Does thoracic injury impair the predictive value of base deficit in trauma patients?

Introduction: This study used data from a prospectively maintained trauma database to assess the level of systolic blood pressure at which mortality rates for trauma begin to increase and to compare systolic blood pressure with base deficit as a predictor of outcome. Methodology: The Pietermaritzburg Metropolitan Trauma Service maintains a prospective digital trauma registry. All trauma patients admitted to the service for the period January 2012–January 2015 were included. Analysis was performed on systolic blood pressure relative to a number of selected markers of outcome and a variety of physiological parameters. Results: Out of an original data set of 2974 trauma patients, a total of 169 elective patients, 799 patients with isolated traumatic brain injury, and 27 patients with incomplete data were excluded to leave a sample size of 2148 patients. Of these, 1830 (85.2%) were males and 318 (14.8%) were females. The mean age (standard deviation) was 31.8 (12.0) years. The median age (interquartile range) was 29 (23–37) years. There were 89 deaths in this cohort (4.1%). The median systolic blood pressure (interquartile range) was 123 (112–136) mmHg. The median base deficit was −1.4 (interquartile range: −4.5 to 1). The inflection curves below with fitted non-linear curve clearly show the upward change in mortality frequency around a systolic blood pressure of ⩽110 mmHg as well for a base deficit below −5. A cutoff of <110 for systolic blood pressure yields a high sensitivity and very high positive predictive value of 82% (95% confidence interval: 81–84) and 98% (95% confidence interval: 97–98), but low specificity (56%) and negative predictive value (12%), respectively. Similar optimal cutoff analysis for base deficit versus mortality suggests base deficit >4.8 as a good predictor area under the curve (0.82; 95% confidence interval: 0.75–0.88). This cutoff yields a high sensitivity of 80% (95% confidence interval: 78–82), moderate specificity of 75% (95% confidence interval: 62–85), very high positive predictive value of 98% (95% confidence interval: 97–99) but low negative predictive value of 17% (15–28). Conclusion: The data suggest that traumatic shock starts to become manifest at a systolic blood pressure of 110 mmHg and that a systolic blood pressure reading of 90 mmHg represents an advanced state of shock. Systolic blood pressure by itself is a poor predictor of mortality and outcome. Base deficit appears to be a far better predictor of mortality than systolic blood pressure. Future models to categorize shock will have to combine vital signs with biochemical markers of hypoperfusion.

Download Full-text

Case Report: FAST Ultrasound Interpretation in Trauma Resuscitation

POCUS Journal ◽

10.24908/pocus.v1i3.13263 ◽

2016 ◽

Vol 1 (3) ◽

pp. 13-14

Author(s):

Stuart Douglas, PGY4 ◽

Joseph Newbigging, MD ◽

David Robertson, MD

Keyword(s):

Case Report ◽

Negative Predictive Value ◽

Predictive Value ◽

Life Support ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Ultrasound Probe ◽

Trauma Resuscitation ◽

Highly Sensitive ◽

Pouch Of Douglas

FAST Background: Focused Assessment with Sonography for Trauma (FAST) is an integral adjunct to primary survey in trauma patients (1-4) and is incorporated into Advanced Trauma Life Support (ATLS) algorithms (4). A collection of four discrete ultrasound probe examinations (pericardial sac, hepatorenal fossa (Morison’s pouch), splenorenal fossa, and pelvis/pouch of Douglas), it has been shown to be highly sensitive for detection of as little as 100cm3 of intraabdominal fluid (4,5), with a sensitivity quoted between 60-98%, specificity of 84-98%, and negative predictive value of 97-99% (3).

Download Full-text

Early Packed Red Blood Cell Transfusion and Acute Respiratory Distress Syndrome after Trauma

Anesthesiology ◽

10.1097/aln.0b013e3181948a97 ◽

2009 ◽

Vol 110 (2) ◽

pp. 351-360 ◽

Cited By ~ 95

Author(s):

Onuma Chaiwat ◽

John D. Lang ◽

Monica S. Vavilala ◽

Jin Wang ◽

Ellen J. MacKenzie ◽

...

Keyword(s):

Acute Respiratory Distress Syndrome ◽

Respiratory Distress Syndrome ◽

Respiratory Distress ◽

Odds Ratio ◽

Adjusted Odds Ratio ◽

Distress Syndrome ◽

Red Blood Cell Transfusion ◽

Thoracic Injury ◽

National Study ◽

Trauma Patients

Background Transfusion of packed red blood cells (PRBCs) is a risk factor for acute respiratory distress syndrome (ARDS) in trauma patients. Yet, there is a paucity of information regarding the risk of ARDS with incremental PRBCs exposure. Methods For this retrospective analysis, eligible patients from National Study on Costs and Outcomes of Trauma were included. Our main exposure was defined as units of PRBCs transfused during the first 24 h after admission. The main outcome was ARDS. Results A total of 521 (4.6%) of 14070 patients developed ARDS, and 331 patients (63.5%) who developed ARDS received PRBCs transfusion. Injury severity, thoracic injury, polytrauma, and pneumonia receiving more than 5 units of fresh frozen plasma and 6-10 units of PRBCs were independent predictors of ARDS. Patients receiving more than 5 units of PRBCs had higher risk of developing ARDS (patients who received 6-10 units: adjusted odds ratio 2.5, 95% CI 1.12-5.3; patients who received more than 10 units: odds ratio 2.6, 95% CI 1.1-6.4). Each additional unit of PRBCs transfused conferred a 6% higher risk of ARDS (adjusted odds ratio 1.06; 95% CI 1.03-1.10). Conclusions Early transfusion of PRBCs is an independent predictor of ARDS in adult trauma patients. Conservative transfusion strategies that decrease PRBC exposure by even 1 unit may be warranted to reduce the risk of ARDS in injured patients.

