The trauma patient in hemorrhagic shock: how is the C-priority addressed between emergency and ICU admission?

Sigune Peiniger,Bertil Bouillon,Philip C Spinella,Manuel Mutschler,Thomas Paffrath,Traumaregister Dgu ,Thomas Brockamp,Marc Maegele,Matthew Borgmann

doi:10.1186/1757-7241-20-78

Abstract

BackgroundTrauma is the leading cause of death in young people with an injury related mortality rate of 47.6/100,000 in European high income countries. Early deaths often result from rapidly evolving and deteriorating secondary complications e.g. shock, hypoxia or uncontrolled hemorrhage. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock.MethodsA retrospective analysis of data documented in the TraumaRegister of the ‘Deutsche Gesellschaft für Unfallchirurgie’ (TR-DGU®) was conducted. Relevant clinical and laboratory parameters reflecting status and basic physiology of severely injured patients (ISS ≥ 25) in either moderate or severe shock according to base excess levels (BE -2 to -6 or BE < -6) as surrogate for shock and hemorrhage combined with coagulopathy (Quick’s value <70%) were analyzed upon ER arrival and ICU admission.ResultsA total of 517 datasets was eligible for analysis. Upon ICU admission shock was reversed to BE > -2 in 36.4% and in 26.4% according to the subgroups. Two of three patients with initially moderate shock and three out of four patients with severe shock upon ER arrival were still in shock upon ICU admission. All patients suffered from coagulation dysfunction upon ER arrival (Quick’s value ≤ 70%). Upon ICU admission 3 out of 4 patients in both groups still had a disturbed coagulation function. The number of patients with significant thrombocytopenia had increased 5-6 fold between ER and ICU admission.ConclusionThe C-priority including coagulation management was not adequately addressed during primary survey and initial resuscitation between ER and ICU admission, in this cohort of severely injured patients.

Highlights

Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/ 100,000 in European high income countries
The present study assessed in how far ABC priorities with focus on C-priority including coagulation management are addressed during early in-hospital care and to what extent basic physiology has been restored prior to intensive care unit (ICU) admission among patients arriving to the emergency room (ER) in states of moderate or severe hemorrhagic shock
A total of 517 datasets of severely injured adults derived from the TraumaRegister DGUW (TR-DGUW) between 2002 and 2008 were eligible for analysis

Summary

Introduction

Trauma is the leading cause of death in young people with an injury related mortality rate of 47.6/ 100,000 in European high income countries. The present study assessed how well ABC priorities (A: Airway, B: Breathing/Ventilation and C: Circulation with hemorrhage control) with focus on the C-priority including coagulation management are addressed during early trauma care and to what extent these priorities have been controlled for prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock. While the immediate deaths after trauma are usually due to apnoea, severe brain or spinal cord injury or large vessel rupture, early deaths often result from rapidly evolving and deteriorating secondary complications such as shock, hypoxia, respiratory failure or uncontrolled hemorrhage. The present study assessed in how far ABC priorities with focus on C-priority including coagulation management are addressed during early in-hospital care and to what extent basic physiology has been restored prior to ICU admission among patients arriving to the ER in states of moderate or severe hemorrhagic shock

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