The utility of Advanced Trauma Life Support (ATLS) clinical shock grading in assessment of trauma.

BACKGROUND: Acute haemorrhage is a major contributor to trauma related morbidity and mortality. Quantifying blood loss acutely and accurately is a difficult task and no currently accepted standard exists. We introduce a simple shock grading tool incorporating vital signs, fluid response and estimated blood loss to describe shock grade during the primary survey based on the original Advanced Trauma Life Support (ATLS) classification. METHODS: We performed a prospective cohort study of all trauma patients admitted to our emergency room over a 1-year period to evaluate the utility of this tool for emergency physicians to detect significant haemorrhage in the trauma patient. Shock grades were prospectively assigned to patients by the trauma team as part of the primary survey, and followed up to assess for outcomes. The primary outcome was a composite endpoint of clinical, radiological and operative findings consistent with significant haemorrhage. Data were analysed using linear and logistic regression to assess predictive ability and receiver operator characteristic curve to assess overall diagnostic accuracy. RESULTS: The overall sensitivity of the shock grading tool was 83%. The diagnostic accuracy based on area under receiver operator characteristic curve was 0.86. There was also a significant association between increasing shock grade and both injury severity score (ß coefficient 7.0, p<0.001, 95% CI 6.2 to 7.8) and the presence of significant haemorrhage (OR 5.1, p<0.001, 95% CI 3.6 to 7.3). CONCLUSIONS: We conclude that a simple ATLS based clinical tool that objectively categorises haemorrhagic shock is a useful part of the primary survey of the trauma patient, although a larger study with higher statistical power is required to evaluate this conclusion further.

Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital.

OBJECTIVE: To evaluate a two-tiered trauma activation protocol in a major trauma referral hospital in Australia. METHODS: A prospective study performed over a 12-month period of all consecutive trauma activations in a major trauma referral hospital. The triage tool assigned patients into two tiers of trauma activation. The full trauma activation was initiated where physiological or anatomical criteria were present. These patients were assessed by a multispecialty trauma team. A consult trauma activation was initiated where only mechanism of injury criteria was present. These patients were assessed by the Emergency Department Registrar and Surgical Registrar. The primary endpoint was major trauma outcome defined as either injury severity score (ISS) greater than 15, requirement for High Dependency Unit or Intensive Care Unit (HDU/ICU) admission, need for urgent operative intervention, or in hospital mortality. RESULTS: Of 1144 trauma activations, 468 (41%) were full trauma and 676 (59%) were consult trauma activations. The full trauma activation group had a significantly higher proportion of the major trauma outcome (34% vs. 5%, p<0.01) and all 18 patients (2%) who died were in the full trauma activation group. Sensitivity of the triage tool for the major trauma outcome was 83%, specificity was 68%, undertriage was 3% and overtriage was 27%. CONCLUSIONS: The two-tiered trauma activation protocol is effective in identifying patients with major trauma from those with minor trauma. There were no deaths in undertriaged patients.