Pulse Pressure as an Early Warning of Hemorrhage in Trauma Patients.

BACKGROUND: Hypotension based on low systolic blood pressure (SBP) is a well-documented indicator of ongoing blood loss. However, the utility of pulse pressure (PP) for detection of hemorrhage has not been well studied. The purpose of this study was to determine whether a narrowed PP in nonhypotensive patients is an independent predictor of critical administration threshold (CAT+) hemorrhage requiring surgical or endovascular control. STUDY DESIGN: We performed a retrospective single-center study (January 2010 to October 2014), including trauma patients ≥16 years old with SBP ≥ 90 mmHg upon emergency department (ED) admission. We identified patients who were both CAT+ and required either surgical or interventional radiology for definitive hemorrhage control as the active hemorrhage (AH) group. Analyses were then performed to elucidate the association between PP and hemorrhage. RESULTS: Of the total 18,015 patients identified, 283 (1.6%) met the criteria for clinically significant hemorrhage. Mean PP was significantly lower in the AH group compared with the non-AH group (39 ± 18 mmHg vs 53 ± 19 mmHg, p < 0.0001). Multivariate analysis revealed that narrowed initial ED PP is an independent predictor of AH (adjusted odds ratio [AOR] 0.975) along with age (AOR 1.01), penetrating mechanism (AOR 9.476), field SBP (AOR 0.985), ED heart rate (AOR 1.024), and Injury Severity Score (AOR 1.126). Cutoff analysis of PP values identified a significantly higher risk of AH at a PP cutoff of 55 mmHg (AOR 3.44, p = 0.005, AUC 0.955) in patients 61 years or older vs 40 mmHg (AOR 2.73, p < 0.0001, AUC 0.940) for patients 16 to 60 years old. The predicted probability of AH increases as PP narrows. CONCLUSIONS: In patients who are nonhypotensive, a narrowed PP is an independent early predictor of active hemorrhage requiring blood product transfusion and intervention for hemorrhage control.

The diagnostic yield of commonly used investigations in pelvic gunshot wounds.

BACKGROUND: Patients who sustain pelvic gunshot wounds (GSWs) are at significant risk for injury owing to the density of pelvic structures. Currently, the optimal workup for pelvic GSWs is unclear. The aims of this study were to determine the diagnostic yield of tests commonly used in the investigation of pelvic GSWs and to develop a diagnostic algorithm. METHODS: All patients 15 years or older presenting to the Los Angeles County + University of Southern California Medical Center (January 2008 to February 2015) who sustained one or more pelvic GSWs were retrospectively identified. Patients' demographics, clinical assessment, investigations, procedures, and outcomes were abstracted. The diagnostic yield of computed tomographic (CT) scan, cystogram, gross inspection of the urine, urinalysis, endoscopy, and digital rectal examination (DRE) in the detection of clinically significant injuries to the pelvis were calculated. RESULTS: Three hundred seventy patients were included. Patients with peritonitis, hemodynamic instability, an unevaluable abdomen, or evisceration were taken to the operating room for immediate laparotomy (n = 138 [37.3%]). All others (n = 232 [62.7%]) underwent CT scan and further investigations as indicated. The sensitivity, specificity, positive predictive value, and negative predictive value of the investigations were CT scan: 1.00, 0.98, 0.74, and 1.00; cystogram: 1.00 for all parameters; gross inspection of the urine: 1.00 for all parameters; urinalysis: 1.00, 0.71, 0.17, and 1.00; endoscopy: 1.00, 0.82, 0.75, and 1.00; and DRE: 0.77, 0.99, 0.77, and 0.99. CONCLUSION: In the workup of pelvic GSWs, patients with hemodynamic instability, peritonitis, evisceration, or an unevaluable abdomen should undergo immediate laparotomy, while all others should undergo CT scan. Computed tomography-positive patients should be managed for their injuries. If the CT is negative, the likelihood of a clinically significant injury is very low. If the CT is equivocal for rectal or bladder injury, endoscopy or cystogram should be used to guide definitive management. There is no role for routine urinalysis or DRE. Further prospective validation of these findings is warranted. LEVEL OF EVIDENCE: Diagnostic study, level III; therapeutic study, level IV.