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Stojek L, Bieler D, Neubert A, Ahnert T, Imach S. The potential of point-of-care diagnostics to optimise prehospital trauma triage: a systematic review of literature. Eur J Trauma Emerg Surg 2023; 49:1727-1739. [PMID: 36703080 PMCID: PMC10449679 DOI: 10.1007/s00068-023-02226-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 01/07/2023] [Indexed: 01/27/2023]
Abstract
PURPOSE In the prehospital care of potentially seriously injured patients resource allocation adapted to injury severity (triage) is a challenging. Insufficiently specified triage algorithms lead to the unnecessary activation of a trauma team (over-triage), resulting in ineffective consumption of economic and human resources. A prehospital trauma triage algorithm must reliably identify a patient bleeding or suffering from significant brain injuries. By supplementing the prehospital triage algorithm with in-hospital established point-of-care (POC) tools the sensitivity of the prehospital triage is potentially increased. Possible POC tools are lactate measurement and sonography of the thorax, the abdomen and the vena cava, the sonographic intracranial pressure measurement and the capnometry in the spontaneously breathing patient. The aim of this review was to assess the potential and to determine diagnostic cut-off values of selected instrument-based POC tools and the integration of these findings into a modified ABCDE based triage algorithm. METHODS A systemic search on MEDLINE via PubMed, LIVIVO and Embase was performed for patients in an acute setting on the topic of preclinical use of the selected POC tools to identify critical cranial and peripheral bleeding and the recognition of cerebral trauma sequelae. For the determination of the final cut-off values the selected papers were assessed with the Newcastle-Ottawa scale for determining the risk of bias and according to various quality criteria to subsequently be classified as suitable or unsuitable. PROSPERO Registration: CRD 42022339193. RESULTS 267 papers were identified as potentially relevant and processed in full text form. 61 papers were selected for the final evaluation, of which 13 papers were decisive for determining the cut-off values. Findings illustrate that a preclinical use of point-of-care diagnostic is possible. These adjuncts can provide additional information about the expected long-term clinical course of patients. Clinical outcomes like mortality, need of emergency surgery, intensive care unit stay etc. were taken into account and a hypothetic cut-off value for trauma team activation could be determined for each adjunct. The cut-off values are as follows: end-expiratory CO2: < 30 mm/hg; sonography thorax + abdomen: abnormality detected; lactate measurement: > 2 mmol/L; optic nerve diameter in sonography: > 4.7 mm. DISCUSSION A preliminary version of a modified triage algorithm with hypothetic cut-off values for a trauma team activation was created. However, further studies should be conducted to optimize the final cut-off values in the future. Furthermore, studies need to evaluate the practical application of the modified algorithm in terms of feasibility (e.g. duration of application, technique, etc.) and the effects of the new algorithm on over-triage. Limiting factors are the restriction with the search and the heterogeneity between the studies (e.g. varying measurement devices, techniques etc.).
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Affiliation(s)
- Leonard Stojek
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
| | - Dan Bieler
- Department of Orthopedics and Trauma Surgery, Reconstructive Surgery, Hand Surgery, Plastic Surgery and Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz, Germany
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Anne Neubert
- Department of Orthopedics and Trauma Surgery, Medical Faculty University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
- TraumaEvidence @ German Society of Traumatology, Berlin, Germany
| | - Tobias Ahnert
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany
| | - Sebastian Imach
- Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University Witten/Herdecke, Cologne, Germany.
- Helicopter Emergency Medical Service (HEMS) Christoph 3, Cologne, Germany.
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Halvachizadeh S, Kalbas Y, Teuben MPJ, Teuber H, Cesarovic N, Weisskopf M, Cinelli P, Pape HC, Pfeifer R. Effects of Occult Hypoperfusion on Local Circulation and Inflammation - An Analysis in a Standardized Polytrauma Model. Front Immunol 2022; 13:894270. [PMID: 35799796 PMCID: PMC9254728 DOI: 10.3389/fimmu.2022.894270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionOccult hypoperfusion (OH) is defined as persistent lactic acidosis despite normalization of vital parameters following trauma. The aim of this study was to analyze the association of occult hypoperfusion with local circulation and inflammation of injured soft tissue in a porcine polytrauma model.MethodsThis experimental study was performed with male landrace pigs who suffered a standardized polytrauma, including a femoral fracture, blunt chest trauma, liver laceration and a mean arterial pressure (MAP) controlled hemorrhagic shock. One hour after induction of trauma, the animals were resuscitated with retrograde femoral nailing, liver packing and volume replacement. Animals were stratified into Group Norm (normalizing lactate levels after resuscitation) and Group occult hypoperfusion (OH) (persistent lactate levels above 2 mmol/l with normalizing vital parameters after resuscitation). Local circulation (oxygen saturation, hemoglobin amount, blood flow) was measured with optical sensors at the subcutaneous soft tissue at the fractured extremity as well as at the stomach and colon. Local inflammatory parameters [interleukin (IL) 6, 8, 10, and heat shock protein (HSP)] were analyzed in the subcutaneous tissue of the fractured extremity.ResultsGroup Norm (n = 19) and Group OH (n = 5) were comparable in baseline vital and laboratory parameters. The shock severity and total amount of blood loss were comparable among Group Norm and Group OH. Following resuscitation Group OH had significantly lower local relative hemoglobin amount at the injured soft tissue of the fractured extremity when compared with Group Norm (39.4, SD 5.3 vs. 63.9, SD 27.6 A.U., p = 0.031). The local oxygenation was significantly lower in Group OH compared to Group Norm (60.4, SD 4.6 vs. 75.8, SD 12.8, p = 0.049). Local IL-6 in the fatty tissue was significantly higher in Group OH (318.3, SD 326.6 [pg/ml]) when compared with Group Norm (73.9,SD 96.3[pg/ml], p = 0.03). The local circulation at the abdominal organs was comparable in both groups.ConclusionOH is associated with decreased local circulation and increased local inflammation at the injured soft tissue of the extremity in polytrauma. OH might reflect the severity of local soft tissue injuries, and guide treatment strategies.
