Prediction of massive bleeding. Shock index and modified shock index. / Predicción de hemorragia masiva. Índice de shock e índice de shock modificado.

OBJECTIVE: To determine the predictive value of the Shock Index and Modified Shock Index in patients with massive bleeding due to severe trauma. DESIGN: Retrospective cohort. SETTING: Severe trauma patient's initial attention at the intensive care unit of a tertiary hospital. SUBJECTS: Patients older than 14 years that were admitted to the hospital with severe trauma (Injury Severity Score >15) form January 2014 to December 2015. VARIABLES: We studied the sensitivity (Se), specificity (Sp), positive and negative predictive value (PV+ and PV-), positive and negative likelihood ratio (LR+ and LR-), ROC curves (Receiver Operating Characteristics) and the area under the same (AUROC) for prediction of massive hemorrhage. RESULTS: 287 patients were included, 76.31% (219) were male, mean age was 43,36 (±17.71) years and ISS was 26 (interquartile range [IQR]: 21-34). The overall frequency of massive bleeding was 8.71% (25). For Shock Index: AUROC was 0.89 (95% confidence intervals [CI] 0.84 to 0.94), with an optimal cutoff at 1.11, Se was 91.3% (95% CI: 73.2 to 97.58) and Sp was 79.69% (95% CI: 74.34 to 84.16). For the Modified Shock Index: AUROC was 0.90 (95% CI: 0.86 to 0.95), with an optimal cutoff at 1.46, Se was 95.65% (95% CI: 79.01 to 99.23) and Sp was 75.78% (95% CI: 70.18 to 80.62). CONCLUSION: Shock Index and Modified Shock Index are good predictors of massive bleeding and could be easily incorporated to the initial workup of patients with severe trauma.

Mortality prediction using TRISS methodology in the Spanish ICU Trauma Registry (RETRAUCI).

OBJECTIVES: To validate Trauma and Injury Severity Score (TRISS) methodology as an auditing tool in the Spanish ICU Trauma Registry (RETRAUCI). DESIGN: A prospective, multicenter registry evaluation was carried out. SETTING: Thirteen Spanish Intensive Care Units (ICUs). PATIENTS: Individuals with traumatic disease and available data admitted to the participating ICUs. INTERVENTIONS: Predicted mortality using TRISS methodology was compared with that observed in the pilot phase of the RETRAUCI from November 2012 to January 2015. Discrimination was evaluated using receiver operating characteristic (ROC) curves and the corresponding areas under the curves (AUCs) (95% CI), with calibration using the Hosmer-Lemeshow (HL) goodness-of-fit test. A value of p<0.05 was considered significant. MAIN VARIABLES OF INTEREST: Predicted and observed mortality. RESULTS: A total of 1405 patients were analyzed. The observed mortality rate was 18% (253 patients), while the predicted mortality rate was 16.9%. The area under the ROC curve was 0.889 (95% CI: 0.867-0.911). Patients with blunt trauma (n=1305) had an area under the ROC curve of 0.887 (95% CI: 0.864-0.910), and those with penetrating trauma (n=100) presented an area under the curve of 0.919 (95% CI: 0.859-0.979). In the global sample, the HL test yielded a value of 25.38 (p=0.001): 27.35 (p<0.0001) in blunt trauma and 5.91 (p=0.658) in penetrating trauma. TRISS methodology underestimated mortality in patients with low predicted mortality and overestimated mortality in patients with high predicted mortality. CONCLUSIONS: TRISS methodology in the evaluation of severe trauma in Spanish ICUs showed good discrimination, with inadequate calibration - particularly in blunt trauma.

Epidemiology of severe trauma in Spain. Registry of trauma in the ICU (RETRAUCI). Pilot phase. / Epidemiología del trauma grave en España. REgistro de TRAuma en UCI (RETRAUCI). Fase piloto.

