The utility of Advanced Trauma Life Support (ATLS) clinical shock grading in assessment of trauma

Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma

PURPOSE

Base deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma.

MATERIALS AND METHODS

We retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1-6.0 mmol/L; III, 6.1-10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13-17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels.

RESULTS

In total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods.

CONCLUSION

BD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.

Predictive factors for intraoperative blood loss in surgery for adolescent idiopathic scoliosis

Background

Adolescent idiopathic scoliosis (AIS) is a common spinal deformity. Posterior spinal fusion remains an important surgical treatment for AIS. This study aims to determine the predictive factors for intraoperative blood loss in AIS surgery.

Methods

Patients who had undergone posterior spinal fusion for adolescent idiopathic scoliosis in a single university hospital were reviewed over a 7-year period. Predictive factors for intra-operative blood loss were studied by multivariate analysis to derive a regression model. Receiver operating characteristic analysis was performed to determine the cut-off values of factors contributing to significant intraoperative blood loss (≥500 ml).

Results

Two hundred and twelve patients were included. Intraoperative blood loss was found to be correlated with gender (r_s = 0.30 (0.17–0.43)), preoperative hemoglobin level (r_s = 0.20 (0.04–0.31)), preoperative Cobb angle (r_s = 0.20 (0.02–0.29)), number of fused levels (r_s = 0.46 (0.34–0.58)), operation duration (r_s = 0.65 (0.54–0.75)), number of anchors (r_s = 0.47 (0.35–0.59)), and p-value ranged from < 0.001 to < 0.05. Significant intraoperative blood loss was influenced by the male gender, operation duration greater than 257.5 min and more than 10 anchors used.

Conclusions

Male gender, increased operation duration and higher number of anchors predicted higher intra-operative blood loss.

Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients

Background

Total hip arthroplasty (THA) can cause considerable blood loss and perioperative transfusion in ankylosing spondylitis (AS) patients. This study aimed to identify the factors related to blood loss in AS patients with hip involvement undergoing THA.

Methods

We analyzed 243 AS patients with advanced hip involvement undergoing primary THA from 2012 to 2017. Bilateral THA was performed by a one-stage operation during one general anesthesia session. The patients were divided into three groups according to the grade of blood loss, as determined by the Advanced Trauma Life Support hypovolemic shock classification system. Ordinal logistic regression was used to identify factors associated with blood loss in the patients.

Results

The proportion of patients who were male, underwent bilateral THA, had a hip range of motion (ROM) = 0°, had a BASRI-hip score of 4, underwent iliopsoas and adductor release, and underwent autologous or allogenic transfusion increased significantly with the grade of blood loss, while that of the patients who received tranexamic acid (TXA) decreased significantly (P < 0.05). The preoperative hemoglobin (Hb) level, hematocrit level, and operating time also increased significantly with the grade of blood loss (P < 0.05). The ordinal logistic regression results identified the factors related to blood loss during THA in AS patients with hip involvement to be the male sex (odds ratio [OR] = 3.287; 95% confidence interval [CI] 1.022, 10.567), bilateral THA (OR = 13.896; 95% CI 4.950, 39.011), hip ROM = 0° (OR = 2.513; 95% CI 1.277, 4.946), an elevated erythrocyte sedimentation rate (ESR) level (OR = 3.042; 95% CI 1.320, 7.014), an elevated preoperative Hb level (OR = 1.043; 95% CI 1.017, 1.070), a long operating time (OR = 1.009; 95% CI 1.003, 1.016), and the administration of TXA (OR = 0.252; 95% CI 0.134, 0.472).

Conclusions

The male sex, bilateral THA, a hip ROM = 0°, an elevated ESR level, a high preoperative Hb level, and a long operating time are risk factors associated with blood loss in AS patients with hip involvement undergoing THA, while the administration of TXA is a protective factor. These results might help determine the risk of bleeding in the perioperative assessment and develop more efficient blood management strategies for THA in AS patients with hip involvement.

Transparent Reporting of Multivariable Prediction Models in Journal and Conference Abstracts: TRIPOD for Abstracts

Clear and informative reporting in titles and abstracts is essential to help readers and reviewers identify potentially relevant studies and decide whether to read the full text. Although the TRIPOD (Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis) statement provides general recommendations for reporting titles and abstracts, more detailed guidance seems to be desirable. The authors present TRIPOD for Abstracts, a checklist and corresponding guidance for reporting prediction model studies in abstracts. A list of 32 potentially relevant items was the starting point for a modified Delphi procedure involving 110 experts, of whom 71 (65%) participated in the web-based survey. After 2 Delphi rounds, the experts agreed on 21 items as being essential to report in abstracts of prediction model studies. This number was reduced by merging some of the items. In a third round, participants provided feedback on a draft version of TRIPOD for Abstracts. The final checklist contains 12 items and applies to journal and conference abstracts that describe the development or external validation of a diagnostic or prognostic prediction model, or the added value of predictors to an existing model, regardless of the clinical domain or statistical approach used.

