Understanding traumatic shock: out-of-hospital hypotension with and without other physiologic compromise

BACKGROUND

Among trauma patients with out-of-hospital hypotension, we evaluated the predictive value of systolic blood pressure (SBP) with and without other physiologic compromise for identifying trauma patients requiring early critical resources.

METHODS

This was a secondary analysis of a prospective cohort of injured patients 13 years or older with out-of-hospital hypotension (SBP ≤ 90 mm Hg) who were transported by 114 emergency medical service agencies to 56 Level I and II trauma centers in 11 regions of the United States and Canada from January 1, 2010, through June 30, 2011. The primary outcome was early critical resource use, defined as blood transfusion of 6 U or greater, major nonorthopedic surgery, interventional radiology, or death within 24 hours.

RESULTS

Of 3,337 injured patients with out-of-hospital hypotension, 1,094 (33%) required early critical resources and 1,334 (40%) had serious injury (Injury Severity Score [ISS] ≥ 16). Patients with isolated hypotension required less early critical resources (14% vs. 52%), had less serious injury (20% vs. 61%), and had lower mortality (24 hours, 1% vs. 26%; in-hospital, 3% vs. 34%). The standardized probability of requiring early critical resources was lowest among patients with blunt injury and isolated moderate hypotension (0.12; 95% confidence interval, 0.09-0.15) and steadily increased with additional physiologic compromise, more severe hypotension, and penetrating injury (0.94; 95% confidence interval, 0.90-0.98).

CONCLUSION

A minority of trauma patients with isolated out-of-hospital hypotension require early critical resuscitation resources. However, hypotension accompanied by additional physiologic compromise or penetrating injury markedly increases the probability of requiring time-sensitive interventions.

LEVEL OF EVIDENCE

Prognostic study, level II.

Factors affecting prognosis in patients with gastric trauma

Morbidity and mortality after gastric injury is usually the result of associated injuries. The authors conducted a retrospective study of 544 consecutive patients with gastric trauma requiring emergency surgery. Blunt injuries had the highest mortality and length of stay. The mortality of a proximal stomach injury was 43 per cent (9 of 21) and was significantly higher than the 19 per cent mortality seen in patients with more distal injuries (P < 0.01). The majority of gastric injuries were closed primarily (492 of 544 or 90%). The patients requiring more than a primary repair had a higher mortality (22 of 52 or 42% vs. 87 of 492 or 18%; P < 0.001), required more blood (16+/-16 U vs. 6+/-11 U; P < 0.001), had an increased rate of surgical site infections (17 of 52 or 33% vs. 75 of 492 or 15%; P = 0.001), and had an increased length of stay (20+/-30 days vs. 13+/-18 days; P = 0.024). There were 22 patients with an isolated gastric injury, and all of these patients survived. Patients with an associated arterial injury had the highest mortality (49%) and highest incidence of shock (64%). Patients with colon and gastric injuries had the highest (48 of 176 or 52%) surgical site infection rate. Isolated gastric injury is rare, but is associated with low morbidity and mortality. The mechanism of injury, location of injury, and type of repair used all affect patient outcomes with gastric injury.

Analysis of clustered data in multicentre trauma studies

INTRODUCTION

In order to design multicentre studies an estimate of the correlation of the observations within each centre is necessary. A standard measure of the correlation between observations within each centre is the Intraclass Correlation Coefficient (ICC).

METHOD

We used the National Trauma Data Bank (NTDB). By 2004, 448 trauma centres (including 110 level I and 123 level II trauma centres) from 43 states and US territories contributed over 1.2 million records to the NTDB. Data of patients directly transported from the scene of injury to level I or II trauma centres were used to calculate the ICC of in-hospital trauma fatality and emergency department (ED) shock rate.

