Defining the optimal time to the operating room may salvage early trauma deaths

Remick, Kyle N.; Schwab, C. William; Smith, Brian P.; Monshizadeh, Amir; Kim, Patrick K.; Reilly, Patrick

doi:10.1097/ta.0000000000000218

Cited by 45 publications

(31 citation statements)

References 9 publications

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“…Harvin et al 24 found that hypotensive trauma patients requiring emergent laparotomy (within 90 minutes of admission) had a 46% mortality; 65% of those deaths were related to hemorrhage. In another study looking at trauma deaths within 4 hours of admission, 50% of patients died within the first hour 15. In our study, OR placement was associated with longer time to AO (75 minutes vs. 23 minutes), although location of placement and time to AO were not associated with increased in-hospital mortality after controlling for admission physiology and GCS score.…”

Section: Discussioncontrasting

confidence: 51%

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Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Vella

Dumas

DuBose

et al. 2019

Trauma Surg Acute Care Open

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BackgroundResuscitative endovascular balloon occlusion of the aorta (REBOA) is a less-invasive technique for aortic occlusion (AO). Commonly performed in the emergency department (ED), the role of intraoperative placement is less defined. We hypothesized that operating room (OR) placement is associated with increased in-hospital mortality.MethodsThe American Association for the Surgery of Trauma AORTA registry was used to identify patients undergoing REBOA. Injury characteristics and outcomes data were compared between OR and ED groups. The primary outcome was in-hospital mortality; secondary outcomes included total AO time, transfusion requirements, and acute kidney injury.ResultsLocation and timing of catheter insertion were available for 305 of 321 (95%) subjects. 58 patients underwent REBOA in the OR (19%). There were no differences with respect to sex, admission lactate, and Injury Severity Score. The OR group was younger (33 years vs. 41 years, p=0.01) and with more penetrating injuries (36% vs. 15%, p<0.001). There were significant differences with respect to admission physiology. Time from admission to AO was longer in the OR group (75 minutes vs. 23 minutes, p<0.001) as was time to definitive hemostasis (116 minutes vs. 79 minutes, p=0.01). Unadjusted mortality was lower in the OR group (36.2% vs. 68.8%, p<0.001). There were no differences in secondary outcomes. After controlling for covariates, there was no association between insertion location and in-hospital mortality (OR 1.8, 95% CI 0.30 to 11.50).DiscussionOR REBOA placement is common and generally employed in patients with more stable admission physiology. OR placement was not associated with increased in-hospital mortality despite longer times to AO and definite hemostasis when compared with catheters placed in the ED.Level of evidenceIV; therapeutic/care management.

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Section: Discussioncontrasting

confidence: 51%

“…Because the median time to death from severe hemorrhage is approximately 1 hour,15 there is now appropriate emphasis on shortening the time to hemostasis as much as possible 5. Currently, the majority of REBOA catheters are placed either in the emergency department (ED) or the operating room (OR) 16.…”

Section: Introductionmentioning

confidence: 99%

Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Vella

Dumas

DuBose

et al. 2019

Trauma Surg Acute Care Open

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“…Immediate surgical/radiological intervention for hemostasis is a key component of management in hemorrhagic trauma 1,2 . Immediate blood transfusion to maintain hemodynamics and adequate tissue oxygenation is often needed 3 .…”

Section: Introductionmentioning

confidence: 99%

Prehospital lactate improves prediction of the need for immediate interventions for hemorrhage after trauma

Fukuma

Nakada

Shimada

et al. 2019

Sci Rep

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The blood lactate level is used to guide the management of trauma patients with circulatory disturbance. We hypothesized that blood lactate levels at the scene (Lac scene) could improve the prediction for immediate interventions for hemorrhage. We prospectively measured blood lactate levels and assessed retrospectively in 435 trauma patients both at the scene and on arrival at the emergency room (ER) of a level I trauma center. Primary outcome was immediate intervention for hemorrhage defined as surgical/radiological intervention and/or blood transfusion within 24 h. Physiological variables plus Lac scene significantly increased the predictive value for immediate intervention (area under the curve [AUC] 0.882, 95% confidence interval [CI] 0.839–0.925) compared to that using physiological variables only (AUC 0.837, 95% CI 0.787–0.887, P = 0.0073), replicated in the validation cohort (n = 85). There was no significant improvement in predicting value of physiological variables plus Lac scene for massive transfusion compared to physiological variables (AUC 0.903 vs 0.895, P = 0.32). The increased blood lactate level per minute from scene to ER was associated with increased probability for immediate intervention (P < 0.0001). Both adding Lac scene to physiological variables and the temporal elevation of blood lactate levels from scene to ER could improve the prediction of the immediate intervention.

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“…A reduced time to intervention is well known to be associated with decreased mortality, such as in acute coronary syndrome [7] and trauma [8]. The effect of reduced time to embolization among hemodynamically unstable patients with pelvic fracture has been described [9][10][11][12].…”

Section: Introductionmentioning

confidence: 99%

Delayed embolization associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival

Aoki

Abe

Matsumoto³

et al. 2021

World J Emerg Surg

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Background Embolization is widely used for controlling arterial hemorrhage associated with pelvic fracture. However, the effect of a delay in embolization among hemodynamically stable patients at hospital arrival with a pelvic fracture is unknown. Therefore, our aim was to investigate the association between the time to embolization and mortality in hemodynamically stable patients at hospital arrival with a pelvic fracture. Methods A multicenter, retrospective cohort study was undertaken using data from the Japan Trauma Data Bank between 2004 and 2018. Hemodynamically, stable patients with a pelvic fracture who underwent an embolization within 3 h were divided into six groups of 30-min blocks of time until pelvic embolization (0–30, 30–60, 60–90, 90–120, 120–150, and 150–180 min). We compared the adjusted 30-day mortality rate according to time to embolization. Results We studied 620 hemodynamically stable patients with a pelvic fracture who underwent pelvic embolization within 3 h of hemorrhage. The median age was 68 (48–79) years and 55% were male. The median injury severity score was 26 (18–38). Thirty-day mortality was 8.9% (55/620) and 24-h mortality was 4.2% (26/619). A Cochran–Armitage test showed that a 30-min delay for embolization was associated with increased 30-day (p = 0.0186) and 24-hour (p = 0.033) mortality. Mortality within 0–30 min to embolization was 0%. The adjusted 30-day mortality rate increased with delayed embolization and was up to 17.0% (10.2–23.9) for the 150–180 min group. Conclusion Delayed embolization was associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival. When you decide to embolize pelvic fracture patients, the earlier embolization may be desirable to promote improved survival regardless of hemodynamics.

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Defining the optimal time to the operating room may salvage early trauma deaths

Abstract: Epidemiologic study, level III.

Cited by 45 publications

References 9 publications

Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Intraoperative REBOA: an analysis of the American Association for the Surgery of Trauma AORTA registry

Prehospital lactate improves prediction of the need for immediate interventions for hemorrhage after trauma

Delayed embolization associated with increased mortality in pelvic fracture with hemodynamic stability at hospital arrival

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