Management of Occult Hypoperfusion Syndrome in Trauma Patients: A Narrative Review

Occult hypoperfusion (OH) is connected with higher levels of morbidity and mortality after trauma. Occult hypoperfusion, defined as serum lactate concentration of more than 2.5 mmol / L persisting in the intensive care unit for more than 12 hours after admission. This refers to the reversible risk factor for negative results after traumatic injury. Occult hypoperfusion can be observed and patients at risk of complications should be classified other than frequently regulated metrics (blood pressure and heart rate), central venous oxygen saturation, and blood lactate levels. An elevated hospital duration of stay (LOS) and a greater incidence of postoperative difficulties are linked with OH. The focus of this review article is to assess the different approaches and methods involved in the management of OH syndrome in trauma patients. Identification of OH treatment methods can be helpful in reducing morbidity in patients with various injuries. The outcomes from this review article may prove beneficial to patients by rapid resuscitation and aggressive monitoring of OH. These management practices will severely reduce OH-associated morbidity and mortality. LOS, ICU readmission incidence and post-operative complications per patient was decreased by early treatment of OH.

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Anion Gap as a Predictor of Trauma Outcomes in the Older Trauma Population: Correlations with Injury Severity and Mortality

The American Surgeon ◽

10.1177/000313481307901126 ◽

2013 ◽

Vol 79 (11) ◽

pp. 1203-1206 ◽

Cited By ~ 5

Author(s):

John J. Leskovan ◽

Carla F. Justiniano ◽

John A. Bach ◽

Charles H. Cook ◽

David E. Lindsey ◽

...

Keyword(s):

Injury Severity ◽

Traumatic Injury ◽

Serum Lactate ◽

Anion Gap ◽

Morbidity And Mortality ◽

Trauma Patients ◽

Metabolic Derangement ◽

Trauma Outcomes ◽

Tissue Hypoperfusion ◽

Trauma Population

The relationship among traumatic injury, the associated metabolic/physiologic responses, and mortality is well established. Tissue hypoperfusion and metabolic derangement may not universally correlate with initial clinical presentation. We hypothesized that anion gap (AG) could be a useful gauge of trauma-related physiologic response and mortality in older patients with relatively lower injury acuity. We retrospectively analyzed data from 711 trauma patients older than 45 years. Parameters examined included demographics, injury characteristics, laboratories, morbidity, and mortality. Univariate and survival analyses were performed using PASW 18. A step-wise correlation exists between increasing Injury Severity Score and AG. Although AG less than 8 to 15 was not associated with a significant increase in mortality, greater mortality was seen for AG greater than 16 with further stepwise increases for AGs greater than 22. Anion gap correlated moderately with serum lactate and poorly with base excess. Increasing AG also correlated with morbidity and greater incidence of intensive care admissions. The presence of any complication increased from 28.6 per cent for patients with AG 12 or less to 45.5 per cent for patients with AG 22 or greater ( P < 0.04). These findings support the contention that “low acuity” trauma patients with high AGs may not appear acutely ill but may harbor significant underlying metabolic and physiologic disturbances that could contribute to morbidity and mortality. Higher AG values (i.e., greater than 16) may be associated with worse clinical outcomes.

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Intraoperative Serum Lactate Concentration and Central Venous Oxygen Saturation as Early Predictors for Early Graft Function during Liver Transplant

Journal of Anesthesia & Intensive Care Medicine ◽

10.19080/jaicm.2018.05.555655 ◽

2018 ◽

Vol 5 (1) ◽

Author(s):

Sayed E

Keyword(s):

Liver Transplant ◽

Oxygen Saturation ◽

Lactate Concentration ◽

Graft Function ◽

Central Venous Oxygen Saturation ◽

Serum Lactate ◽

Central Venous ◽

Early Predictors ◽

Venous Oxygen Saturation ◽

Early Graft

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Serum Lactate –An indicator of morbidity and mortality in polytrauma and multi-trauma patients

Nepal Orthopaedic Association Journal ◽

10.3126/noaj.v2i1.8134 ◽

2013 ◽

Vol 2 (1) ◽

pp. 7-13 ◽

Cited By ~ 1

Author(s):

P Lamichhane ◽

S Shrestha ◽

B Banskota ◽

AK Banskota

Keyword(s):