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

Background

Severe traumatic injury continues to present challenges to healthcare systems around the world, and post-traumatic bleeding remains a leading cause of potentially preventable death among injured patients. Now in its fifth edition, this document aims to provide guidance on the management of major bleeding and coagulopathy following traumatic injury and encourages adaptation of the guiding principles described here to individual institutional circumstances and resources.

Methods

The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma was founded in 2004, and the current author group included representatives of six relevant European professional societies. The group applied 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 re-examined and revised based on scientific evidence that has emerged since the previous edition 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.

Results

Advances in our understanding of the pathophysiology of post-traumatic coagulopathy have supported improved management strategies, including evidence that early, individualised goal-directed treatment improves the outcome of severely injured patients. The overall organisation of the current guideline has been designed to reflect the clinical decision-making process along the patient pathway in an approximate temporal sequence. Recommendations are grouped behind the rationale for key decision points, which are patient- or problem-oriented rather than related to specific treatment modalities. While these recommendations provide guidance for the diagnosis and treatment of major bleeding and coagulopathy, emerging evidence supports the author group’s belief that the greatest outcome improvement can be achieved through education and the establishment of and adherence to local clinical management algorithms.

Conclusions

A multidisciplinary approach and adherence to evidence-based guidance are key to improving patient outcomes. If incorporated into local practice, these clinical practice guidelines have the potential to ensure a uniform standard of care across Europe and beyond and better outcomes for the severely bleeding trauma patient.

Electronic supplementary material

The online version of this article (10.1186/s13054-019-2347-3) contains supplementary material, which is available to authorized users.

Heller A, Sabashnikov A, Teske W. The Nomenclature, Definition and Distinction of Types of Shock

BACKGROUND

A severe mismatch between the supply and demand of oxygen is the common feature of all types of shock. We present a newly developed, clinically oriented classification of the various types of shock and their therapeutic implications.

METHODS

This review is based on pertinent publications (1990-2018) retrieved by a selective search in PubMed, and on the relevant guidelines and meta-analyses.

RESULTS

There are only four major categories of shock, each of which is mainly related to one of four organ systems. Hypovolemic shock relates to the blood and fluids compartment while distributive shock relates to the vascular system; cardiogenic shock arises from primary cardiac dysfunction; and obstructive shock arises from a blockage of the circulation. Hypovolemic shock is due to intravascular volume loss and is treated by fluid replacement with balanced crystalloids. Distributive shock, on the other hand, is a state of relative hypovolemia resulting from pathological redistribution of the absolute intravascular volume and is treated with a combination of vasoconstrictors and fluid replacement. Cardiogenic shock is due to inadequate function of the heart, which shall be treated, depending on the situation, with drugs, surgery, or other interventional procedures. In obstructive shock, hypoperfusion due to elevated resistance shall be treated with an immediate life-saving intervention.

CONCLUSION

The new classification is intended to facilitate the goal-driven treatment of shock in both the pre-hospital and the inpatient setting. A uniform treatment strategy should be established for each of the four types of shock.

Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects

The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.

Diverse coagulopathies in a rabbit model with different abdominal injuries

BACKGROUND

Although coagulopathy can be very common in severe traumatic shock patients, the exact incidence and mechanism remain unclear. In this study, a traumatic shock rabbit model with special abdomen injuries was developed and evaluated by examining indicators of clotting and fibrinolysis.

METHODS

Forty New Zealand white rabbits were randomly divided into four groups: group 1 (sham), group 2 (hemorrhage), group 3 (hemorrhage-liver injury), and group 4 (hemorrhage-liver injury/intestinal injury-peritonitis). Coagulation was detected by thromboelastography before trauma (T₀), at 1 hour (T₁) and 4 hours (T₂) after trauma.

