Impact of time to surgery on mortality in hypotensive patients with noncompressible torso hemorrhage: An AAST multicenter, prospective study

Abstract

BACKGROUND:Death from noncompressible torso hemorrhage (NCTH) may be preventable with improved prehospital care and shorter inhospital times to hemorrhage control. We hypothesized that shorter times to surgical intervention for hemorrhage control would decrease mortality in hypotensive patients with NCTH. METHODS:This was an AAST-sponsored multicenter, prospective analysis of hypotensive patients aged 15+ years who presented with NCTH from May 2018 to December 2020. Hypotension was defined as an initial systolic blood pressure (SBP) ≤ 90 mm Hg. Primary outcomes of interest were time to surgical intervention and in-hospital mortality. RESULTS:There were 242 hypotensive patients, of which 48 died (19.8%). Nonsurvivors had higher mean age (47.3 vs. 38.8; p = 0.02), higher mean New Injury Severity Score (38 vs. 29; p < 0.001), lower admit systolic blood pressure (68 vs. 79 mm Hg; p < 0.01), higher incidence of vascular injury (41.7% vs. 21.1%; p = 0.02), and shorter median (interquartile range, 25-75) time from injury to operating room start (74 minutes [48-98 minutes] vs. 88 minutes [61-128 minutes]; p = 0.03) than did survivors. Multivariable Cox regression showed shorter time from emergency department arrival to operating room start was not associated with improved survival ( p = 0.04). CONCLUSION:Patients who died arrived to a trauma center in a similar time frame as did survivors but presented in greater physiological distress and had significantly shorter times to surgical hemorrhage intervention than did survivors. This suggests that even expediting a critically ill patient through the current trauma system is not sufficient time to save lives from NCTH. Civilian prehospital advance resuscitative care starting from the patient first contact needs special consideration.

Emergency department versus operating room intubation of patients undergoing immediate hemorrhage control surgery

“…The observation that 35% of ED intubation patients received massive transfusion, whereas more than 50% of OR intubation patients received no blood transfusion, was evidence of this confounding. Similar limitations affect interpretation of the forthcoming paper by Duchesne et al 16 Among 237 patients undergoing surgery for noncompressible torso hemorrhage, the median GCS score before ED intubation was 8, compared with the median GCS score of 15 among patients treated with deferred intubation. Such profound confounding could not be reliably adjusted for in either study.…”

“…Patients were predominantly young men (8,046 male [83%]; median age, 33 years [interquartile range (IQR), 24-46 years]) who suffered penetrating injuries (4,887 firearm injury [51%]; 2,019 stab injury [21%]). The median ISS was 18 (IQR, [10][11][12][13][14][15][16][17][18][19][20][21][22][23][24][25][26]. The median GCS score on arrival was 15 (IQR, 14-15), and the median SBP was 108 mm Hg (IQR, 88-130 mm Hg).…”

“…Previous studies evaluating ED intubation of operative trauma patients were limited by small sample size and confounding by indication. 15,16 Therefore, there is need to further clarify the impact of intubation location on outcomes for patients requiring urgent hemorrhage control surgery.…”

Management and Outcomes of Firearm-Related Vascular Injuries

“…This may indicate a need for more advanced prehospital resuscitative care starting from the rst patient contact. 14 The use of prehospital blood transfusion seems bene cial but an in-hospital survival bene t in hemorrhagic trauma patients is still unclear 15 The mortality after rearm related vascular injuries was high and associated with non-compressible thoracoabdominal vascular injuries but also injury to the femoral artery. An overall mortality from abdominal vascular injuries of 54% has previously been reported.…”

Advances in the Management of Coagulopathy in Trauma: The Role of Viscoelastic Hemostatic Assays across All Phases of Trauma Care

“…The management of patients with active bleeding should follow an intentional strategy focused on hemorrhage control, appropriate resuscitation, and individualized correction of coagulopathy. 31,32 Hemorrhage control is paramount since, without hemorrhage control, all other attempts at patient salvage are futile. For most trauma patients, definitive hemorrhage control is achieved in the operating room (OR) or the interventional suite/hybrid OR.…”