Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study

Background

Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients.

Methods

A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed.

Results

Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0).

Conclusions

Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.

Traumatic aortic injury presenting to an adult major trauma centre

Introduction

Traumatic aortic injury is an uncommon condition. Timely diagnosis may enable early haemostatic resuscitation, essential to prevent worsening of the injury prior to definitive management. The aim of this study was to assess the utility of initial vital signs and presenting clinical characteristics to confirm or rule out aortic injury.

Methods

A retrospective review of patients from The Alfred Trauma Registry was conducted. Patients presenting between January 2006 and July 2014 and diagnosed with aortic injury were identified. Demographics and presenting clinical characteristics were extracted. Sensitivity of individual clinical variables for the detection of aortic injury was calculated.

Results

There were 77 patients identified with aortic injury, with an in-hospital mortality rate of 19.5% (95% CI: 10.6–28.3%). Of these, 68 (88.3%) patients presented after high-energy blunt mechanisms. Clinical signs and early chest X-ray findings were poorly sensitive to detect aortic injury. Patients who presented with hypotension had a greater severity of aortic injury, more commonly had associated abnormal investigation findings and were more likely to require blood products and inotropic agents (p < 0.05). However, sensitivity of initial hypotension to rule out aortic injury was 39.0% (95% CI: 28.1–49.9%).

Conclusions

The diagnosis of aortic injury was uncommon in hospital. Most injuries were secondary to high-velocity road traffic crashes or high falls. Clinical signs were not adequately sensitive to be used for the exclusion of aortic injury. We recommend a high degree of clinical suspicion and liberal imaging among cases where aortic injury is possible.

Do patients with blunt thoracic aortic injury present to hospital with unstable vital signs? A systematic review and meta-analysis

BACKGROUND

Blunt thoracic aortic injury (BTAI) is an uncommon diagnosis, usually developing as a consequence of high-impact acceleration-deceleration mechanisms. Timely diagnosis may enable early resuscitation and reduction of shear forces, essential to prevent worsening of the injury prior to definitive management. Death is commonly due to haemorrhagic shock, but clinical features may be absent until sudden and massive haemorrhage.

OBJECTIVES

The aim of this systematic review was to determine the proportion of patients with BTAI who present with unstable vital signs.

METHODS

Manuscripts were identified through a search of MEDLINE, EMBASE and the Cochrane Library databases, focusing on subject headings and keywords related to the aorta and trauma. Mechanisms of injury, haemodynamic status and mortality from the included manuscripts were reviewed. Meta-analysis of presenting haemodynamic status among a select group of similar papers was conducted.

RESULTS

Nineteen studies were included, with five selected for meta-analysis. Most reported cases of BTAI (80.0%-100%) were caused by road traffic incidents, with mortality consistently higher among initially unstable patients. There was statistically significant heterogeneity among the included studies (P<0.01). The pooled proportion of patients with haemodynamic instability in the setting of BTAI was 48.8% (95% CI 8.3 to 89.4).

CONCLUSIONS

Normal vital signs do not rule out aortic injury. A high degree of clinical suspicion and liberal use of imaging is necessary to prevent missed or delayed diagnoses.

Cruciform position for trauma resuscitation

Multiply injured patients represent a particularly demanding subgroup of trauma patients as they require urgent simultaneous clinical assessments using physical examination, ultrasound and invasive monitoring together with critical management, including tracheal intubation, thoracostomies and central venous access. Concurrent access to multiple body regions is essential to facilitate the concept of 'horizontal' resuscitation. The current positioning of trauma patient, with arms adducted, restricts this approach. Instead, the therapeutic cruciform positioning, with arms abducted at 90°, allows planning and performing of multiple life-saving interventions simultaneously. This positioning also provides a practical surgical field with improved sterility and procedural access.