RESULTS

Rabbits that suffered from hemorrhage alone did not differ in coagulation capacity compared with the sham group. The clot initiations (R times) of group 3 at T₁ and T₂ were both shorter than those of groups 1, 2, and 4 (P<0.05). In group 4, clot strength was decreased at T₁ and T₂ compared with those in groups 1, 2, and 3 (P<0.05), whereas the R time and clot polymerization were increased at T₂ (P<0.05). The clotting angle significantly decreased in group 4 compared with groups 2 and 3 at T₂ (P<0.05).

CONCLUSION

This study suggests that different abdominal traumatic shock show diverse coagulopathy in the early phase. Isolated hemorrhagic shock shows no obvious effect on coagulation. In contrast, blunt hepatic injury with hemorrhage shows hypercoagulability, whereas blunt hepatic injury with hemorrhage coupled with peritonitis caused by a ruptured intestine shows a tendency toward hypocoagulability.

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

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.

Prediction of critical haemorrhage following trauma: A narrative review

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.

Benefits of Initial Limited Crystalloid Resuscitation in Severely Injured Trauma Patients at Emergency Department

Background

Whether initial limited crystalloid resuscitation (LCR) benefits to all severely injured trauma patients receiving blood transfusions at emergency department (ED) is uncertain. We aimed to determine the role of LCR and its associations with packed red blood cell (PRBC) transfusion during initial resuscitation.

Methods

Trauma patients receiving blood transfusions were reviewed from 2004 to 2013. Patients with LCR (L group, defined as < 2,000 mL) and excessive crystalloid resuscitation (E group, defined as ≥ 2,000 mL) were compared separately in terms of basic demographic, clinical variables, and hospital outcomes. Logistic regression, R-square (R²), and Spearman rho correlation were used for analysis.

Results

A total of 633 patients were included. The mortality was 51% in L group and 45% in E group (P = 0.11). No statistically significant difference was found in terms of basic demographics, vital signs upon arrival at ED, or injury severity between the groups. The volume of blood transfused strongly correlated with the volume of crystalloid infused in E group (R² = 0.955). Crystalloid to PRBC (C/PRBC) ratio was 0.8 in L group and 1.3 in E group (P < 0.01). The correlations between C/PRBC and ED versus ICU versus hospital length of stay (LOS) via Spearman rho were 0.25, 0.22, and 0.22, respectively.

Conclusions

Similar outcomes were observed in trauma patients receiving blood transfusions regardless of the crystalloid infusion volume. More crystalloid infusions were associated with more blood transfusions. The C/PRBC did not demonstrate predictive value regarding mortality but might predict LOS in severely injured trauma patients.

Incremental cost-effectiveness of trauma service improvements for road trauma casualties: experience of an Australian major trauma centre

Objective The aim of the present study was to estimate the cost-effectiveness of trauma service funding enhancements at an inner city major trauma centre. Methods The present study was a cost-effectiveness analysis using retrospective trauma registry data of all major trauma patients (injury severity score >15) presenting after road trauma between 2001 and 2012. The primary outcome was cost per life year gained associated with the intervention period (2007-12) compared with the pre-intervention period (2001-06). Incremental costs were represented by all trauma-related funding enhancements undertaken between 2007 and 2010. Risk adjustment for years of life lost was conducted using zero-inflated negative binomial regression modelling. All costs were expressed in 2012 Australian dollar values. Results In all, 876 patients were identified during the study period. The incremental cost of trauma enhancements between 2007 and 2012 totalled $7.91million, of which $2.86million (36%) was attributable to road trauma patients. After adjustment for important covariates, the odds of in-hospital mortality reduced by around half (adjusted odds ratio (OR) 0.48; 95% confidence interval (CI) 0.27, 0.82; P=0.01). The incremental cost-effectiveness ratio was A$7600 per life year gained (95% CI A$5524, $19333). Conclusion Trauma service funding enhancements that enabled a quality improvement program at a single major trauma centre were found to be cost-effective based on current international and Australian standards. What is known about this topic? Trauma quality improvement programs have been implemented across most designated trauma hospitals in an effort to improve hospital care processes and outcomes for injured patients. These involve a combination of education and training, the use of audit and key performance indicators. What does this paper add? A trauma quality improvement program initiated at an Australian Major Trauma Centre was found to be cost-effective over 12 years with respect to years of life saved in road trauma patients. What are the implications for practitioners? The results suggest that adequate resourcing of trauma centres to enable quality improvement programs may be a cost-effective measure to reduce in-hospital mortality following road trauma.

[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]

BACKGROUND

The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries.

AIM

This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies.

MATERIAL AND METHODS

In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations.

RESULTS

The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients.

CONCLUSION

The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.