Multiple Trauma ◽

Blood Lactate ◽

Lactate Level ◽

Life Support ◽

Serum Lactate ◽

Morbidity And Mortality ◽

Trauma Patients ◽

Serum Lactate Level ◽

Lactate Levels ◽

Elevated Lactate

Background: The search for the best marker or set of markers for the diagnosis, prognosis and treatment of ‘at risk’ trauma patients is ongoing. Serial estimation of serum lactate values are thought to help predict morbidity and mortality in trauma victims. There is evidence to support the use of blood lactate levels as an end point of resuscitation. The presence of elevated lactic acid levels in the serum can direct the treating physician to safe and correct timing of any surgical intervention. Early identification and aggressive resuscitation measures aimed at correcting the impaired metabolic dysfunction improves survival and reduces complications in severely injured trauma patients. Methods: A prospective analytical study of 52 patients with polytrauma and multiple trauma admitted within 12 hours of injury to our institution between March 2007 to February 2008 was carried out. All the patients were resuscitated as per the advance trauma life support (ATLS) protocol in the emergency room. Serum lactate level was analyzed on the 1st, 5th and 14th day of injury. Serum lactate levels greater than 2 milimoles/L was considered abnormal and serum lactate level greater than 5 milimoles/L was considered significant. Results: There were 45 males and 7 females with an average age of 32.8 years (18-82). 18 patients out of 52 sustained polytrauma. Of these 18 patients, 8 patients sustained chest injury, 4 had head injury and 2 had abdominal injury. In the polytrauma group (n-18), 5 patients had an elevated lactate above 2 milimoles/Lon admission. 2 patients who had significant rise of lactate (>5 milimoles/L) on admission died on the 5th day. Out of 34 multiple trauma patients, 13 patients had an elevated lactate level at admission. One patient in this group with lactate level 7.2 died of ARDS on 3rd day of admission. Conclusion: Blood lactate appears to be a reliable marker reflecting not only the severity of the shock, but also for predicting survival. The longer the lactate is elevated, the more a patient is likely to develop multiple organ dysfunctions and die. Lactate levels followed over time is more reliable than isolated values. DOI: http://dx.doi.org/10.3126/noaj.v2i1.8134 Nepal Orthopaedic Association Journal Vol.2(1) 2011: 7-13

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Venous thromboembolism in a general hospital. An update with low molecular weight heparin prophylaxis

VASA ◽

10.1024/0301-1526.36.1.17 ◽

2007 ◽

Vol 36 (1) ◽

pp. 17-22

Author(s):

Schulz ◽

Kesselring ◽

Seeberger ◽

Andresen

Keyword(s):

Molecular Weight ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Low Molecular Weight ◽

Trauma Patients ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Patients At Risk ◽

Hospital Stays ◽

Event Rates

Background: Patients admitted to hospital for surgery or acute medical illnesses have a high risk for venous thromboembolism (VTE). Today’s widespread use of low molecular weight heparins (LMWH) for VTE prophylaxis is supposed to have reduced VTE rates substantially. However, data concerning the overall effectiveness of LMWH prophylaxis is sparse. Patients and methods: We prospectively studied all patients with symptomatic and objectively confirmed VTE seen in our hospital over a three year period. Event rates in different wards were analysed and compared. VTE prophylaxis with Enoxaparin was given to all patients at risk during their hospital stay. Results: A total of 50 464 inpatients were treated during the study period. 461 examinations were carried out for symptoms suggestive of VTE and yielded 89 positive results in 85 patients. Seventy eight patients were found to have deep vein thrombosis, 7 had pulmonary embolism, and 4 had both deep venous thrombosis and pulmonary embolism. The overall in hospital VTE event rate was 0.17%. The rate decreased during the study period from 0.22 in year one to 0,16 in year two and 0.13 % in year three. It ranged highest in neurologic and trauma patients (0.32%) and lowest (0.08%) in gynecology-obstetrics. Conclusions: With a simple and strictly applied regimen of prophylaxis with LMWH the overall rate of symptomatic VTE was very low in our hospitalized patients. Beside LMWH prophylaxis, shortening hospital stays and substantial improvements in surgical and anasthesia techniques achieved during the last decades probably play an essential role in decreasing VTE rates.

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How Can a Deep Learning Algorithm Improve Fracture Detection on X-rays in the Emergency Room?

Journal of Imaging ◽

10.3390/jimaging7070105 ◽

2021 ◽

Vol 7 (7) ◽

pp. 105

Author(s):

Guillaume Reichert ◽

Ali Bellamine ◽

Matthieu Fontaine ◽

Beatrice Naipeanu ◽

Adrien Altar ◽

...

Keyword(s):

Deep Learning ◽

Emergency Room ◽

Learning Algorithm ◽

Traumatic Injury ◽

Diagnostic Tools ◽

Appendicular Skeleton ◽

Trauma Patients ◽

X Rays ◽

Fracture Detection ◽

Local Data

The growing need for emergency imaging has greatly increased the number of conventional X-rays, particularly for traumatic injury. Deep learning (DL) algorithms could improve fracture screening by radiologists and emergency room (ER) physicians. We used an algorithm developed for the detection of appendicular skeleton fractures and evaluated its performance for detecting traumatic fractures on conventional X-rays in the ER, without the need for training on local data. This algorithm was tested on all patients (N = 125) consulting at the Louis Mourier ER in May 2019 for limb trauma. Patients were selected by two emergency physicians from the clinical database used in the ER. Their X-rays were exported and analyzed by a radiologist. The prediction made by the algorithm and the annotation made by the radiologist were compared. For the 125 patients included, 25 patients with a fracture were identified by the clinicians, 24 of whom were identified by the algorithm (sensitivity of 96%). The algorithm incorrectly predicted a fracture in 14 of the 100 patients without fractures (specificity of 86%). The negative predictive value was 98.85%. This study shows that DL algorithms are potentially valuable diagnostic tools for detecting fractures in the ER and could be used in the training of junior radiologists.