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Affiliation(s)
- Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
- *Correspondence: Sascha Halvachizadeh,
| | - Yannik Kalbas
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | | | - Henrik Teuber
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
| | - Nikola Cesarovic
- Department of Health Sciences and Technology, Eidgenössische Technische Hochschule (ETH) Zurich, Zurich, Switzerland
| | - Miriam Weisskopf
- Center for Surgical Research, University Hospital Zurich, University Zurich, Zurich, Switzerland
| | - Paolo Cinelli
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Zurich, Switzerland
- Harald Tscherne Research Laboratory, University of Zurich, Zurich, Switzerland
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Koome G, Thuita F, Egondi T, Atela M. Association between traumatic brain injury (TBI) patterns and mortality: a retrospective case-control study. F1000Res 2021; 10:795. [PMID: 35186268 PMCID: PMC8829093 DOI: 10.12688/f1000research.54658.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/27/2022] [Indexed: 11/20/2022] Open
Abstract
Background: Low and medium income countries (LMICs) such as Kenya experience nearly three times more cases of traumatic brain injury (TBI) compared to high income countries (HICs). This is primarily exacerbated by weak health systems especially at the pre-hospital care level. Generating local empirical evidence on TBI patterns and its influence on patient mortality outcomes is fundamental in informing the design of trauma-specific emergency medical service (EMS) interventions at the pre-hospital care level. This study determines the influence of TBI patterns and mortality. Methods: This was a case-control study with a sample of 316 TBI patients. Data was abstracted from medical records for the period of January 2017 to March 2019 in three tertiary trauma care facilities in Kenya. Logistic regression was used to assess influence of trauma patterns on TBI mortality, controlling for patient characteristics and other potential confounders. Results: The majority of patients were aged below 40 years (73%) and were male (85%). Road traffic injuries (RTIs) comprised 58% of all forms of trauma. Blunt trauma comprised 71% of the injuries. Trauma mechanism was the only trauma pattern significantly associated with TBI mortality. The risk of dying for patients sustaining RTIs was 2.83 times more likely compared to non-RTI patients [odds ratio (OR) 2.83, 95% confidence interval (CI) 1.62-4.93, p=0.001]. The type of transfer to hospital was also significantly associated with mortality outcome, with a public hospital having a two times higher risk of death compared to a private hospital [OR 2.18 95%CI 1.21-3.94, p<0.009]. Conclusion: Trauma mechanism (RTI vs non-RTI) and type of tertiary facility patients are transferred to (public vs private) are key factors influencing TBI mortality burden. Strengthening local EMS trauma response systems targeting RTIs augmented by adequately resourced and equipped public facilities to provide quality lifesaving interventions can reduce the burden of TBIs.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, 00200, Kenya
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, 00200, Kenya
| | - Thaddaeus Egondi
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, 00200, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, Cambridge, UK
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Koome G, Thuita F, Egondi T, Atela M. Association between traumatic brain injury (TBI) patterns and mortality: a retrospective case-control study. F1000Res 2021; 10:795. [PMID: 35186268 PMCID: PMC8829093 DOI: 10.12688/f1000research.54658.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/13/2021] [Indexed: 09/18/2023] Open
Abstract
Background: Low and medium income countries (LMICs) such as Kenya experience nearly three times more cases of traumatic brain injury (TBI) compared to high income countries (HICs). This is primarily exacerbated by weak health systems especially at the pre-hospital care level. Generating local empirical evidence on TBI patterns and its influence on patient mortality outcomes is fundamental in informing the design of trauma-specific emergency medical service (EMS) interventions at the pre-hospital care level. This study determines the influence of TBI patterns and mortality. Methods: This was a case-control study with a sample of 316 TBI patients. Data was abstracted from medical records for the period of January 2017 to March 2019 in three tertiary trauma care facilities in Kenya. Logistic regression was used to assess influence of trauma patterns on TBI mortality, controlling for patient characteristics and other potential confounders. Results: The majority of patients were aged below 40 years (73%) and were male (85%). Road traffic injuries (RTIs) comprised 58% of all forms of trauma. Blunt trauma comprised 71% of the injuries. Trauma mechanism was the only trauma pattern significantly associated with TBI mortality. The risk of dying for patients sustaining RTIs was 2.83 times more likely compared to non-RTI patients [odds ratio (OR) 2.83, 95% confidence interval (CI) 1.62-4.93, p=0.001]. The type of transfer to hospital was also significantly associated with mortality outcome, with a public hospital having a two times higher risk of death compared to a private hospital [OR 2.18 95%CI 1.21-3.94, p<0.009]. Conclusion: Trauma mechanism (RTI vs non-RTI) and type of tertiary facility patients are transferred to (public vs private) are key factors influencing TBI mortality burden. Strengthening local EMS trauma response systems targeting RTIs augmented by adequately resourced and equipped public facilities to provide quality lifesaving interventions can reduce the burden of TBIs.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, 00200, Kenya