RESULTS

The ICCs of ED shock and in-hospital fatality rate were 0.010 (95% confidence interval (CI): 0.003-0.018) and 0.039 (95% CI: 0.028-0.050), respectively. The ICC of shock in the ED was the highest for penetrating injuries (0.017, 95% CI: 0.003-0.032) and the lowest for women (0.008, 95% CI: 0.002-0.013) although the observed difference between men and women was not statistically significant. The ICC of trauma fatality was the highest for penetrating injuries (0.073, 95% CI: 0.047-0.098), and the lowest for blunt injuries (0.029, 95% CI: 0.020-0.037).

DISCUSSION

Although the calculated ICCs might seem so small as to be ignored, the required sample size in studies with exclusively exposed or non-exposed clusters depends on the ICC and the average number of subjects within clusters. Therefore, investigators should be aware of the influence that these ICCs might have on sample size and power of their studies.

[Diagnosis and treatment of wounds of the gluteal area]

The authors present results of surgical treatment of 98 patients with gluteal wounds. In 93.9% of cases the wounds were not penetrating and in 6.1% there were penetrating wounds. All the patients admitted to hospitals in state of shock as well as suspected to the penetrating character of the wound underwent general laparoscopy. In 2 patients with penetrating wounds of the abdominal cavity and in 7 patients with non-penetrating wounds ligation of the internal iliac artery was necessary because of huge bleeding. Two patients (2%) with penetrating wounds of the abdominal cavity died.

Apparative Diagnostik im Schockraum

Opinions vary with regard to the equipment and structural furnishings required for adequate management of the trauma patient in the dedicated shock suite. In order to assess the current situation in Germany, we conducted a survey of the 76 centers participating in the Polytrauma Registry of the DGU. Fifty-one questionnaires were returned by centers representing all levels of care. Responses revealed, for example, that not all centers possess capabilities for conventional radiography in the shock suite (7/51). Only 20 centers had a fixed table; the remaining 24 hospitals used either an image converter or a mobile X-ray unit. A dedicated ultrasound scanner was provided for the shock suite in 39 of 51 centers responding. Dedicated computed tomography scanners were provided for the shock suite in only eight centers (one dedicated trauma center, three level 3 centers, four university hospitals). All eight scanners use helical CT technology; at least three of the units are 8- or 16-slice. Of 51 shock suites, 12 are air-conditioned in compliance with sterile criteria (and are officially designated as surgical suites), while the remaining 39 are not. In acute cases, emergency surgeries can be performed in the shock suite in 37 centers, but not in the remaining 14 shock suites. According to the survey, slightly less than half of the hospitals responding are un-satisfied with the shock suite infrastructure ( n=24) and, of these, 13 centers are actively planning changes (the necessary financial resources have been guaranteed in 10 centers). Fourteen centers desire changes but do not currently have the required money. Information provided by Philips and Siemens suggests that the cost of furnishing a new shock suite ranges between 1.4 and 1.7 million euros. Responses to our survey show that a large gap remains between wishes and reality in the technical infrastructure in many shock suites in Germany.

[Pathogenetical features of the acute period of traumatic disease. Traumatic shock as a special manifestation of the acute period]

Clinico-pathogenetical features of the acute period of trauma disease due to a severe combined injury were studied in 644 patients. An analysis of clinical indices was made in 428 of them, clinico-laboratory indices--in 216 patients. The results have shown that the main form of the acute period of the trauma disease are traumatic shock (62.8%), traumatic coma (18.3%), acute respiratory insufficiency (5.7%). Dramatically decreased delivery and consumption of oxygen lower than the metabolic requirements of the tissues accompany the traumatic shock which results in the suppression of tissue metabolism. Pronounced endotoxicosis developing along with the traumatic shock results not from the degree of injured tissues only, but from the centralization of blood circulation. It is also supported by the insufficient detoxicating function of the kidneys. A severe degree of the traumatic shock causes disseminated intravascular coagulation (DIC) of the II-III degree. After helping out from shock the patient has normocoagulation or the I degree DIC. Traumatic shock with marked hypotension and metabolic acidosis is a significant factor of high risk of the development of acute lesion of the lungs.

