Déficit de base, lactato e índice de shock como predictores de mortalidad en lesionados múltiples / Base Deficit, Lactate and Shock Index as Mortality Predictors in Trauma Patients

Introducción: Las respuestas fisiológicas a la hemorragia, como hipotensión y taquicardia, no siempre son proporcionales al estado de choque, lo cual ha llevado a la necesidad de usar otros predictores. Objetivo: Analizar el comportamiento del déficit de base, lactato e índice de shock severo como predictores de mortalidad en pacientes lesionados múltiples. Métodos: Se realizó un estudio analítico, observacional y retrospectivo en el Servicio de Anestesiología y Reanimación del Hospital Universitario "General Calixto García", entre agosto de 2018 y agosto de 2020. La muestra fue de 50 pacientes, según criterio de selección no probabilístico del investigador. Resultados: Los pacientes que sufrieron trauma craneal tuvieron siete veces más riesgo de morir. El índice de shock severo, a las tres horas triplicó el riesgo de morir. El lactato y el déficit de base se correlacionaron con un índice de shock mayor de uno, de forma significativa. La transfusión sanguínea duplicó el riesgo de morir, mientras que los requerimientos de aminas, no mostraron ser factores de mal pronóstico. Dentro de las complicaciones la respuesta inflamatoria sistémica mostró tener nueve veces mayor riesgo de morir y la disfunción múltiple de órgano siete veces, pero la presencia de neumonía no influyó en la muerte. Conclusiones: El índice de shock severo se consideró un factor pronóstico de mortalidad en pacientes politraumatizados al triplicar el riesgo de morir y guardó relación con el lactato elevado y la alteración de los valores del déficit de bases(AU)

Introduction: Physiological responses to hemorrhage, such as hypotension and tachycardia, are not always proportional to the state of shock, which has led to the need to use other predictors. Objective: To analyze the characteristics of base deficit, lactate and severe shock index as predictors of mortality in multiply injured patients. Methods: An analytical, observational and retrospective study was carried out in the anesthesiology and resuscitation service of General Calixto García University Hospital, between August 2018 and August 2020. The sample was made up of 50 patients, according to nonprobabilistic selection criteria of the researcher. Results: Patients who suffered cranial trauma were seven times more likely to die. The index of severe shock at three hours tripled the risk of death. Lactate and baseline deficit correlated significantly with shock index greater than one. Blood transfusion doubled the risk of death, while amine requirements were not shown to be poor prognostic factors. Among complications, systemic inflammatory response was shown to have nine times higher risk of dying and multiple organ dysfunction seven times, but the presence of pneumonia did not influence death. Conclusions: The severe shock index was considered a prognostic factor for mortality in polytraumatized patients, as far as it tripled the risk of dying and was related to elevated lactate and altered base deficit values(AU)

Prevalence and outcome of abdominal vascular injury in severe trauma patients based on a TraumaRegister DGU international registry analysis.

This study details the etiology, frequency and effect of abdominal vascular injuries in patients after polytrauma based on a large registry of trauma patients. The impact of arterial, venous and mixed vascular injuries on patients' outcome was of interest, as in particular the relevance of venous vessel injury may be underestimated and not adequately assessed in literature so far. All patients of TraumaRegister DGU with the following criteria were included: online documentation of european trauma centers, age 16-85 years, presence of abdominal vascular injury and Abbreviated Injury Scale (AIS) ≥ 3. Patients were divided in three groups of: arterial injury only, venous injury only, mixed arterial and venous injuries. Reporting in this study adheres to the STROBE criteria. A total of 2949 patients were included. All types of abdominal vessel injuries were more prevalent in patients with abdominal trauma followed by thoracic trauma. Rate of patients with shock upon admission were the same in patients with arterial injury alone (n = 606, 33%) and venous injury alone (n = 95, 32%). Venous trauma showed higher odds ratio for in-hospital mortality (OR: 1.48; 95% CI 1.10-1.98, p = 0.010). Abdominal arterial and venous injury in patients suffering from severe trauma were associated with a comparable rate of hemodynamic instability at the time of admission. 24 h as well as in-hospital mortality rate were similar in in patients with venous injury and arterial injury. Stable patients suspected of abdominal vascular injuries should be further investigated to exclude or localize the possible subtle venous injury.

Use of Vasopressor Increases the Risk of Mortality in Traumatic Hemorrhagic Shock: A Nationwide Cohort Study in Japan.