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, 00200, Kenya
| | - Thaddaeus Egondi
- Strathmore Institute of Mathematical Sciences, Strathmore University, Nairobi, 00200, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, Cambridge, UK
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Bayissa BB, Alemu S. Pattern of trauma admission and outcome among patients presented to Jimma University Specialized Hospital, south-western Ethiopia. Trauma Surg Acute Care Open 2021; 6:e000609. [PMID: 34151026 PMCID: PMC8183195 DOI: 10.1136/tsaco-2020-000609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 05/13/2021] [Indexed: 11/04/2022] Open
Abstract
Background Trauma is an ever evolving world problem that needs close attention and devising means to prevent and treat. The aim of the study is to identify the main reason for trauma admissions and assess the patient outcome after intervention. Therefore, knowing its actual nature might aid in postulating possible intervention as well as prevention measures. Method A cross-sectional study was conducted from August to December 2015 in Jimma University Specialized Hospital, which is located in south-western Ethiopia. Two hundred and eleven consecutive trauma admissions to surgery department were included in the study. Data were collected and analyzed using computer software SPSS V.23. Result A total of 211 admitted trauma patients were studied with male to female ratio of 3.14. The leading cause of trauma admission was road traffic collision at 84 (39.8%) and the least being bullet injury which was 6 (2.8%). Hospital mortality was 31 (14.7%). Factors associated with outcome of patients before discharge from hospital were male sex, adjusted OR (AOR)=2.3, 95% CI 1.08 to 4.75; Glasgow Coma Scale score 15/15, AOR=0.04, 95% CI 0.00 to 0.46; and hemoglobin >10 g/L, AOR=0.225, 95% CI 0.074 to 0.464, p<0.05. Conclusion Road traffic collision takes the top position from all causes of trauma and unlike other developed countries and low and middle-income countries, pedestrians and motorcyclists were the major victims of the collision in this study.Level of evidence VI (This level of effectiveness rating scheme is based on the following: Ackley, B. J., Swan, B. A., Ladwig, G., & Tucker, S. (2008). Evidence-based nursing care guidelines: Medical-surgical interventions. (p. 7). St. Louis, MO: Mosby Elsevier.
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Affiliation(s)
| | - Seifu Alemu
- Surgery, Jimma University, College of Public Health and Medical Sciences, Jimma, Ethiopia
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Warwick JW, Davenport DL, Bettis A, Bernard AC. Association of Prehospital Step 1 Vital Sign Criteria and Vital Sign Decline with Increased Emergency Department and Hospital Death. J Am Coll Surg 2020; 232:572-579. [PMID: 33348016 DOI: 10.1016/j.jamcollsurg.2020.12.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/01/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND This study analyzed data from the 2017 American College of Surgeons National Trauma Data Bank to examine the effects of pre-hospital Field Triage Decision Scheme Step 1 vital sign criteria (S1C) and vital sign decline on subsequent emergency department (ED) and hospital death in emergency medical services (EMS) transported trauma victims. STUDY DESIGN Patient and injury characteristics, transport time, and ED and hospital disposition were collected. S1C (respiratory rate [RR]<10, RR>29 breaths/min, systolic blood pressure [SBP]<90 mmHg, Glasgow Coma Scale [GCS]<14) were recorded at the injury scene and hospital arrival. Decline was defined as a change ≥ 1 standard deviation (SD) into or within an S1C range. S1C and decline were analyzed relative to ED and hospital death using logistic regression. RESULTS Of 333,213 included patients, 54,849 (16.5%) met Step 1 criteria at the scene, and 21,566 (6.9%) declined en route. The ED death rate was 0.4% (n = 1,188), and the hospital death/hospice rate was 4.0% (11,624 of 287,675). Patients who met S1C at the scene or who declined were more likely to require longer hospital lengths of stay, ICU admission, and surgical intervention. S1C and decline patients had higher odds of death in both the ED (S1C odds ratio [OR] 15.1, decline OR 2.4, p values < 0.001) and hospital (S1C OR 4.8, decline OR 2.0, p values < 0.001) after adjusting for patient demographics, transport time and mode, injury severity, and injury mechanism. Each S1C and decline measure was independently predictive of death. CONCLUSIONS This study quantifies the mortality risks associated with individual S1C and validates their use as an indicator for injury severity and pre-hospital triage tool.
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Affiliation(s)
- James W Warwick
- University of Kentucky College of Medicine, University of Kentucky College of Medicine, Lexington, KY
| | - Daniel L Davenport
- Division of Healthcare Outcomes and Optimal Patient Services, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Amber Bettis
- Division of Healthcare Outcomes and Optimal Patient Services, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY
| | - Andrew C Bernard
- University of Kentucky and the Division of Acute Care Surgery, Trauma, and Critical Care, Department of Surgery, University of Kentucky College of Medicine, Lexington, KY.