[Guidelines for severe multiple and multiorgan traumatic injuries]

Traumatic injuries have been described as the largest epidemic of the 20th century. In view of the number of victims and the associated costs, they have been also called the most severe and longest war of the contemporary world. According to Lipiński, every year every tenth Pole is involved in an accident and every one hundred-thirteenth Polish citizen requires specialist medical care. Thus, the general incidence is approximately 750 accidents per 100,000 Poles per year. 300,000 of them need hospital treatment, 30,000 die from accidents. Despite considerable progress in medical sciences and profound changes in the organization of emergency services within the past quarter of this century, multiple traumas continue to be a major problem in traumatology and the associated mortality rates in the best centers worldwide exceed 10%. Although, according to the recent reports, the most common cause of hospital deaths (30-50% or more of all fatal outcomes) is found in late complications of a severe trauma and posttraumatic shock, for example septic complications and multiorgan failure (MOF). Apart from severe primary injuries of the central nervous system, exsanguination continues to be the main cause of death (50-70%) immediately after the injury, at the site of the accident and in the ambulance (i.e. in the pre-hospital period) and in the first hours of hospitalization. The third life threatening cause is acute respiratory insufficiency after thoracic trauma. The "golden hour" procedures are particularly described as a prehospital time period (ABC ... system), emergency room period (ATLS system), damage control period and other life saving operations period. The general conception of these standards is minimalization of the effects of shock, respiratory insufficiency and intracranial hypertension in multitrauma patients.

[Gunshot wounds of the urogenital system organs]

The article makes a comparative analysis between Afghan war and previous wars concerning the gunshot injuries of urogenital organs. The authors mark limitations in specific symptoms of gunshot urogenital injuries and emphasize the importance of roentgenological method of examination with application of contrast substances. There are indications for surgical interventions and the analysis of medical errors in secondary surgical care.

[The effect of multiple and combined shock-inducing trauma on the processes of bone tissue reparation and on the recovery of work capacity in the victims]

Terms of consolidation of fractures and working ability were studied in 273 patients. Patients with multiple fractures of bones and with fractures associated with cranio-cerebral traumas were found to have slow consolidation (in 66.41%) or formation of a false joint (in 6.1%) due to severity of the trauma. It is just the cause of prolonged treatment and disability of the I or II group (in 66.6%). Active surgical treatment of such patients is necessary.

[Endogenous intoxication in chest and abdominal injuries]

Results of clinico-laboratory examinations of the endogenic intoxication in patients with injuries of the chest and abdomen are presented. Correlative relationships of the endogenic intoxication parameters and their association with the degree and character of injuries were established, the clinical informative value and prognostic significance of certain laboratory tests were determined. A conclusion is made on the necessity of a correction of endogenic intoxication in complex treatment of these patients.

[Traumatic shock in multiple fractures of bones of the limbs in children]

An analysis of 11230 case histories of children aged to 15 who had fractures of the extremity bones has shown multiple fractures of the extremity bones in 3% of the patients. It was established that traumatic shock in children with multiple fractures of the extremities was diagnosed in 14,1% (I degree--in 51%, II--in 42,6% and III--in 6,4%). The article concerns the incidence and severity of shock in children of different age groups as well as fractures of bones of various character and localization.

Burns unit in Stockholm: a report on patients treated 1971--1975 for acute burn injuries

A review of 297 burn patients treated 1971--1975 is presented to illustrate burn problems in a West European, mainly urban population. Patients were treated by exposure and warm dry air. Tubbing usually started five days after injury. Sequential wound revisions were performed. Surgical excision was usually delayed until days 14--21. Autografting was performed as soon as possible. For temporary cover homografts were frequently used. The majority of the patients were adults. Twelve per cent were older than 65 years. The patients revealed many social problems. Cardiopulmonary disease, mental disorder and alcohol or drug addiction were fairly common. The most common cause of the burn was fire and a majority of the patients sustained injuries in leisure time. 28% were classified as due to accident. 43% were considered diagnosed in 17 patients (5.7%). Five patients died due to septicemia.