Pulse Pressure as an Early Warning of Hemorrhage in Trauma Patients

Transfusion Practices in Severely Injured Patients at a Level 1 Trauma Center

Introduction

Acute trauma resuscitation is challenging and disorganized in low- and middle-income countries as there is lack of evidence-based transfusion practices with respect to ratio, volume, trigger, cutoff points for various triggers. This study aims to study the patterns of blood use in various mechanisms of injury, by interfacility transfer status and define triggers for transfusion of various blood components. Prospective observational study, emergency department of level 1 trauma center (August 2017-August 2018).

Methods

Demographic, injury, clinical, laboratory, transfusion characteristics, and patient outcomes were collected from electronic hospital records and transfusion service records. We used multivariate logistic regression to identify triggers of transfusion of red blood cells, plasma, platelets (PLTs), cryoprecipitate, and mortality predictors.

Results

Among 986 severely injured patients 80% were males, 92% had blunt injuries and commonest trauma was Head. The median length of intensive care unit stay and hospital stay were more in a referred group. Patients brought to center directly received more massive transfusions (56, 13.05% vs. 48, 8.62%). Railway track injuries received the most total median packed red blood cells (PRBCs) units in both groups. The triggers for various blood product transfusions include: Hematocrit < 32.08 for PRBC, PT >16.9 s for plasma, PLT count <130 lakhs for platelets, MAP <89.7 mmHg and PT >18.2 s for cryoprecipitate.

Conclusion

Railway track injuries with inferior extremity injuries required maximum transfusion requirements and were a trigger for PRBC, plasma, PLTs, and cryoprecipitate. Smartphone-based apps and transfusion prediction models can be framed based on the triggers and cut points.

Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma

INTRODUCTION

Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma.

METHODS

A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate.

RESULTS

We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not.

CONCLUSIONS

Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Undertriage of Severely Injured Trauma Patients

INTRODUCTION

The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25).

OBJECTIVES

Delineate patient demographics, injuries, and outcomes after SU.

PARTICIPANTS

Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU).

RESULTS

Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%.

CONCLUSION

Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

Pulse Pressure: A Predictor of Intervention in Blunt Abdominal Trauma

BACKGROUND

Patients with life-threatening hemorrhages due to blunt torso trauma are at a particularly high risk of being underdiagnosed. The pulse pressure (PP) starts narrowing down before the traditional parameters start changing, making it a useful tool for assessing and planning early intervention.

OBJECTIVE

To assess the utility of low PP in predicting massive transfusion (MT) or operative intervention in patients with isolated blunt abdominal trauma.

MATERIAL AND METHODS

A total of 186 patients were included. The PP and mean arterial pressure (MAP) were calculated. Vitals, PP, and MAP were monitored every 15 min during the first 6 h, then every 30 min during the next 6 h, and afterward, every 4 h until discharge. A Chi-square test and an independent t-test (as appropriate) were applied to compare variables with PP at the time of presentation. Differences were considered statistically significant at p-value ≤ 0.05.

RESULTS

A total of 55.9% of these patients had injuries due to road traffic accidents (RTA). Emergency operative intervention was provided to 26.3% of the patients. Death was 4.3%. MT was required by 26.3% of the patients. There was a statistically significant association between low PP and sex, length of stay, repeat extended focused assessment with sonography in trauma (eFAST), emergency operational intervention, outcome, MT, number of crystalloids consumed within the first four hours after presentation, injury severity score, systolic blood pressure (SBP), and pulse rate.

CONCLUSION

The PP <30 mmHg was observed as a useful predictor for increased blood loss requiring blood transfusion or operative intervention.

The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition

BACKGROUND

Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management.

METHODS

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation.

RESULTS

This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury.

CONCLUSION

A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.

Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock

INTRODUCTION

Agitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients.

METHODS

We performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization).

RESULTS

Of 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005).

CONCLUSIONS

Agitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.

Prediction of pre-hospital blood transfusion in trauma patients based on scoring systems

BACKGROUND

Pre-hospital blood transfusion (PHBT) is a safe and gradually expanding procedure applied to trauma patients. A proper decision to activate PHBT with the presently limited diagnostic options at the site of an incident poses a challenge for pre-hospital crews. The purpose of this study was to compare the selected scoring systems and to determine whether they can be used as valid tools in identifying patients with PHBT requirements.

METHODS

A retrospective single-center study was conducted between June 2018 and December 2020. Overall, 385 patients (aged [median; IQR]: 44; 24-60; 73% males) were included in this study. The values of five selected scoring systems were calculated in all patients. To determine the accuracy of each score for the prediction of PHBT, the Receiver Operating Characteristic (ROC) analysis was used and to measure the association, the odds ratio with 95% confidence intervals was counted (Fig. 1).