OBJECTIVE: To describe the characteristics and management of severe trauma disease in Spanish Intensive Care Units (ICUs). Registry of trauma in the ICU (RETRAUCI). Pilot phase. DESIGN: A prospective, multicenter registry. SETTING: Thirteen Spanish ICUs. PATIENTS: Patients with trauma disease admitted to the ICU. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Epidemiology, out-of-hospital attention, registry of injuries, resources utilization, complications and outcome were evaluated. RESULTS: Patients, n=2242. Mean age 47.1±19.02 years. Males 79%. Blunt trauma 93.9%. Injury Severity Score 22.2±12.1, Revised Trauma Score 6.7±1.6. Non-intentional in 84.4% of the cases. The most common causes of trauma were traffic accidents followed by pedestrian and high-energy falls. Up to 12.4% were taking antiplatelet medication or anticoagulants. Almost 28% had a suspected or confirmed toxic influence in trauma. Up to 31.5% required an out-of-hospital artificial airway. The time from trauma to ICU admission was 4.7±5.3hours. At ICU admission, 68.5% were hemodynamically stable. Brain and chest injuries predominated. A large number of complications were documented. Mechanical ventilation was used in 69.5% of the patients (mean 8.2±9.9 days), of which 24.9% finally required a tracheostomy. The median duration of stay in the ICU and in hospital was 5 (range 3-13) and 9 (5-19) days, respectively. The ICU mortality rate was 12.3%, while the in-hospital mortality rate was 16.0%. CONCLUSIONS: The pilot phase of the RETRAUCI offers a first impression of the epidemiology and management of trauma disease in Spanish ICUs.

Innovation and new trends in critical trauma disease.

The management of critical trauma disease (CTD) has always trends the trends in military war experiences. These conflicts have historically revolutionized clinical concepts, clinical practice guidelines and medical devices, and have marked future lines of research and aspects of training and learning in severe trauma care. Moreover, in the civil setting, the development of intensive care, technological advances and the testing of our healthcare systems in the management of multiple victims, hasve also led to a need for innovation in our trauma care systems.

[Trauma registries: a health priority, a strategic project for the SEMICYUC]. / Registros de trauma: una prioridad sanitaria, un proyecto estratégico para la SEMICYUC.

The most efficient approach to traumatologic disease is prevention, but physicians also must supervise care of the victims. An operational and effective trauma registry requires financial support, adequate software, a well-defined population, personnel committed to training, and a detailed process for data collection, reporting, validation and the maintenance of confidentiality. Above all, however, motivation is required. Registries can offer many benefits in relation to these highly prevalent disorders, with an impact in terms of health promotion and even advantages in the form of cost reductions, as well as relief from the suffering caused by trauma (mortality, disability)-contributing to improve the efficiency and quality of critical trauma care. The SEMICYUC has demonstrated its ability to establish and maintain records of national interest, and this should become a priority project.

Patients with severe polytrauma: management and imaging protocols.

Traumatic injuries can be severe and complex, requiring the coordinated efforts of a multidisciplinary team. Imaging tests play a fundamental role in rapid and accurate diagnosis. In particular, whole-body computed tomography (CT) has become a key tool. There are different CT protocols depending on the patient's condition; whereas dose-optimized protocols can be used in stable patients, time/precision protocols prioritizing speed at the cost of delivering higher doses of radiation should be used in more severe patients. In unstable patients who cannot be examined by CT, X-rays of the chest and pelvis and FAST or e-FAST ultrasound studies, although less sensitive than CT, enable the detection of situations that require immediate treatment. This article reviews the imaging techniques and CT protocols for the initial hospital workup for patients with multiple trauma.

[Development of communication tool for patient safety ("Briefing"). Experience in a trauma and emergency intensive care unit]. / Desarrollo de una herramienta de comunicación para la seguridad del paciente (Briefing). Experiencia en una unidad de cuidados intensivos de trauma y emergencias.