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Prehospital resuscitation

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2021-000729 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000729

Author(s):

Alexandra M P Brito ◽

Martin Schreiber

Keyword(s):

Young People ◽

Tranexamic Acid ◽

New Technologies ◽

Blood Product ◽

Traumatic Injury ◽

Trauma Patients ◽

Blood Products ◽

Front Line ◽

The Usa ◽

Review Current

Traumatic injury is the leading cause of death in young people in the USA. Our knowledge of prehospital resuscitation is constantly evolving and is often informed by research based on military experience. A move toward balanced blood product resuscitation and away from excessive crystalloid use has led to improvements in outcomes for trauma patients. This has been facilitated by new technologies allowing more front-line use of blood products as well as use of tranexamic acid in the prehospital setting. In this article, we review current practices in prehospital resuscitation and the studies that have informed these practices.

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Evaluation of Microvascular Perfusion and Resuscitation after Severe Injury

The American Surgeon ◽

10.1177/000313481508101231 ◽

2015 ◽

Vol 81 (12) ◽

pp. 1272-1278 ◽

Cited By ~ 1

Author(s):

Yann-Leei L. Lee ◽

Jon D. Simmons ◽

Mark N. Gillespie ◽

Diego F. Alvarez ◽

Richard P. Gonzalez ◽

...

Keyword(s):

Injury Severity ◽

Capillary Flow ◽

Severe Trauma ◽

Dark Field ◽

Serum Lactate ◽

Microvascular Perfusion ◽

Trauma Patients ◽

Sidestream Dark Field ◽

Trauma Population ◽

Severity Scores

Achieving adequate perfusion is a key goal of treatment in severe trauma; however, tissue perfusion has classically been measured by indirect means. Direct visualization of capillary flow has been applied in sepsis, but application of this technology to the trauma population has been limited. The purpose of this investigation was to compare the efficacy of standard indirect measures of perfusion to direct imaging of the sublingual microcirculatory flow during trauma resuscitation. Patients with injury severity scores >15 were serially examined using a handheld sidestream dark-field video microscope. In addition, measurements were also made from healthy volunteers. The De Backer score, a morphometric capillary density score, and total vessel density (TVD) as cumulative vessel area within the image, were calculated using Automated Vascular Analysis (AVA3.0) software. These indices were compared against clinical and laboratory parameters of organ function and systemic metabolic status as well as mortality. Twenty severely injured patients had lower TVD (X = 14.6 ± 0.22 vs 17.66 ± 0.51) and De Backer scores (X = 9.62 ± 0.16 vs 11.55 ± 0.37) compared with healthy controls. These scores best correlated with serum lactate (TVD R2 = 0.525, De Backer R2 = 0.576, P < 0.05). Mean arterial pressure, heart rate, oxygen saturation, pH, bicarbonate, base deficit, hematocrit, and coagulation parameters correlated poorly with both TVD and De Backer score. Direct measurement of sublingual microvascular perfusion is technically feasible in trauma patients, and seems to provide real-time assessment of micro-circulatory perfusion. This study suggests that in severe trauma, many indirect measurements of perfusion do not correlate with microvascular perfusion. However, visualized perfusion deficiencies do reflect a shift toward anaerobic metabolism.

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Tranexamic Acid Treatment for Trauma Victims

Seminars in Thrombosis and Hemostasis ◽

10.1055/s-0041-1725097 ◽

2021 ◽

Author(s):

Ian Roberts ◽

Amy Brenner ◽

Haleema Shakur-Still

Keyword(s):

Tranexamic Acid ◽

Traumatic Injury ◽

Low Risk ◽

Baseline Risk ◽

Trauma Patients ◽

Wide Range ◽

Risk Patients ◽

Polytrauma Patients ◽

Time Critical ◽

Proportional Reduction

AbstractWorldwide, traumatic injury is responsible for over 5 million deaths per year, the majority due to exsanguination and head injury. The antifibrinolytic drug tranexamic acid is the only drug proven to reduce deaths after traumatic injury. Several large randomized controlled trials have provided high-quality evidence of its effectiveness and safety in trauma patients. Early tranexamic acid reduces deaths on the day of the injury in polytrauma patients and patients with isolated traumatic brain injury by around 20%. Treatment is time critical; for patients to benefit, tranexamic acid must be given as soon as possible after injury. Intramuscular administration is well tolerated and rapidly absorbed, with the potential to reduce time to treatment. Because the proportional reduction in bleeding death with tranexamic acid does not vary by baseline risk, a wide range of trauma patients stands to benefit. There are far more low-risk trauma patients than high-risk patients, with a substantial proportion of bleeding deaths in the low-risk group. As such, treatment should not be limited to patients with severe traumatic hemorrhage. We must give paramedics and physicians the confidence to treat a far wider range of trauma patients while emphasizing the importance of early treatment.

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