additional tool for evaluating fetal acid-base status.