RESULTS

Regarding the proper indication of PHBT, shock index (SI) and pulse pressure (PP) revealed the highest value of AUC and sensitivity/specificity ratio (SI: AUC 0.88; 95% CI 0.82-0.93; PP: AUC 0.85 with 95% CI 0.79-0.91).

CONCLUSION

Shock index and pulse pressure are suitable tools for predicting PHBT in trauma patients.

THE INITIAL ION SHIFT INDEX AS A PROGNOSTIC INDICATOR TO PREDICT PATIENT SURVIVAL IN TRAUMATIC DAMAGE CONTROL LAPAROTOMY PATIENTS

ABSTRACT

Objective: The ion shift index (ISI), which considers extracellular fluid ions such as phosphate, calcium, and magnesium, represents the ion shift following ischemia; concentrations of these ions are maintained within narrow normal ranges by adenosine triphosphate-dependent homeostasis. The ISI is defined as follows: {potassium (mmol/L-1) + phosphate (mmol/L-1) + Mg (mmol/L-1)}/calcium (mmol/L-1). This study investigated the possibility of predicting the 30-day survival rate of patients who underwent traumatic damage control laparotomy by comparing ISI and other laboratory findings, as well as the initial Trauma and Injury Severity Score (TRISS) and shock indices. Methods: Among the 134 patients who underwent damage control surgery between November 2012 and December 2021, 115 patients were enrolled in this study. Data regarding injury mechanism, age, sex, laboratory findings, vital signs, Glasgow Coma Scale score, Injury Severity Score, Abbreviated Injury Scale score, blood component transfusion, type of surgery, postoperative laboratory outcomes, morbidity, mortality rates, fluids administered, and volume of transfusions were collected and analyzed. Results: In univariate analysis, the odds ratio of the initial ISI was 2.875 (95% confidence interval, 1.52-5.43; P = 0.04), which showed a higher correlation with mortality compared with other indices. The receiver operating characteristic (ROC) curve and area under the ROC curve (AUC) were derived from different multivariable logistic regression models. The initial ISI had high sensitivity and specificity in predicting patient mortality (AUC, 0.7378). In addition, in the model combining the initial ISI, crystalloids, and TRISS, the AUC showed a high value (AUC, 0.8227). Conclusion: The ISI evaluated using electrolytes immediately after admission in patients undergoing traumatic damage control surgery may be a predictor of patient mortality.

Predictive value of tachycardia for mortality in trauma-related haemorrhagic shock: a systematic review and meta-regression

OBJECTIVES

Heart rate (HR) is one of the physiological variables in the early assessment of trauma-related haemorrhagic shock, according to Advanced Trauma Life Support (ATLS). However, its efficiency as predictor of mortality is contradicted by several studies. Furthermore, the linear association between HR and the severity of shock and blood loss presented by ATLS is doubtful. This systematic review aims to update current knowledge on the role of HR in the initial haemodynamic assessment of patients who had a trauma.

DESIGN

This study is a systematic review and meta-regression that follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations.

DATA SOURCES

EMBASE, MEDLINE, CENTRAL and Web of Science databases were systematically searched through on 1 September 2020.

ELIGIBILITY CRITERIA

Papers providing early HR and mortality data on bleeding patients who had a trauma were included. Patient cohorts were considered haemorrhagic if the inclusion criteria of the studies contained transfusion and/or positive focused assessment with sonography for trauma and/or postinjury haemodynamical instability and/or abdominal gunshot injury. Studies on burns, traumatic spinal or brain injuries were excluded. Papers published before January 2010 were not considered.

DATA EXTRACTION AND SYNTHESIS

Data extraction and risk of bias were assessed by two independent investigators. The association between HR and mortality of patients who had a trauma was assessed using meta-regression analysis. As subgroup analysis, meta-regression was performed on patients who received blood products.

RESULTS

From a total of 2017 papers, 19 studies met our eligibility criteria. Our primary meta-regression did not find a significant relation (p=0.847) between HR and mortality in patients who had a trauma with haemorrhage. Our subgroup analysis included 10 studies, and it could not reveal a linear association between HR and mortality rate.

CONCLUSIONS

In accordance with the literature demonstrating the multiphasic response of HR to bleeding, our study presents the lack of linear association between postinjury HR and mortality. Modifying the pattern of HR derangements in the ATLS shock classification may result in a more precise teaching tool for young clinicians.