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Koome G, Atela M, Thuita F, Egondi T. Health system factors associated with post-trauma mortality at the prehospital care level in Africa: a scoping review. Trauma Surg Acute Care Open 2020; 5:e000530. [PMID: 33083557 PMCID: PMC7528423 DOI: 10.1136/tsaco-2020-000530] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Accepted: 07/30/2020] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Africa accounts forabout 90% of the global trauma burden. Mapping evidence on health systemfactors associated with post-trauma mortality is essential in definingpre-hospital care research priorities and mitigation of the burden. The studyaimed to map and synthesize existing evidence and research gaps on healthsystem factors associated with post-trauma mortality at the pre-hospital carelevel in Africa. METHODS A scoping review of published studies and grey literature was conducted. The search strategy utilized electronic databases comprising of Medline, Google Scholar, Pub-Med, Hinari and Cochrane Library. Screening and extraction of eligible studies was done independently and in duplicate. RESULTS A total of 782 study titles and or abstracts were screened. Of these, 32 underwent full text review. Out of the 32, 17 met the inclusion criteria for final review. The majority of studies were literature reviews (24%) and retrospective studies (23%). Retrospective and qualitative studies comprised 6% of the included studies, systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%), systematic reviews (6%), cross-sectional studies (17%), Delphi studies (6%), panel reviews (6%) and qualitative studies (12%). Reported post-trauma mortality ranged from 13% in Ghana to 40% in Nigeria. Reported preventable mortality is as high as 70% in South Africa, 60% in Ghana and 40% in Nigeria. Transport mode is the most studied health system factor (reported in 76% of the papers). Only two studies (12%) included access to pre-hospital care interventions aspects, nine studies (53%) included care providers aspects and three studies (18%) included aspects of referral pathways. The types of transport mode and referral pathway are the only factors significantly associated with post-trauma mortality, though the findings were mixed. None of the included studies reported significant associations between pre-hospital care interventions, care providers and post-trauma mortality. DISCUSSION Although research on health system factors and its influence on post-trauma mortality at the pre-hospital care level in Africa are limited, anecdotal evidence suggests that access to pre-hospital care interventions, the level of provider skills and referral pathways are important determinants of mortality outcomes. The strength of their influence will require well designed studies that could incorporate mixed method approaches. Moreover, similar reviews incorporating other LMICs are also warranted. Key Words: Health System Factors, Emergency Medical Services [EMS], Pre-hospital Care, Post-Trauma mortality, Africa.
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Affiliation(s)
- Gilbert Koome
- School of Public Health, University of Nairobi, Nairobi, Kenya
| | - Martin Atela
- Peterhouse, University of Cambridge, Cambridge, UK
| | - Faith Thuita
- School of Public Health, University of Nairobi, Nairobi, Kenya
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Perfusion Index Measurement in Predicting Hypovolemic Shock in Trauma Patients. J Emerg Med 2020; 59:238-245. [DOI: 10.1016/j.jemermed.2020.04.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/01/2020] [Accepted: 04/08/2020] [Indexed: 01/14/2023]
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Abstract
Trauma is a global health problem and a leading cause of mortality. One of the major predictors of trauma mortality is the Injury Severity Score (ISS). Theoretically, as the ISS increases, the probability of survival decreases; ISS = 75 is considered to be not survivable. Studies have shown that some deaths are preventable and some potentially preventable. Hemorrhagic shock is a potentially preventable cause of trauma mortality. A retrospective database review was conducted of the Mississippi Trauma Registry and point-by-serial correlational analyses were conducted to determine the direction of any significant relations between blood product usage, traditional vital signs, and shock index. Pearson correlation, logistic regressions, and odds ratio calculation results revealed that shock index can signal impending hemorrhagic compromise better than traditional vital signs; thus, facilitating early intervention, specifically, as heart rate and shock index increase, the use of blood products increases, and as blood pressure increases, the use of blood products decreases. Independent t tests for shock index and ISS revealed significant differences in the means with relationship to the subgroups "Dead" and "Alive." Higher ISS were found to correlate with higher shock indices. Evaluation of ISS and survivability demonstrates that ISS = 75 is survivable and should not lead one to reflexively assume otherwise. A total mortality finding of only 1.58% (n = 2,010) was unexpected but very encouraging.