OBJECTIVE: To validate a safety tool used in high-risk sectors (safety briefing) in intensive care medicine. DESIGN: A prospective, observational and analytical study was carried out. SETTING: Trauma and emergency intensive care unit in a tertiary hospital. PATIENTS: Patients with severe trauma (Injury Severity Score ISS≥16). INTERVENTION: Documentation of incidents related to patient safety (PS). VARIABLES: Patients characteristics, state of the Unit, patient safety incidents, aspects of the tool (SP) and safety culture impact. RESULTS: We included 441 patients (75.15% males, mean age 39.9±17.5 years), with blunt trauma in 89% and a 10.5% mortality rate. The tool was applied in 586 out of 798 possible shifts (73.4%), and documented 942 events (2.20 incidents per patient). The incidents were more frequently associated with medication (20.7%), devices (placement 4.03%, and maintenance 17.8%) and airway and mechanical ventilation (MV) (17.09%). A correlation was established between the occurrence of incidents and the characteristics of the patient (higher Injury Severity Score, presence of MV, and continuous renal replacement therapies) and the status of the Unit (more than 6 patients per shift out of 8 possible, and holiday period). The tool significantly influenced different aspects of the safety culture of the unit (communication frequency, number of events, punitive loss and active work in PS). CONCLUSIONS: Safety briefing is a tool for the documentation of incidents that is simple and easy to use, and is useful for implementing improvements and in influencing safety culture.

[Massive transfusion predictive scores in trauma. Experience of a transfusion registry]. / Escalas predictivas de transfusión masiva en trauma. Experiencia de un registro de transfusiones.

OBJECTIVES: Our purpose is to validate previously described massive transfusion (MT) scoring in our Transfusion Trauma Registry. DESIGN: A retrospective cohort of adult trauma patients. SETTING: Trauma and Emergency Intensive Care Unit of a tertiary hospital. PATIENTS: Patients with severe trauma (injury severity score>15) admitted from October 2006 to July 2009. INTERVENTIONS: None. VARIABLES: The following MT scoring and cutoff points (CP) were evaluated: Trauma-Associated Severe Hemorrhage (TASH) CP: ≥16 and ≥18; Assessment Blood Consumption (ABC) CP: ≥2 and Emergency Transfusion Score (ETS) CP: ≥3, ≥4, ≥6. MT was defined as the transfusion of 10 units or more of packed red blood cells in the first 24 hours. We studied the sensivity (S), specifity (SP), and positive and negative predictive values (PPV, NPV), the positive and negative likehood ratios (LHR +, LHR-) and area under the receiver operating characteristic curve (ROC). RESULTS: A total of 568 patients were available for analysis; 77.6% were men, with a mean age of 41.16 ± 18 years and an ISS of 30 ± 13. 93.8% with blunt trauma. The overall MT rate was 18.8%. The best S was obtained with ETS ≥3 and best SP was obtained with TASH ≥18. ROC for different scores was: ABC: 0.779, ETS: 0. 784, TASH: 0.889. CONCLUSION: These scales can be useful for characterizing the TM population, for excluding low-risk populations, and for attempting to be objective in hematological damage control and in supporting clinical decisions, based on fe1w and easily obtainable data.

[Prediction of the clinical usefulness of routine chest X-rays in a traumatology ICU]. / Predicción de la utilidad clínica de la radiografía de tórax rutinaria en una unidad de cuidados intensivos de traumatología.

BACKGROUND: The clinical value of routine chest X-rays in critical care has been questioned, but has not been studied in the trauma environment to date. The objective of this study was to identify easy to use clinical predictors of utility in this setting. MATERIAL AND METHODS: A prospective observational study was made in an 8-bed traumatology ICU. Severe trauma patients (ISS > 15), aged 15 or older and admitted for 48 h or longer were included. Pregnant women and radiographs obtained during initial care or for reasons other than routine indication were excluded. A staff physician, separated from clinical duties, independently reviewed the films in search of changes, as described in a closed checklist. Following closed criteria, the attending physicians reported previous day clinical events and changes in clinical management after chest X-ray obtainment. Demographic and epidemiological data were also recorded. The associations among variables were studied by univariate and multivariate analysis. RESULTS: A total of 1440 routine chest X-rays were obtained from 138 consecutive patients during one year. Young males prevailed (82%; 39 ± 16 years). The most common process was severe blunt trauma (97%). Fifty-two percent suffered severe chest trauma. The mean length of stay was 12.9 ± 10.1 days. Mechanical ventilation was used in 86.8% of the cases. A median of 10.4 ± 9.3 films were obtained from each patient. A total of 14% of the X-rays showed changes, most commonly malpositioning of an indwelling device (6.8%) or infiltrates (4.9%). Those findings led to a change in care in 84.6% of the cases. Multivariate analysis identified the following significant (p < 0.05) risk factors for radiographic changes: first two days of evolution, mechanical ventilation, worsening of PaO2/FiO2, worsening of lung compliance and changes in respiratory secretions. CONCLUSIONS: Based on the results obtained, the risk of not identifying dangerous conditions by restricting routine chest X-rays prescription to the described conditions is low. Observing this policy would probably mean substantial savings and a reduction in radiation exposure.