OBJECTIVES: To evaluate the possible association of vasopressor use with mortality in traumatic hemorrhagic shock patients. DESIGN: Retrospective cohort study. SETTING: Traumatic hemorrhagic shock patients at 260 emergency hospitals in Japan between 2004 and 2015. PATIENTS: Three-thousand five-hundred fifty-one traumatic hemorrhagic shock patients who had systolic hypotension (< 90 mm Hg) on arrival at the emergency department and a blood transfusion received within the first 24 hours. INTERVENTIONS: The use of vasopressor for traumatic hemorrhagic shock within the first 24 hours. MEASUREMENTS AND MAIN RESULTS: Among 236,698 trauma patients, 3,551 were included in the study. Overall, 198 of 459 patients (43%) in the vasopressor+ group expired compared with 481 of 3,092 patients (16%) in the vasopressor- group. Use of vasopressor had an odds ratio of 2.172 (95% CI, 1.666-2.833) for in-hospital mortality adjusted for age, gender, year of onset, cause of injury, mechanism of injury, vital signs at the emergency department, Injury Severity Score, use of prehospital IV fluid, and volume of blood transfusion within the first 24 hours. In the propensity score-matched cohort and two subgroup analyses (massive transfusion and survivable injury models), use of vasopressor was associated with higher mortality (odds ratio, 2.168; 95% C, 1.442-3.320), (odds ratio, 2.029; 95% CI, 1.414-2.911; massive transfusion model), and (odds ratio, 1.959; 95% CI, 1.364-2.814; survivable injury model). CONCLUSIONS: Use of vasopressor for traumatic hemorrhagic shock was associated with mortality after controlling for biases (trauma severity; volume of fluid resuscitation).

Vital sign based shock scores are poor at triaging South African trauma patients.

BACKGROUND: Traumatic shock cannot be diagnosed by a single physiological measurement and a number of vital sign based combined shock scores (CSS) have been proposed to identify and triage trauma patients with shock. This audit uses data from a prospectively entered electronic trauma registry to compare the ability of these CSS to predict in-hospital mortality, need for surgery, need for blood transfusion and ICU admission. MATERIALS AND METHODS: The data used in the study was obtained from the Hybrid Electronic Medical Record (HEMR) in Pietermaritzburg from January 2012-September 2015. The calculated scores (Systolic Blood Pressure [SBP], Mean Arterial Pressure [MAP], Shock Index [SI], Modified Shock Index [MSI] and Shock Index multiplied by Age [SIA]) were plotted against each outcome parameter and the inflection points at which they started to increase, for each parameter, was determined and compared. RESULTS: A total of 8793 patients met the inclusion criteria. After the datasets with missing data were removed, a total of 7623 patients were available for analyses. There was a slightly higher incidence of blunt trauma (46%) compared to penetrating trauma (43%). Area under the Receiver Operating Curves (AUROC) for prediction of mortality revealed the MSI and SIA performed best, with values of 0.69 and 0.70, respectively. In both the 'need for ICU' prediction as well as the 'need for blood transfusion' prediction, MSI performed best with scores of 0.73 and 0.79, respectively. None of the parameters performed well in the 'need for surgery' prediction. None of the CSS parameters reached a 'good predictor capability' score of 0.8. CONCLUSION: The currently available vital sign based scores (SBP, MAP, SI, MSI, SIA) used in the prediction of shock severity and triage are not good predictors of mortality, need for ICU, need for theatre or need for blood transfusion in our population where half the trauma is penetrating and there are long pre-hospital delays. Our data suggests that none of the proposed CSS's are capable of reliably and accurately identifying and categorizing shock states in South African trauma patients.

Can venous base excess replace arterial base excess as a marker of early shock and a predictor of survival in trauma?

INTRODUCTION: Arterial base excess is an established marker of shock and predictor of survival in trauma patients. However, venous blood is more quickly and easily obtained. This study aimed to determine if venous base excess could replace arterial base excess as a marker in trauma patients at presentation and if venous base excess is predictive of survival at 24 hours and one week. METHODS: This was a prospective study of 394 trauma patients presenting to the emergency department of a tertiary hospital over a 17-month period. Data on base excess at presentation, vital signs, shock index (SI), injury severity score (ISS), and mortality at 24 hours and one week was collected and analysed. RESULTS: Arterial and venous blood gas tests were performed on 260 and 134 patients, respectively. Patients were stratified into groups based on their SI and ISS for analysis. There was no statistical difference between mean venous blood gas and arterial blood gas levels at presentation when SI > 0.7, regardless of ISS (p > 0.05). The mortality rate was 4.57%. Both venous and arterial base excess was lower in nonsurvivors compared to survivors (p < 0.05). However, at 24 hours and one week, the difference in base excess values at presentation between survivors and nonsurvivors was greater when using venous base excess compared to arterial base excess (11.53 vs. 4.28 and 11.41 vs. 2.66, respectively). CONCLUSION: In conclusion, venous base excess can replace arterial base excess in trauma patients as a means of identifying and prognosticating early shock.