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Sheehan BM, Grigorian A, de Virgilio C, Fujitani RM, Kabutey NK, Lekawa M, Schubl SD, Nahmias J. Predictors of blunt abdominal aortic injury in trauma patients and mortality analysis. J Vasc Surg 2019; 71:1858-1866. [PMID: 31699513 DOI: 10.1016/j.jvs.2019.07.095] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Accepted: 07/18/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Blunt abdominal aortic injury (BAAI) occurs in less than 0.1% of blunt traumas. A previous multi-institutional study found an associated mortality rate of 39%. We sought to identify risk factors for BAAI and risk factors for mortality in patients with BAAI using a large national database. We hypothesized that an Injury Severity Score of 25 or greater, and thoracic trauma would both increase the risk of mortality in patients with BAAI. METHODS The Trauma Quality Improvement Program (2010-2016) was queried for individuals with blunt trauma. Patients with and without BAAI were compared. Covariates were included in a multivariable logistic regression model to determine mechanisms of injury, examination findings, and concomitant injuries associated with increased risk for BAAI. An additional multivariable analysis was performed for mortality in patients with BAAI. RESULTS From 1,056,633 blunt trauma admissions, 1012 (0.1%) had BAAI. The most common mechanism of injury was motor vehicle accident (MVA; 57.5%). More than one-half the patients had at least one rib fracture (54.0%), or a spine fracture (53.9%), whereas 20.8% had hypotension on admission and 7.8% had a trunk abrasion. The average length of stay was 13.4 days and 24.6% required laparotomy, with 6.6% receiving an endovascular repair and 2.9% an open repair. The risk of death in those treated with endovascular vs open repair was similar (P = .28). On multivariable analysis, MVA was the mechanism associated with the highest risk of BAAI (odds ratio [OR], 4.68; 95% confidence interval [CI], 3.87-5.65; P < .001) followed by pedestrian struck (OR, 4.54; 95% CI, 3.47-5.92; P < .001). Other factors associated with BAAI included hypotension on admission (OR, 3.87; 95% CI, 3.21-4.66; P < .001), hemopneumothorax (OR, 3.67; 95% CI, 1.16-11.58; P < .001), abrasion to the trunk (OR, 1.49; 95% CI, 1.15-1.94; P = .003), and rib fracture (OR, 1.46; 95% CI, 1.25-1.70; P < .001). The overall mortality rate was 28.0%. Of the variables examined, the strongest risk factor associated with mortality in patients with BAAI was hemopneumothorax (OR, 12.49; 95% CI, 1.25-124.84; P = .03) followed by inferior vena cava (IVC) injury (OR, 12.05; 95% CI, 2.80-51.80; P < .001). CONCLUSIONS In the largest nationwide series to date, BAAI continues to have a high mortality rate with hemopneumothorax and IVC injury associated with the highest risk for mortality. The mechanism most strongly associated with BAAI is MVA followed by pedestrian struck. Other risk factors for BAAI include rib fracture and trunk abrasion. Providers must maintain a high suspicion of injury for BAAI when these mechanisms of injury, physical examination or imaging findings are encountered.
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Affiliation(s)
| | - Areg Grigorian
- Department of Surgery, University of California, Irvine, Orange, Calif
| | | | - Roy M Fujitani
- Department of Surgery, University of California, Irvine, Orange, Calif
| | - Nii-Kabu Kabutey
- Department of Surgery, University of California, Irvine, Orange, Calif
| | - Michael Lekawa
- Department of Surgery, University of California, Irvine, Orange, Calif
| | | | - Jeffry Nahmias
- Department of Surgery, University of California, Irvine, Orange, Calif
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Accuracy of National Early Warning Score 2 (NEWS2) in Prehospital Triage on In-Hospital Early Mortality: A Multi-Center Observational Prospective Cohort Study. Prehosp Disaster Med 2019; 34:610-618. [PMID: 31648657 DOI: 10.1017/s1049023x19005041] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center. HYPOTHESIS/PROBLEM The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs. METHODS This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours. RESULTS From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2). CONCLUSION Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. Older age is associated with a reduced likelihood of ambulance transport to a trauma centre after major trauma in Perth. Emerg Med Australas 2019; 31:763-771. [PMID: 30827060 DOI: 10.1111/1742-6723.13244] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 11/28/2018] [Accepted: 01/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe the characteristics and outcomes of older adult (≥65 years) major trauma patients in comparison with younger adults (16-64 years). To determine whether older age is associated with a reduced likelihood of transport (directly or indirectly) to a major trauma centre and whether this is associated with in-hospital mortality. METHODS A retrospective cohort study of major trauma patients transported to hospital by St John Ambulance paramedics in Perth, Western Australia, between 1 January 2013 and 31 December 2016. Multivariate logistic regression was used to test the relationship between age and major trauma centre transport. Multivariate logistic regression analysis using inverse probability of treatment weighting was used to determine if major trauma centre transport was associated with in-hospital mortality in older adults. RESULTS One thousand six hundred and twenty-five patients were included; of these 576 (35%) were ≥65 years. In comparison with younger adults, older adults had more falls as their mechanism of injury (n = 358 [62%] versus n = 102 [10%], P ≤ 0.001) and more major head injuries (n = 472 [82%] versus n = 609 [58%], P ≤ 0.001). Older adults had lower odds (adjusted odds ratio 0.52, 95% confidence interval [CI] 0.35-0.78) of major trauma centre transport and this was associated with 1.7 times the likelihood of in-hospital mortality (95% CI 1.04-2.7). CONCLUSIONS Older adults who were not transported to the trauma centre had an increased odds of in-hospital mortality. However, older age was associated with a significantly reduced likelihood of trauma centre transport. With the aging population, the development of specific prehospital triage criteria to enable the complexities of this higher-risk population to be identified is important.