Management of temperature control in post-cardiac arrest care: an expert report. / Manejo con control de temperatura en los cuidados posparada cardiaca: documento de expertos.

Targeted temperature management (TTM) through induced hypothermia (between 32-36 oC) is currently regarded as a first-line treatment during the management of post-cardiac arrest patients admitted to the Intensive Care Unit (ICU). The aim of TTM is to afford neuroprotection and reduce secondary neurological damage caused by anoxia. Despite the large body of evidence on its benefits, the TTM is still little used in Spain. There are controversial issues referred to its implementation, such as the optimal target body temperature, timing, duration and the rewarming process. The present study reviews the best available scientific evidence and the current recommendations contained in the international guidelines. In addition, the study focuses on the practical implementation of TTM in post-cardiac arrest patients in general and cardiological ICUs, with a discussion of the implementation strategies, protocols, management of complications and assessment of the neurological prognosis.

[Diagnostic blood losses in severe trauma patients]. / Pérdidas sanguíneas diagnósticas en pacientes con trauma grave.

OBJECTIVE: To analyze diagnostic (blood drawings) and iatrogenic (Continuous Renal Replacement Therapy, CRRT) blood losses (BL) in severe trauma patients. METHOD: A one-year descriptive, prospective and observational study. We included patients over 15 years of age, admitted with severe trauma and who had a score of > or =16 on the Injury Severity Index (ISS). Those patients in whom limitation of therapeutic effort had been indicated were excluded. A total of 225 patients with 1619 days of evolution were analyzed for volume of BL/day/patient, type of diagnostic test, clinical outcome and utilization of CRRT. The variables were described as mean +/- standard deviation with the Student's T test. RESULTS: Average blood loss of patient per day was 55.5+/-32.2 cc. Statistically significant differences were found between the blood volume drawn when the first day was compared to the second day, 73.5+/-32.2 vs. 56.3+/-21.9 (p<0.001); clinical outcome (alive vs death) 54.8+/-33 vs. 60.7+/-24.9 (p<0.05); severity (ISS<31 or > or =31) 54.65+/-20 vs. 61.5+/-28.5 (p<0.001), No RRT vs RRT: 50.9+/-18.9 vs. 97.2+/-72.6 (p<0.001). CONCLUSIONS: The greatest diagnostic BL occurs during the resuscitation phase, in the patients who die, in those with greater severity and those undergoing CRRT.

Risk and protective factors of secondary traumatic stress in Intensive Care Units: An exploratory study in a hospital in Madrid (Spain). / Factores de riesgo y protección del estrés traumático secundario en los cuidados intensivos: un estudio exploratorio en un hospital terciario de Madrid.

AIM: To propose a predictive model of secondary traumatic stress. DESIGN: A descriptive cross-sectional study was carried out. CONTEXT: The study was conducted in the Intensive Care Units of a hospital in Madrid (Spain). PARTICIPANTS: The sample comprised 103 health professionals. INTERVENTIONS: A series of questionnaires were created and completed by the participants. Network analysis and multiple regression were used for data analysis. VARIABLES OF INTEREST: Sociodemographic variables such as gender, years of experience and position, secondary traumatic stress, passion for work, work stressors, emotional effort, empathy and self-compassion were evaluated. RESULTS: The result identified the following: a) years of experience as a risk factor for compassion fatigue (ß=0.224 and P=0.029), and harmonious passion as a protector (ß=-0.363 and P=0.001); b) emotional effort and empathy as risk factors for shattered assumptions (ß=0.304 and P=0.004; ß=0.394 and P=0.000, respectively); and c), work stressors and empathy as risk factors for symptomatology (ß=0.189 and P=0.039; ß=0.395 and P=0.000, respectively), and years of experience as a protector (ß=-0.266 and P=0.002). CONCLUSIONS: This predictive model of secondary traumatic stress identifies protective factors which could be reinforced, such as harmonious passion, and risk factors which should be reduced, such as empathy and emotional effort, with a view to promoting quality of care and quality of life among these professionals.