Download Full-text

Predictive value of prognostic factors at multiple trauma patients in intensive care admission

Bratislava Medical Journal ◽

10.4149/bll_2021_046 ◽

2021 ◽

Vol 122 (04) ◽

pp. 277-279

Author(s):

B. Atik ◽

G. Kilinc ◽

V. Yarar

Keyword(s):

Intensive Care ◽

Prognostic Factors ◽

Multiple Trauma ◽

Predictive Value ◽

Trauma Patients ◽

Intensive Care Admission ◽

Multiple Trauma Patients

Download Full-text

Ultrasound Detection of Pneumothorax Compared with Chest X-Ray and Computed Tomography Scan

The American Surgeon ◽

10.1177/000313481107700427 ◽

2011 ◽

Vol 77 (4) ◽

pp. 480-483 ◽

Cited By ~ 29

Author(s):

Khanjan Nagarsheth ◽

Stanley Kurek

Keyword(s):

Ct Scan ◽

Negative Predictive Value ◽

Predictive Value ◽

Chest Ct ◽

Trauma Patients ◽

X Rays ◽

Thoracic Ultrasound ◽

X Ray ◽

Chest X Ray ◽

Chest Ct Scan

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.

Download Full-text

Elevated arterial base deficit in trauma patients: a marker of impaired oxygen utilization

Journal of the American College of Surgeons ◽

10.1016/s1072-7515(98)00202-6 ◽

1998 ◽

Vol 187 (4) ◽

pp. 384-392 ◽

Cited By ~ 94

Author(s):

Edward H Kincaid ◽

Preston R Miller ◽

J.Wayne Meredith ◽

Naeem Rahman ◽

Michael C Chang

Keyword(s):

Base Deficit ◽

Trauma Patients ◽

Oxygen Utilization

Download Full-text

The “Death Diamond”: Death beyond Trauma

The American Surgeon ◽

10.1177/000313481908500738 ◽

2019 ◽

Vol 85 (7) ◽

pp. 757-760

Author(s):

Michael Farrell ◽

Thomas Marconi ◽

John Getchell ◽

Raymond Green ◽

Mark Cipolle ◽

...

Keyword(s):

Positive Predictive Value ◽

Retrospective Review ◽

Predictive Value ◽

Median Survival Time ◽

Trauma Patients ◽

Invasive Procedures ◽

Multicenter Studies ◽

Trauma Population ◽

Futile Care ◽

Prognostic Implications

Thromboelastography (TEG) has become a critical tool for the diagnosis, assessment, and management of hyperfibrinolysis and coagulopathy in trauma. In 2015, Chapman et al. of the Denver group coined the term “Death Diamond” (DD) to describe a TEG tracing identified in a unique trauma population. The DD was associated with a 100 per cent positive predictive value for mortality. Given the potential prognostic implications and resource savings associated with validating the DD as a marker of futile care, we sought to further evaluate DD outcomes. A retrospective review of 6850 TEGs, 34 patients (24 trauma and 10 nontrauma), displayed a DD tracing. Through invasive procedures and transfusions, nine DD tracing “normalized,” but, ultimately, this did not impact the outcome because the DD had a positive predictive value of 100 per cent for mortality in both populations. The median survival time in trauma patients was two hours compared with seven hours in nontrauma patients. Overall, this study further validates the predictive value of the DD in a trauma population while also serving as an assessment of the DD in a nontrauma population. Given these findings, a DD may prove to be an indicator of futile care. Further multicenter studies should be conducted to confirm these results.

Download Full-text

Blunt Cardiac Injury: A Single-Center 15-Year Experience

The American Surgeon ◽

10.1177/000313482008600432 ◽

2020 ◽

Vol 86 (4) ◽

pp. 354-361

Author(s):

Jin-Mou Gao ◽

Hui Li ◽

Gong-Bin Wei ◽

Chao-Pu Liu ◽

Ding-Yuan Du ◽

...

Keyword(s):

Traffic Accidents ◽

Early Recognition ◽

Cardiac Injury ◽

Shock Rate ◽

Thoracic Injury ◽

Trauma Patients ◽

Myocardial Contusion ◽

Blunt Cardiac Injury ◽

Group A ◽

Group B

In recent years, the incidence of blunt cardiac injury (BCI) has increased rapidly and is an important cause of death in trauma patients. This study aimed to explore early diagnosis and therapy to increase survival. All patients with BCI during the past 15 years were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. The patients were divided into two groups according to the needs of their condition—nonoperative (Group A) and operative (Group B). Comparisons of the groups were performed. A total of 348 patients with BCI accounted for 18.3 per cent of 1903 patients with blunt thoracic injury. The main cause of injury was traffic accidents, with an incidence of 48.3 per cent. In Group A (n = 305), most patients sustained myocardial contusion, and the mortality was 6.9 per cent. In Group B (n = 43), including those with cardiac rupture and pericardial hernia, the mortality was 32.6 per cent. Comparisons of the groups regarding the shock rate and mortality were significant ( P < 0.01). Deaths directly resulting from BCI in Group B were greater than those in Group A ( P < 0.05). In all 348 patients, the mortality rate was 10.1 per cent. When facing a patient with blunt thoracic injury, a high index of suspicion for BCI must be maintained. To manage myocardial contusion, it is necessary to protect the heart, alleviate edema of the myocardium, and control arrhythmia with drugs. To deal with those requiring operation, early recognition and expeditious thoracotomy are essential.

Download Full-text