Development of Machine Learning Models Predicting Estimated Blood Loss during Liver Transplant Surgery

The incidence of major hemorrhage and transfusion during liver transplantation has decreased significantly over the past decade, but major bleeding remains a common expectation. Massive intraoperative hemorrhage during liver transplantation can lead to mortality or reoperation. This study aimed to develop machine learning models for the prediction of massive hemorrhage and a scoring system which is applicable to new patients. Data were retrospectively collected from patients aged >18 years who had undergone liver transplantation. These data included emergency information, donor information, demographic data, preoperative laboratory data, the etiology of hepatic failure, the Model for End-stage Liver Disease (MELD) score, surgical history, antiplatelet therapy, continuous renal replacement therapy (CRRT), the preoperative dose of vasopressor, and the estimated blood loss (EBL) during surgery. The logistic regression model was one of the best-performing machine learning models. The most important factors for the prediction of massive hemorrhage were the disease etiology, activated partial thromboplastin time (aPTT), operation duration, body temperature, MELD score, mean arterial pressure, serum creatinine, and pulse pressure. The risk-scoring system was developed using the odds ratios of these factors from the logistic model. The risk-scoring system showed good prediction performance and calibration (AUROC: 0.775, AUPR: 0.753).

Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention after Trauma

BACKGROUND

The pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma.

METHODS

Patients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma.

RESULTS

In total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009).

CONCLUSION

Prehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival.

Evaluation of the ability of haemodynamic variables obtained with minimally invasive techniques to assess fluid responsiveness in endotoxaemic Beagles

OBJECTIVE

To examine the ability of different haemodynamic variables recorded by minimally invasive monitoring techniques to assess fluid responsiveness (FR) in endotoxaemic Beagles.

STUDY DESIGN

Prospective terminal experimental study.

ANIMALS

A group of six healthy, purpose-bred Beagle dogs (three intact females and males), age 5-9.8 years (range) and weighing 11.4-17.9 kg.

METHODS

Endotoxaemic shock was induced by injecting 1 mg kg^-1Escherichia coli lipopolysaccharide (LPS) intravenously in six sevoflurane-anaesthetized mechanically ventilated Beagles for another project. After 10 minutes, three Ringer's acetate boluses (10 mL kg^-1) were administered each over 10 minutes with collection of haemodynamic data immediately before and after each bolus. Thereafter, arterial hypotension was treated with noradrenaline ± dexmedetomidine until arterial pressures increased to a target value. After a wash-out period of 20 minutes another three boluses of fluid were administered and measurements were repeated equally. For each fluid bolus, FR was considered positive when change (Δ) in stroke volume measured by pulmonary artery thermodilution was ≥15%. To test predictive accuracy for FR, we recorded heart rate, invasive arterial, right atrial and pulmonary capillary wedge pressures, pulse wave transit time with haemodynamic monitors, calculated pulse pressure, shock index and rate over pressure evaluation (ROPE) and measured stroke distance and corrected flow time (FTc) with oesophageal Doppler monitoring.

RESULTS

A total of 35 measurements (19 positive and 16 negative responses) were evaluated. A FTc < 330 ms, Δ pulse pressure ≥20%, Δ shock index ≤-14% and ΔROPE ≤-17% were the most significant indicators of positive FR with an area under the receiver operating characteristics curve between 0.72 and 0.74.

CONCLUSIONS AND CLINICAL RELEVANCE

In endotoxaemic Beagles, none of the assessed haemodynamic variables could predict FR with high sensitivity and specificity.

Narrowed pulse pressure predicts massive transfusion and emergent operative intervention following penetrating trauma

INTRODUCTION

The early identification of hemorrhagic shock may be challenging. The objective of this study was to examine the utility of a narrowed pulse pressure in identifying the need for emergent interventions following penetrating trauma.

METHODS

In this 2.5-year retrospective study of adult patients with a penetrating mechanism, patients with a narrowed pulse pressure (<30 mmHg) were compared to those without. Main outcomes measures were the need for a massive transfusion or emergent operation.

RESULTS

There were 957 patients, of which the majority were male (86%) and 55% presented with gunshot wounds. On multivariate analysis, a narrowed pulse pressure was associated with the need for massive transfusion (OR 3.74, 95% C.I. 1.8-7.7, p = 0.0003) and emergent surgery (OR 1.68, 95% C.I. 1.14-2.48, p = 0.009).

CONCLUSIONS

A narrowed pulse pressure is associated with the presence of hemorrhagic shock and need for emergent interventions among patients with penetrating torso trauma.