Outcomes of very elderly trauma ICU patients. Results from the Spanish trauma ICU registry.

OBJECTIVE: To analyze outcomes and factors related to mortality among very elderly trauma patients admitted to intensive care units (ICUs) participating in the Spanish trauma ICU registry. DESIGN: A multicenter nationwide registry. Retrospective analysis. November 2012-May 2017. SETTING: Participating ICUs. PATIENTS: Trauma patients aged ≥80 years. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: The outcomes and influence of limitation of life sustaining therapy (LLST) were analyzed. Comparisons were established using the Wilcoxon test, Chi-squared test or Fisher's exact test as appropriate. Multiple logistic regression analysis was performed to analyze variables related to mortality. A p-value <0.05 was considered statistically significant. RESULTS: The mean patient age was 83.4±3.3 years; 281 males (60.4%). Low-energy falls were the mechanisms of injury in 256 patients (55.1%). The mean ISS was 20.5±11.1, with a mean ICU stay of 7.45±9.9 days. The probability of survival based on the TRISS methodology was 69.8±29.7%. The ICU mortality rate was 15.5%, with an in-hospital mortality rate of 19.2%. The main cause of mortality was intracranial hypertension (42.7%). The ISS, the need for first- and second-tier measures to control intracranial pressure, and being admitted to the ICU for organ donation were independent mortality predictors. LLST was applied in 128 patients (27.9%). Patients who received LLST were older, with more severe trauma, and with more severe brain injury. CONCLUSIONS: Very elderly trauma ICU patients presented mortality rates lower than predicted on the basis of the severity of injury.

Evaluation of quality of care in trauma patients using international scoring systems. / Valoración de la calidad asistencial al traumatismo grave mediante comparación con estándares internacionales.

OBJECTIVE: To evaluate the ability of the TRISS and PS14 models to predict mortality rates in our medical system and population. DESIGN: A retrospective observational study was carried out over a 66-month period. BACKGROUND: The study was conducted in the Trauma Intensive Care Unit (ICU) of a third level hospital. PATIENTS: All severe trauma patients (Injury Severity Score≥16 and/or Revised Trauma Score <12) aged> 14 years were included. VARIABLES OF INTEREST: Medical care data were prospectively recorded. The "W" statistic (difference between expected and observed mortality for every 100 patients) and its significance were calculated for each model. Discrimination and calibration were evaluated by means of receiver operating characteristic (ROC) curves, and the Hosmer-Lemeshow test and GiViTI calibration belt, respectively. RESULTS: A total of 1240 patients were included. Survival at hospital discharge was 81.9%. The "W" scores for the TRISS, TRISS 2010 and PS14 models were+6.72 (P<.01), +1.48 (P=.08) and +2.74 (P<.01) respectively. Subgroup analysis revealed significant favorable results for some populations. The areas under the ROC curve for the TRISS, TRISS 2010 and PS14 models were 0.915, 0.919 and 0.914, respectively. There were no significant differences among them (P>.05). Both the Hosmer-Lemeshow test and GiViTI calibration belt demonstrated poor calibration for the three models. CONCLUSIONS: These models are suitable tools for assessing quality of care in a Trauma ICU, affording excellent discrimination but poor calibration. In our institution, survival rates higher than expected were observed.

Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. / Predicción de hemorragia masiva a nivel extrahospitalario: validación de seis escalas.

OBJECTIVE: To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting. DESIGN: Retrospective cohort. SETTING: Prehospital attention of patients with severe trauma. SUBJECTS: Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid. VARIABLES: To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score. RESULTS: 548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68). CONCLUSION: In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.