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Affiliation(s)
- Elizabeth Brown
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia
| | - Hideo Tohira
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia
| | - Paul Bailey
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Emergency Department, St John of God Murdoch Hospital, Perth, Western Australia, Australia
| | - Daniel Fatovich
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,Emergency Medicine, Royal Perth Hospital, The University of Western Australia, Perth, Western Australia, Australia.,Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Gavin Pereira
- School of Public Health, Curtin University, Perth, Western Australia, Australia.,Telethon Kids Institute, Perth, Western Australia, Australia
| | - Judith Finn
- Prehospital Resuscitation and Emergency Care Research Unit (PRECRU), School of Nursing, Midwifery and Paramedicine, Curtin University, Perth, Western Australia, Australia.,St John Ambulance Western Australia, Perth, Western Australia, Australia.,Division of Emergency Medicine, The University of Western Australia, Perth, Western Australia, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Brown E, Tohira H, Bailey P, Fatovich D, Pereira G, Finn J. Longer Prehospital Time was not Associated with Mortality in Major Trauma: A Retrospective Cohort Study. PREHOSP EMERG CARE 2019; 23:527-537. [PMID: 30462550 DOI: 10.1080/10903127.2018.1551451] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: The objective of this study was to determine the association between prehospital time and outcomes in adult major trauma patients, transported by ambulance paramedics. Methods: A retrospective cohort study of major trauma patients (Injury Severity Score >15) attended by St John Ambulance paramedics in Perth, Western Australia, who were transported to hospital between January 1, 2013 and December 31, 2016. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to limit selection bias and confounding. The primary outcome was 30-day mortality and the secondary outcome was the length of hospital stay (LOS) for 30-day survivors. Multivariate logistic and log-linear regression analyses with IPTW were used to determine if prehospital time of more than the one hour (from receipt of the emergency call to arrival at hospital) or any individual prehospital time interval (response, on-scene, transport, or total time) was associated with 30-day mortality or LOS. Results: A total of 1,625 major trauma patients were included and 1,553 included in the IPTW sample. No significant association between prehospital time of one hour and 30-day mortality was found (adjusted odds ratio 1.10, 95% confidence interval (CI) 0.71-1.69). No association between any individual prehospital time interval and 30-day mortality was identified. In the 30-day survivors, one-minute increase of on-scene time was associated with 1.16 times (95% CI 1.03-1.31) longer LOS. Conclusion: Longer prehospital times were not associated with an increased likelihood of 30-day mortality in major trauma patients transported to hospital by ambulance paramedics. We found no evidence to support the hypothesis that prehospital time longer than one hour resulted in an increased risk of 30-day mortality. However, longer on-scene time was associated with longer hospital LOS (for 30-day survivors). Our recommendation is that prehospital care is delivered in a timely fashion and delivery of the patient to hospital is reasonably prompt.
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Nordgarden T, Odland P, Guttormsen AB, Ugelvik KS. Undertriage of major trauma patients at a university hospital: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2018; 26:64. [PMID: 30107855 PMCID: PMC6092794 DOI: 10.1186/s13049-018-0524-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 07/02/2018] [Indexed: 12/12/2022] Open
Abstract
Background Studies show increased mortality among severely injured patients not met by trauma team. Proper triage is important to ensure that all severely injured patients receive vital trauma care. In 2017 a new national trauma plan was implemented in Norway, which recommended the use of a modified version of “Guidelines for Field Triage of Injured Patients” to identify severely injured patients. Methods A retrospective study of 30,444 patients admitted to Haukeland University Hospital in 2013, with ICD-10 injury codes upon discharge. The exclusion criteria were department affiliation considered irrelevant when identifying trauma, patients with injuries that resulted in Injury Severity Score < 15, patients that did receive trauma team, and patients admitted > 24 h after time of injury. Information from patient records of every severely injured patient admitted in 2013 was obtained in order to investigate the sensitivity of the new guidelines. Results Trauma team activation was performed in 369 admissions and 85 patients were identified as major trauma. Ten severely injured patients did not receive trauma team resuscitation, resulting in an undertriage of 10.5%. Nine out of ten patients were men, median age 54 years. Five patients were 60 years or older. All of the undertriaged patients experienced fall from low height (< 4 m). Traumatic brain injury was seen in six patients. Six patients had a Glasgow Coma Scale score ≤ 13. The new trauma activation guidelines had a sensitivity of 95.0% in our 2013 trauma population. The degree of undertriage could have been reduced to 4.0% had the guidelines been implemented and correctly applied. Conclusions The rate of undertriage at Haukeland University Hospital in 2013 was above the recommendations of less than 5%. Use of the new trauma guidelines showed increased triage precision in the present trauma population.
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Affiliation(s)
- Terje Nordgarden
- Faculty of Medicine, University of Bergen, Haukelandsveien 28, 5009, Bergen, Norway.
| | - Peter Odland
- Faculty of Medicine, University of Bergen, Haukelandsveien 28, 5009, Bergen, Norway
| | - Anne Berit Guttormsen
- Department of Clinical Medicine 1, Jonas Lies vei 65, 5021, Bergen, Norway.,Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway
| | - Kristina Stølen Ugelvik
- Regional Trauma Center, Surgical Department, Haukeland University Hospital, Jonas Lies vei 65, 5021, Bergen, Norway
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A Novel Approach to Identify Polytraumatized Patients in Extremis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7320158. [PMID: 29850559 PMCID: PMC5932503 DOI: 10.1155/2018/7320158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Revised: 02/11/2018] [Accepted: 02/27/2018] [Indexed: 12/01/2022]
Abstract
Introduction Due to the fact that early objective identification of polytraumatized patients in extremis is crucial for carrying out immediate life-saving measures, our objectives were to provide and scrutinize a definition that results in a particularly high mortality rate and to identify predictors of mortality in this group. Materials and Methods A polytraumatized patient (ISS ≥ 16) was classified “in extremis” if five out of seven parameters (arterial paCO2 > 50 mmHg, hemoglobin < 9.5 g/dl, pH value < 7.2, lactate level > 4 mmol/l, base excess < −6 mmol/l, shock index > 1, and Horowitz index < 300) were met. By applying this definition, polytraumatized patients (age ≥ 18 years), admitted to our level I trauma center within a time period of three years, were retrospectively allocated to the “in extremis” group and to an age-, gender-, and ISS-matched “non-in extremis” group for comparison. Results Out of 64 polytraumatized patients (mean ISS, 43.6), who formed the “in extremis” group, 36 patients (56.3%) died, thus revealing a threefold higher mortality rate than in the matched group (18.9%). Within the “in extremis” group, age and ISS were identified as predictors of mortality. Conclusion Our definition might serve as a valuable early warning score or at least an impetus for defining polytraumatized patients in extremis in clinical practice.
