Manuel Mutschler

The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU.

IntroductionIsolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters.MethodsBetween 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU® database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock.ResultsWorsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick’s values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock.ConclusionSI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

Predicting on-going hemorrhage and transfusion requirement after severe trauma: a validation of six scoring systems and algorithms on the TraumaRegister DGU®

IntroductionThe early aggressive management of the acute coagulopathy of trauma may improve survival in the trauma population. However, the timely identification of lethal exsanguination remains challenging. This study validated six scoring systems and algorithms to stratify patients for the risk of massive transfusion (MT) at a very early stage after trauma on one single dataset of severely injured patients derived from the TR-DGU (TraumaRegister DGU® of the German Trauma Society (DGU)) database.MethodsRetrospective internal and external validation of six scoring systems and algorithms (four civilian and two military systems) to predict the risk of massive transfusion at a very early stage after trauma on one single dataset of severely injured patients derived from the TraumaRegister DGU® database (2002-2010). Scoring systems and algorithms assessed were: TASH (Trauma-Associated Severe Hemorrhage) score, PWH (Prince of Wales Hospital/Rainer) score, Vandromme score, ABC (Assessment of Blood Consumption/Nunez) score, Schreiber score and Larsen score. Data from 56,573 patients were screened to extract one complete dataset matching all variables needed to calculate all systems assessed in this study. Scores were applied and area-under-the-receiver-operating-characteristic curves (AUCs) were calculated. From the AUC curves the cut-off with the best relation of sensitivity-to-specificity was used to recalculate sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).ResultsA total of 5,147 patients with blunt trauma (95%) was extracted from the TR-DGU. The mean age of patients was 45.7 ± 19.3 years with a mean ISS of 24.3 ± 13.2. The overall MT rate was 5.6% (n = 289). 95% (n = 4,889) patients had sustained a blunt trauma. The TASH score had the highest overall accuracy as reflected by an AUC of 0.889 followed by the PWH-Score (0.860). At the defined cut-off values for each score the highest sensitivity was observed for the Schreiber score (85.8%) but also the lowest specificity (61.7%). The TASH score at a cut-off ≥ 8.5 showed a sensitivity of 84.4% and also a high specificity (78.4%). The PWH score had a lower sensitivity (80.6%) with comparable specificity. The Larson score showed the lowest sensitivity (70.9%) at a specificity of 80.4%.ConclusionsWeighted and more sophisticated systems such as TASH and PWH scores including higher numbers of variables perform superior over simple non-weighted models. Prospective validations are needed to improve the development process and use of scoring systems in the future.

Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®

IntroductionThe recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival.MethodsBetween 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU® database, classified into four strata of worsening BD [class I (BD ≤ 2 mmol/l), class II (BD > 2.0 to 6.0 mmol/l), class III (BD > 6.0 to 10 mmol/l) and class IV (BD > 10 mmol/l)] and assessed for demographics, injury characteristics, transfusion requirements and fluid resuscitation. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock.ResultsWith worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (± 11.9) in class I to 36.7 (± 17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes. The number of blood units transfused increased from 1.5 (± 5.9) in class I patients to 20.3 (± 27.3) in class IV patients. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p < 0.001).ConclusionsBD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

Administration of fibrinogen concentrate in exsanguinating trauma patients is associated with improved survival at 6 hours but not at discharge.

BACKGROUND Despite poor evidence and high costs, fibrinogen concentrate (FC) represents one of the most frequently used hemostatic agents in exsanguinating trauma. The aim was to assess whether the administration of FC in severely injured patients was associated with improved outcomes. METHODS Patients documented in the Trauma Registry of the German Society for Trauma Surgery (primary admissions, Injury Severity Score [ISS] ≥16) who had received FC during initial care between emergency department (ED) arrival and intensive care unit admission (FC+) were matched with patients who had not received FC (FC−). RESULTS The matched-pairs analysis yielded two comparable cohorts (n = 294 in each group) with a mean ISS of 37.6 ± 13.7 (FC+) and 37.1 ± 13.3 (FC−) (p = 0.73); the mean age was 40 ± 17 versus 40 ± 16 (p = 0.72), respectively. Patients were predominantly male (71.1% in both groups, p = 1.0). On emergency department arrival, hypotension (systolic blood pressure, ⩽90 mm Hg) occurred in 51.4% (FC+) and 48.0% (FC−) (p = 0.41), and base excess was −7.4 ± 5.3 mmol/L for FC+ and was −7.5 ± 6.2 mmol/L for FC− (p = 0.96). Patients were administered 12.8 ± 14.3 (FC+) versus 11.3 ± 10.0 (FC−) packed red blood cell units (p = 0.20). Thromboembolism occurred in 6.8% (FC+) versus 3.4% (FC−) (p = 0.06), and multiple organ failure occurred in 61.2% versus 49.0% (p = 0.003), respectively. Whereas 6-hour mortality was 10.5% for FC+ versus 16.7% for FC− (p = 0.03), the mean time to death was 7.5 ± 14.6 days versus 4.7 ± 8.6 days (p = 0.006). The overall hospital mortality rate was 28.6% versus 25.5% (p = 0.40), respectively. CONCLUSION This is the first study to investigate the effect of FC administration in bleeding trauma. In our large population of severely injured patients, the early use of FC was associated with a significantly lower 6-hour mortality and an increased time to death, but also an increased rate of multiple organ failure. A reduction of overall hospital mortality was not observed in patients receiving FC. LEVEL OF EVIDENCE Therapeutic study, level IV.

Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid?

Objective Validation of the classification of hypovolaemic shock suggested by the prehospital trauma life support (PHTLS) in its sixth student course manual. Methods Adults, entered into the TraumaRegister DGU® database between 2002 and 2011, were classified into reference ranges for heart rate (HR), systolic blood pressure (SBP) and Glasgow coma scale (GCS) according to the PHTLS classification of hypovolaemic shock. First, patients were grouped by a combination of all three parameters (HR, SBP and GCS) as suggested by PHTLS. Second, patients were classified by only one parameter (HR, SBP or GCS) according to PHTLS and alterations in the remaining two parameters were assessed. Furthermore, subgroup analysis for trauma mechanism and traumatic brain injury (TBI) were performed. Results Out of 46 689 patients, only 12 432 (26.5%) could be adequately classified according to PHTLS if a combination of all three criteria was assessed. In TBI patients, only 12.2% could be classified adequately, whereas trauma mechanism had no significant influence. When patients were grouped by HR, there was only a slight reduction in SBP. When grouped by SBP, GCS dropped from 14 to 8, while no significant tachycardia was observed in any group. In patients with a GCS less than 12, HR was unaltered whereas SBP was slightly reduced to 114 (±42) mm Hg. On average, GCS in TBI patients was lower within all shock groups. In penetrating trauma patients, changes in HR and SBP were more distinct, but still less than predicted by PHTLS. Conclusions The PHTLS classification of hypovolaemic shock displays substantial deficits in adequately risk-stratifying trauma patients.

Is the ATLS classification of hypovolaemic shock appreciated in daily trauma care? An online-survey among 383 ATLS course directors and instructors

Objective For the early recognition and management of hypovolaemic shock, ATLS suggests four shock classes based upon an estimated blood loss in percent. The aim of this study was to assess the confidence and acceptance of the ATLS classification of hypovolaemic shock among ATLS course directors and instructors in daily trauma care. Methods During a 2-month period, ATLS course directors and instructors from the ATLS region XV (Europe) were invited to participate in an online survey comprising 15 questions. Results A total of 383 responses were received. Ninety-eight percent declared that they would follow the ‘A, B, C, D, E’ approach by ATLS in daily trauma care. However, only 48% assessed ‘C-Circulation’ according to the ATLS classification of hypovolaemic shock. One out of four respondents estimated that in daily clinical routine, less than 50% of all trauma patients can be classified according to the current ATLS classification of hypovolaemic shock. Additionally, only 10.9% considered the ATLS classification of hypovolaemic shock as a ‘good guide’ for fluid resuscitation and blood product transfusion, whereas 45.1% stated that this classification only ‘may help’ or has ‘no impact’ to guide resuscitation strategies. Conclusions Although the ‘A, B, C, D, E’ approach according to ATLS is widely implemented in daily trauma care, the use of the ATLS classification of hypovolaemic shock in daily practice is limited. Together with previous analyses, this study supports the need for a critical reassessment of the current ATLS classification of hypovolaemic shock.

‘Time to TASH’: how long does complete score calculation take to assess major trauma hemorrhage?

