Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level

Abstract

Background Trauma activation level is determined by prehospital criteria. The American College of Surgeons (ACS) recommends trauma activation criteria; however, their accuracy may be limited. Prehospital lactate has shown promise in predicting trauma center resource requirements. Our objective was to investigate the added value of incorporating prehospital lactate in an algorithm to designate trauma activation level. Methods Air medical trauma patients undergoing prehospital lactate measurement were included. Algorithms using ACS activation criteria (ACS) and ACS activation criteria plus prehospital lactate (ACS+LAC) to designate trauma activation level were compared. Test characteristics and net reclassification improvement (NRI), which evaluates reclassification of patients among risk categories with additional predictive variables, were calculated. Algorithms were compared to predict trauma center need (TCN) defined as >1unit of blood in the ED; spinal cord injury; advanced airway; thoracotomy or pericardiocentesis; ICP monitoring; emergent operative or interventional radiology procedure; or death. Results There were 6,347 patients included. Twenty-eight percent had TCN. The ACS+LAC algorithm upgraded 256 patients and downgraded 548 patients compared to the ACS algorithm. The ACS+LAC algorithm versus ACS algorithm had a NRI of 0.058 (95%CI 0.044, 0.071; p<0.01), with an event NRI of −0.5% and non-event NRI of 6.2%. When weighted to favor changes in under-triage, the ACS+LAC still had a favorable overall reclassification (wNRI 0.041; 95%CI 0.028, 0.054; p=0.01). The ACS+LAC algorithm increased PPV, NPV, and accuracy. Over-triage was reduced 7.2%, while under-triage only increased 0.7%. The area under the curve (AUC) was significantly higher for the ACS+LAC algorithm (0.79 vs. 0.76, p<0.01). Conclusions The ACS+LAC algorithm reclassified patients to more appropriate levels of trauma activation when compared to the ACS algorithm. This overall benefit is achieved by significant reduction in over-triage relative to very small increase in under-triage. In the context of trauma team activation, this trade-off may be acceptable, especially in the current healthcare environment. Level of Evidence Diagnostic study, Level IV

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

“…The potential usefulness of prehospital lactate was suggested as a tool for urgent ambulance dispatch for patients with circulatory, respiratory, or neurological disorders 12 , as well as a predictive tool for resuscitative care 13 and designation of trauma activation level 14 . Since the prehospital lactate cost per measurement is not large ($2.00 per measurement) in the study, the study results have high translatability into clinical practices.…”

Remote Damage Control Resuscitation in Austere Environments

“…26 Closing this critical knowledge gap would enable resuscitation to be titrated to reduce both risk of rebleeding and optimize tissue perfusion. Although no such technology currently exists, advanced in computer-generated decision support tools utilizing continuous vital sign measures, tissue oxygen saturation monitoring, 27 and serial lactate measurements 28 have all demonstrated promising early results.…”

Determinants of prehospital lactate in trauma patients: a retrospective cohort study

“…Reliance on vital signs and physical exam however, has been reported to miss patients with serious injury [1]. Point of care (POCT) serum lactate measurement is emerging as an adjunct to pre-hospital clinical assessment and has the potential to guide triage and advanced treatment decision-making: pre-hospital lactate levels have been shown to predict the need for resuscitative inhospital care in trauma patients [2][3][4][5], and to predict outcome of trauma patients [6].…”

“…Furthermore, many pharmacological and non-pharmacological) treatments on scene have the potential to modulate beta adrenergic stimulation, and thereby influence lactate levels. Although this will not affect the prognostic ability of elevated prehospital lactate levels as such (several studies have shown that the prognostic ability of lactate exceeds the prognostic ability of markers of end organ hypoperfusion) [2][3][4][5], it might influence the use of lactate as a marker to guide advanced prehospital treatments such as blood product transfusion [8].…”