Prehospital hypotension in blunt trauma: identifying the "crump factor".

BACKGROUND: Trauma activation for prehospital hypotension in blunt trauma is controversial. Some patients subsequently arrive at the trauma center normotensive, but they can still have life-threatening injuries. Admission base deficit (BD)≤-6 correlates with injury severity, transfusion requirement, and mortality. Can admission BD be used to discriminate those severely injured patients who arrive normotensive but "crump," (i.e., become hypotensive again) in the Emergency Department? The purpose is to determine whether admission BD<-6 discriminates patients at risk for future bouts of unexpected hypotension during evaluation. METHODS: Retrospective chart review was performed on all blunt trauma admissions at a Level I trauma center from August 2002 through July 2007. Hypotension was defined as a systolic blood pressure≤90 mm Hg. Patients who were hypotensive in the field but normotensive upon arrival in the emergency department (ED) were included. Age, gender, injury severe score, arterial blood gas analysis, results of focused abdominal sonogram for trauma (FAST), computed tomography, intravenous fluid administration, blood transfusions, and the presence of repeat bouts of hypotension were noted. Patients were stratified by BD≤-6 or ≥-5. Statistical analysis was performed using paired t test, χ, and logistic regression analysis with significance attributed to p<0.05. RESULTS: During the 5-year period, 231 blunt trauma patients had hypotension in the field with subsequent normotension on admission to the ED. Of these, 189 patients had admission BD data recorded. Patients with a BD≤-6 were significantly more likely to have repeat hypotension (78% vs. 30%, p<0.001). Overall mortality was 13% (24 of 189), but patients with repeat hypotension had greater mortality (24% vs. 5%, p<0.003). CONCLUSION: Blunt trauma patients with repeat episodes of hypotension have significantly greater mortality. Patients with transient field hypotension and a BD≤-6 are more than twice as likely to have repeat hypotension (crump). This study reinforces the need for early arterial blood gases and trauma team involvement in the evaluation of these patients. Patients with BD≤-6 should have early invasive monitoring, liberal use of repeat FAST exams, and careful resuscitation before computed tomography scanning. Surgeons should have a low threshold for taking such patients to the operating room.

Cervical spinal cord injury and the need for cardiovascular intervention.

HYPOTHESIS: The level of cervical spinal cord injury (CSCI) can be used to predict the need for a cardiovascular intervention. DESIGN: Retrospective review. Data included level of spinal cord injury, Injury Severity Score, lowest heart rate, and systolic blood pressure in the first 24 hours and intensive care unit course. The level of CSCI was divided into high (cord level C1-C5) or low (cord level C6-C7). Neurogenic shock was defined as bradycardia with hypotension. Statistical analysis was performed with the t test and the chi2 test. SETTING: Level I trauma center. PATIENTS: The patients studied were those with quadriplegia who experienced a CSCI and were admitted to the hospital between December 1, 1993, and October 31, 2001. INTERVENTIONS: Pressors, chronotropic agents, and pacemakers.Main Outcome Measure Use of a cardiovascular intervention in the presence of neurogenic shock. RESULTS: Eighty-three patients met the criteria for CSCI and quadriplegia, 62 in the high (C1-C5) and 21 in the low (C6-C7) level. There was no significant difference between the 2 groups in mean +/- SD age (38.2+/-17.8 vs 34.7+/-15.6 years; P=.43), mean +/- SD Injury Severity Score (35.7+/-17.5 vs 32.5+/-11.2; P=.44), mean +/- SD admission base deficit (-0.7+/-3.6 vs 0.7+/-2.7; P=.06), or mortality (12 [19%] of 62 patients vs 2 [10%] of 21 patients; P=.29). Neurogenic shock was present in 19 (31%) of the 62 patients with high CSCI and in 5 (24%) of the 21 patients with low CSCI (P=.56). There was a marked difference in the use of a cardiovascular intervention between those with a high and those with a low CSCI: 15 (24%) of 62 patients vs 1 (5%) of 21 patients (P=.02). Two patients with C1 through C5 spinal cord injuries required cardiac pacemakers. CONCLUSIONS: There was no significant difference in the frequency of neurogenic shock by injury level. Patients with a high CSCI (C1-C5) had a significantly greater requirement for a cardiovascular intervention compared with patients with lower injuries (C6-C7).