Prevalence, clinical presentation, prognosis, and outcome of 17 dogs with spinal shock and acute thoracolumbar spinal cord disease.

OBJECTIVE: To describe the prevalence, signalment, clinical features, etiology, and outcome in dogs with acute thoracolumbar disease and suspected spinal shock. DESIGN: Retrospective clinical case study (2005-2010). SETTING: Private specialty practice. ANIMALS: Medical records of 263 dogs with thoracolumbar spinal magnetic resonance imaging were reviewed. If decreased or absent withdrawal reflexes were present in 1 or both pelvic limbs, in the absence of a spinal lesion in the lumbosacral intumescence, dogs were diagnosed with spinal shock. Dogs with suspected or confirmed spinal neoplasia, myelomalacia, or meningomyelitis were excluded. Seventeen of 263 dogs (6%) met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Thoracic lesions were significantly more likely to result in spinal shock when compared to lumbar lesions (P = 0.03). Fibrocartilaginous embolism was the most commonly diagnosed etiology (7 of 17 dogs), and was more common in the thoracic spine compared to in the lumbar spine (P = 0.10). Six of 17 dogs (35%) were diagnosed with intervertebral disk herniation; 4 of 17 dogs (24%) with suspected acute noncompressive nucleus pulposus extrusion. Two dogs were lost to follow-up. Fourteen of 15 (93%) dogs had improved or normal reflexes by 60 days post injury. CONCLUSIONS: Although the prevalence of spinal shock was low, it should be considered in any dog presenting with an acute history of thoracolumbar spinal injury with reduced or absent reflexes in the pelvic limbs. The presence of spinal shock should not dissuade a veterinarian from pursuing appropriate diagnostic testing and therapy for the underlying etiology.

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.

Coagulopathy and shock on admission is associated with mortality for children with traumatic injuries at combat support hospitals.

OBJECTIVE: In adults, early traumatic coagulopathy and shock are both common and independently associated with mortality. There are little data regarding both the incidence and association of early coagulopathy and shock on outcomes in pediatric patients with traumatic injuries. Our objective was to determine whether coagulopathy and shock on admission are independently associated with mortality in children with traumatic injuries. METHODS: A retrospective review of the Joint Theater Trauma Registry from U.S. combat support hospitals in Iraq and Afghanistan from 2002 to 2009 was performed. Coagulopathy was defined as an international normalized ratio of ≥1.5 and shock as a base deficit of ≥6. Laboratory values were measured on admission. Primary outcome was inhospital mortality. Univariate analyses were performed on all admission variables followed by reverse stepwise multivariate logistic regression to determine independent associations. SETTING: Combat support hospitals in Iraq and Afghanistan. PATIENTS: Patients <18 yrs of age with Injury Severity Score, international normalized ratio, base deficit, and inhospital mortality were included. Of 1998 in the cohort, 744 (37%) had a complete set of data for analysis. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The incidence of early coagulopathy and shock were 27% and 38.3% and associated with mortality of 22% and 16.8%, respectively. After multivariate logistic regression, early coagulopathy had an odds ratio of 2.2 (95% confidence interval 1.1-4.5) and early shock had an odds ratio of 3.0 (95% confidence interval 1.2-7.5) for mortality. Patients with coagulopathy and shock had an odds ratio of 3.8 (95% confidence interval 2.0-7.4) for mortality. CONCLUSIONS: In children with traumatic injuries treated at combat support hospitals, coagulopathy and shock on admission are common and independently associated with a high incidence of inhospital mortality. Future studies are needed to determine whether more rapid and accurate methods of measuring coagulopathy and shock as well as if early goal-directed treatment of these states can improve outcomes in children.

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.

[Diagnostic apparatus in the shock trauma room]. / 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]. / Patogeneticheskie osobennosti ostrogo perioda travmaticheskoi bolezni. Travmaticheskii shok -- chastnoe proiavlenie ostrogo perioda.

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]. / Ciezkie mnogie i wielonarzadowe obrazenia ciala: zasady postepowania.

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 Lipinski, 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]. / Ognestrel'nye raneniia organov mochepolovoi sistemy.

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]. / Vliianie mnozhestvennoi i sochetannoi shokogennoi travmy na protsessy reparatsii kostnoi tkani i vosstanovlenie trudosposobnosti postradavshikh.

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]. / Endogennaia intoksikatsiia pri povrezhdenii grudi i zhivota.

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]. / Travmaticheskii shok pri mnozhestvennykh perelomakh kostei konechnostei u detei.

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.