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A 12-Month Clinical Audit Comparing Point-of-Care Lactate Measurements Tested by Paramedics with In-Hospital Serum Lactate Measurements. Prehosp Disaster Med 2018; 33:36-42. [DOI: 10.1017/s1049023x17007130] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractObjectivePrehospital point-of-care lactate (pLA) measurement may be a useful tool to assist paramedics with diagnosing a range of conditions, but only if it can be shown to be a reliable surrogate for serum lactate (sLA) measurement. The aim of this study was to determine whether pLA is a reliable predictor of sLA.MethodsThis was a retrospective study of adult patients over a 12-month period who had pLA measured by paramedics in an urban Australian setting and were transported by ambulance to a tertiary hospital where sLA was measured. Patients were excluded if they suffered a cardiopulmonary arrest at any time, had missing data, or if sLA was not measured within 24 hours of arrival. Levels of agreement were determined using methods proposed by Bland and Altman.ResultsA total of 290 patients were transported with a pLA recorded. After exclusions, there were 155 patients (55.0% male; age 71 [SD=18] years) remaining who had sLA recorded within 24 hours. Elevated pLA (>2.0mMol/L) was associated with sLA measurement (76.1% vs 23.9%; OR 3.18; 95% CI, 1.88-5.37; P<.0001). Median time between measurements was 89 minutes (IQR=75). Overall, median pLA was higher than sLA (3.0 [IQR=2.0] mMol/L vs 1.7 [IQR=1.3]; P<.001). Bland-Altman analysis on all participants showed a mean difference of 1.48 mMol/L (95% CI, -3.34 to 6.31). Normal pLA was found to be a true negative in 82.9% of cases, and elevated pLA was a true positive in 48.3% of cases. When the time between measurements was less than 60 minutes (n=25), normal pLA predicted normal sLA with 100% accuracy, with a false-positive rate of 18.2%. As time between measurements increased, accuracy diminished and the false-positive rate increased.ConclusionsOverall, the level of agreement between pLA and sLA was poor. Accuracy of pLA diminished markedly as the time between the two measurements increased. It may be possible to use pLA as a screening tool; when considered this way, pLA performed much better, though larger prospective trials would be needed to confirm this.SwanKL, KeeneT, AvardBJ. A 12-month clinical audit comparing point-of-care lactate measurements tested by paramedics with in-hospital serum lactate measurements. Prehosp Disaster Med. 2018;33(1):36–42.
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Moyron RB, Wall NR. Differential protein expression in exosomal samples taken from trauma patients. Proteomics Clin Appl 2018; 11. [PMID: 28734082 DOI: 10.1002/prca.201700095] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2017] [Revised: 06/18/2017] [Accepted: 07/14/2017] [Indexed: 11/08/2022]
Affiliation(s)
- Ron B Moyron
- Center for Health Disparities Research and Molecular Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Biochemistry, Loma Linda University, Loma Linda, CA, USA
| | - Nathan R Wall
- Center for Health Disparities Research and Molecular Medicine, Loma Linda University, Loma Linda, CA, USA.,Department of Basic Sciences, Division of Biochemistry, Loma Linda University, Loma Linda, CA, USA
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Lilitsis E, Xenaki S, Athanasakis E, Papadakis E, Syrogianni P, Chalkiadakis G, Chrysos E. Guiding Management in Severe Trauma: Reviewing Factors Predicting Outcome in Vastly Injured Patients. J Emerg Trauma Shock 2018; 11:80-87. [PMID: 29937635 PMCID: PMC5994855 DOI: 10.4103/jets.jets_74_17] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome - specifically mortality risk - in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome - more specifically mortality risk - in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured.
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Affiliation(s)
- Emmanuel Lilitsis
- Department of Anesthesiology, University Hospital of Crete, Heraklion, Greece
| | - Sofia Xenaki
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | - Elias Athanasakis
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | | | - Pavlina Syrogianni
- Department of Anesthesiology, University Hospital of Crete, Heraklion, Greece
| | - George Chalkiadakis
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
| | - Emmanuel Chrysos
- Department of General Surgery, University Hospital of Crete, Heraklion, Greece
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Rogobete AF, Sandesc D, Papurica M, Stoicescu ER, Popovici SE, Bratu LM, Vernic C, Sas AM, Stan AT, Bedreag OH. The influence of metabolic imbalances and oxidative stress on the outcome of critically ill polytrauma patients: a review. BURNS & TRAUMA 2017; 5:8. [PMID: 28286784 PMCID: PMC5341432 DOI: 10.1186/s41038-017-0073-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 02/23/2017] [Indexed: 05/03/2023]
Abstract
The critically ill polytrauma patient presents with a series of associated pathophysiologies secondary to the traumatic injuries. The most important include systemic inflammatory response syndrome (SIRS), sepsis, oxidative stress (OS), metabolic disorders, and finally multiple organ dysfunction syndrome (MODS) and death. The poor outcome of these patients is related to the association of the aforementioned pathologies. The nutrition of the critically ill polytrauma patient is a distinct challenge because of the rapid changes in terms of energetic needs associated with hypermetabolism, sepsis, SIRS, and OS. Moreover, it has been proven that inadequate nutrition can prolong the time spent on a mechanical ventilator and the length of stay in an intensive care unit (ICU). A series of mathematical equations can predict the energy expenditure (EE), but they have disadvantages, such as the fact that they cannot predict the EE accurately in the case of patients with hypermetabolism. Indirect calorimetry (IC) is another method used for evaluating and monitoring the energy status of critically ill patients. In this update paper, we present a series of pathophysiological aspects associated with the metabolic disaster affecting the critically ill polytrauma patient. Furthermore, we present different non-invasive monitoring methods that could help the intensive care physician in the adequate management of this type of patient.