Dear Sir, Uncontrolled haemorrhage is still one of the leading causes of death within trauma patients (Evans et al., 2010) and is often exaggerated by the presence of acute traumatic coagulopathy (ATC) (Maegele et al., 2007). Despite substantial improvements in acute trauma care over the past decade, the rapid identification of patients with substantial ongoing bleeding and at risk for massive transfusion remains insufficient. Recently, our group has developed and validated the Trauma-Associated Severe Hemorrhage (TASH)-Score (Yücel et al., 2006; Maegele et al., 2011; Brockamp et al., 2012), as an easy-to-calculate and valid scoring system to predict the individual’s probability for massive transfusion, as a surrogate for life-threatening hemorrhage after multiple trauma. A major criticism of the score has been its potential lack in timely calculation during early trauma resuscitation. In this study, the time to complete TASH calculation was prospectively assessed in a cohort of trauma patients admitted to our level-1 trauma center. The setting for this prospective observational study was the emergency department (ED) of our urban level-1 trauma center, the Cologne-Merheim Medical Center (CMMC), Germany. All patients admitted during regular working hours (7 am to 7 pm) with trauma team activation were included within a 2-month period. An independent physician documented the time point of the patient arrival to the resuscitation room as well as the time point at which each variable necessary to calculate TASH was obtained. Time capture was initiated as soon as the patient arrived to the resuscitation room and prior to transfer of the patient onto the ED stretcher. Base excess (BE) and haemoglobin (Hb) were assessed by using point-of-care (POC) devices (IRMA TruePoint®, Keller Medical, Bad Soden, Germany). Potential pelvic and femoral instability were clinically assessed via manual examination by the trauma/orthopedic surgeon in charge. If in doubt, conventional X-rays were obtained. Potential free intraabdominal fluid was assessed by FAST (focused assessment with sonography for trauma) performed by the general surgeon in charge. Forty trauma patients were enrolled in the present analysis. Patients were predominantly male (78·6%), suffered from blunt trauma (95%) and presented with a mean age of 58·6 (±21·4) years. Overall, the mean time for assessment and complete

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

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.

Comparison of transportation related injury mechanisms and outcome of young road users and adult road users, a retrospective analysis on 24,373 patients derived from the TraumaRegister DGU ®

BackgroundMost young people killed in road crashes are known as vulnerable road users. A combination of physical and developmental immaturity as well as inexperience increases the risk of road traffic accidents with a high injury severity rate. Understanding injury mechanism and pattern in a group of young road users may reduce morbidity and mortality. This study analyzes injury patterns and outcomes of young road users compared to adult road users. The comparison takes into account different transportation related injury mechanisms.MethodsA retrospective analysis using data collected between 2002 and 2012 from the TraumaRegister DGU® was performed. Only patients with a transportation related injury mechanism (motor vehicle collision (MVC), motorbike, cyclist, and pedestrian) and an ISS ≥ 9 were included in our analysis. Four different groups of young road users were compared to adult trauma data depending on the transportation related injury mechanism.ResultsTwenty four thousand three hundred seventy three, datasets were retrieved to compare all subgroups. The mean ISS was 23.3 ± 13.1. The overall mortality rate was 8.61%. In the MVC, the motorbike and the cyclist group, we found young road users having more complex injury patterns with a higher AIS pelvis, AIS head, AIS abdomen and AIS of the extremities and also a lower GCS. Whereas in these three sub-groups the adult trauma group only had a higher AIS thorax. Only in the group of the adult pedestrians we found a higher AIS pelvis, AIS abdomen, AIS thorax, a higher AIS of the extremities and a lower GCS.DiscussionThis study reports on the most common injuries and injury patterns in young trauma patients in comparison to an adult trauma sample. Our analysis show that in contrast to more experienced road users our young collective refers to be a vulnerable trauma group with an increased risk of a high injury severity and high mortality rate. We indicate a striking difference in terms of the region of injury and the mechanism of injury when comparing the young versus the adult trauma collectives.ConclusionsYoung drivers of cars, motorbikes and bikes were shown to be on high risk to sustain a specific severe injury pattern and a high mortality rate compared to adult road users. Our data emphasize a characteristic injury pattern of young trauma patients and may be used to improve trauma care and to guide prevention strategies to decrease injury severity and mortality due to road traffic injuries.

Bilateral carotid artery dissection in a kite surfer by strangulation with the kite lines

While a kite surfer was preparing the kite it was caught by a gust of wind, which blew it 10 m into the air and the cords became entangled around the neck of the kite surfer causing strangulation. After admittance to hospital, the diagnostics revealed multiple injuries including a bilateral dissection of the internal carotid arteries, cerebral edema and multiple fractures. As kitesurfing is gaining popularity severe injuries are becoming more frequent. Safety precautions, such as preparing the kite with two persons, wearing safety equipment and using bars with a safety leash can prevent severe injuries.