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Affiliation(s)
- Alexandru Florin Rogobete
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Dorel Sandesc
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Marius Papurica
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
| | - Emil Robert Stoicescu
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Sonia Elena Popovici
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Lavinia Melania Bratu
- Faculty of Pharmacy, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Corina Vernic
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Adriana Mariana Sas
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Adrian Tudor Stan
- Faculty of Dental Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
| | - Ovidiu Horea Bedreag
- Faculty of Medicine, Victor Babes University of Medicine and Pharmacy, Str. Eftimie Murgu Nr. 2, Timisoara, 300041 Timis Romania
- Clinic of Anaesthesia and Intensive Care, Emergency County Hospital “Pius Brinzeu”, Bd. Liviu Rebreanu Nr.156, Timisoara, 300736 Timis Romania
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Abstract
PURPOSE OF REVIEW Shock occurs because of a failure to deliver adequate oxygen to meet the metabolic demands of the body resulting in metabolic acidosis, inflammation, and coagulopathy. Resuscitation is the process of treating shock in an attempt to restore normal physiology. Various hemodynamic, metabolic, and regional endpoints have been described to evaluate the degree of shock and guide resuscitation efforts. We will briefly describe these endpoints, and propose damage control resuscitation as an additional endpoint. RECENT FINDINGS Serum lactate, base deficit, and pH are well established endpoints of resuscitation that provide valuable information when trended over time; however, a single value is inadequate to determine adequacy of resuscitation. Rapid normalization of central venous oxygen concentration has been associated with improved survival, and bedside transthoracic echocardiography can be a reliable assessment of volume status. In hypovolemic/hemorrhagic shock, early hypotensive, or controlled resuscitation strategies have been associated with improved survival, and hemostatic strategies guided by thrombelastography using a balanced transfusion approach result in improved hemostasis. SUMMARY Numerous endpoints are available; however, no single endpoint is universally applicable. Damage control resuscitation strategies have demonstrated improved survival, hemostasis, and less early death from exsanguination, suggesting that hemorrhage control should be an additional endpoint in resuscitation.
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Abhilash KPP, Chakraborthy N, Pandian GR, Dhanawade VS, Bhanu TK, Priya K. Profile of trauma patients in the emergency department of a tertiary care hospital in South India. J Family Med Prim Care 2016; 5:558-563. [PMID: 28217583 PMCID: PMC5290760 DOI: 10.4103/2249-4863.197279] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Trauma is an increasing cause of morbidity and mortality in India. This study was done to improve the understanding of the mode of trauma, severity of injuries, and outcome of trauma victims in our hospital. MATERIALS AND METHODS This was a retrospective observational study of all adult trauma patients more than 18-year-old presenting to our emergency department (ED). Details of the incident, injuries, and outcome were noted. RESULTS The ED attended to 16,169 patients during the 3-month study period with 10% (1624/16,169) being adult trauma incidents. The gender distribution was 73.6% males and 26.4% females. The mean age was 40.2 ± 16.7 years. The median duration from time of incident to time of arrival to the ED was 3 h (interquartile range [IQR]: 1.5-6.5) for priority one patients, 3 h (IQR: 1.5-7.7) for priority two patients, and 1.5 h (IQR: 1-7) for priority three patients. The average number of trauma incidents increased by 28% during the weekends. Road traffic accident (RTA) (65%) was the most common mode of injury, followed by fall on level ground (13.5%), fall from height (6.3%), work place injuries (6.3%), and others. Traumatic brain injury was seen in 17% of patients while 13.3% had polytrauma with two-wheeler accidents contributing to the majority. The ED team alone managed 23.4% of patients while the remaining 76.6% required evaluation and treatment by the trauma, surgical teams. The in-hospital mortality rate was 2.3%. Multivariate analysis showed low Glasgow coma score (odds ratio [OR]: 0.65, 95% confidence interval [CI]: 0.55-0.76, P < 0.001) and high respiratory rate (OR: 1.15, 95% CI: 1.07-1.24, P < 0.001) to be independent predictors of mortality among polytrauma victims. CONCLUSIONS RTA and falls are the predominant causes of trauma. A simple physiological variable-based scoring system such as the revised trauma score may be used to prioritize patients with polytrauma.
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Affiliation(s)
| | | | - Gautham Raja Pandian
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Thomas Kurien Bhanu
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Krishna Priya
- Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
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Negoi I, Paun S, Hostiuc S, Stoica B, Tanase I, Negoi RI, Constantinescu G, Beuran M. Mortality after acute trauma: Progressive decreasing rather than a trimodal distribution. JOURNAL OF ACUTE DISEASE 2015. [DOI: 10.1016/j.joad.2015.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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