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®

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Abstract

Introduction

The 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.

Methods

Between 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.

Results

With 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).

Conclusions

BD 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.

Related collections

Most cited references 29

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Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma.

, Matthias Vorweg, N Yücel … (2006)

To develop a simple scoring system that allows an early and reliable estimation for the probability of mass transfusion (MT) as a surrogate for life threatening hemorrhage following multiple trauma. Potential clinical and laboratory variables documented in the Trauma Registry of the German Trauma Society (DGU) (1993-2003; n=17,200) were subjected to univariate and multivariate logistic regression analysis to predict the probability for MT. Clinical and laboratory variables available from data sets were screened for their association with mass transfusion. MT was defined by transfusion requirement of >or=10 units of packed red blood cells from emergency room (ER) to intensive care unit admission. Seven independent variables were identified to be significantly correlated with an increased probability for MT: systolic blood pressure ( 120=2 pts), base excess (<-10 mmol/L=4 pts, <-6 mmol/L=3 pts, and <-2 mmol/L=1 pt), and gender (male=1 pt). These variables were incorporated into a risk score, the Trauma Associated Severe Hemorrhage Score (TASH-Score, 0-28 points). Performance of the score was tested with respect to discrimination, precision, and calibration. Increasing TASH-Score points were associated with an increasing probability for MT. The TASH-Score is an easy-to-use scoring system that reliably predicts the probability for MT after multiple trauma. Taken as a surrogate for life threatening bleeding calculation may focus attention on relevant variables indicative for risk and impact strategies to stop bleeding and stabilize coagulation in acute trauma care.

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A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department.

H Blake, R. Nowak, H Smithline … (1994)

Shock index (SI) (heart rate/systolic blood pressure; normal range, 0.5 to 0.7) and conventional vital signs were compared to identify acute critical illness in the emergency department. Quasi-prospective study. Two hundred seventy-five consecutive adults who presented for urgent medical care. Patients had vital signs, SI, and triage priority recorded on arrival in the ED and then their final disposition. Two groups were identified retrospectively by the SI; group 1 (41) had an SI of more than 0.9, and group 2 (234) had an SI of less than 0.9 on arrival in the ED. Although both groups had apparently stable vital signs on arrival, group 1 had a significantly higher proportion of patients who were triaged to a priority requiring immediate treatment (23 versus 45; P < .01) and required admission to the hospital (35 versus 105; P < .01) and continued therapy in an ICU (10 versus 13; P < .01). With apparently stable vital signs, an abnormal elevation of the SI to more than 0.9 was associated with an illness that was treated immediately, admission to the hospital, and intensive therapy on admission. The SI may be useful to evaluate acute critical illness in the ED.

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Admission base deficit predicts transfusion requirements and risk of complications.

K Kaups, J. Davis, S Nicol … (1996)

Trauma center resource management could be facilitated by a readily available indicator of resource consumption. This marker should identify patients more likely to require transfusion and intensive care services and to develop complications. Base deficit (BD) has been shown to be a valuable indicator of shock, abdominal injury, fluid requirements, efficacy of resuscitation, and to be predictive of mortality after trauma. This study was performed to determine whether BD could be used to identify which patients were likely to require blood transfusion in the first 24 hours of hospitalization, and to develop shock-related complications and increased intensive care unit (ICU) and hospital stays. A retrospective review of 2,954 patients admitted to the Valley Medical Center Level I trauma service from July 1990 through August 1995 was done using the trauma registry and blood bank data bases. Medical record review was done to supplement missing data. Transfusion requirements increased as the BD category became more severe (p -6 (p < 0.001, chi 2). Both ICU and hospital length of stay increased with worsening BD (p < 0.015 and p < 0.05, respectively). The frequency of adult respiratory distress syndrome (ARDS) (p < 0.01), renal failure (p = 0.015), coagulopathy (p < 0.001), and multiorgan system failure (MOF) (p = 0.002) all increased with increasingly severe BD. Discriminate analysis using Injury Severity Score (ISS) and BD category demonstrated predictive accuracy of 81%, 77%, and 77% for coagulopathy, ARDS, and MOF, respectively. Mortality also increased with worsening BD. When stratified by BD category, there was no difference between observed and predicted survival. Admission BD identifies patients likely to require early transfusion and increased ICU and hospital stays, and be at increased risk for shock-related complications. Patients with BD < or = -6 should undergo type and cross-match rather than type and screen. The use of ISS and BD category probability curves may identify candidates for early invasive monitoring.

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Author and article information

Journal

Journal ID (nlm-ta): Crit Care

Journal ID (iso-abbrev): Crit Care

Title: Critical Care

Publisher: BioMed Central

ISSN (Print): 1364-8535

ISSN (Electronic): 1466-609X

Publication date (Print): 2013

Publication date (Electronic): 6 March 2013

Volume: 17

Issue: 2

Page: R42

Affiliations

[1 ]Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center (CMMC), University of Witten/Herdecke, Ostmerheimerstr. 200, D-51109 Cologne, Germany

[2 ]Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimerstr. 200, D-51109 Cologne, Germany

[3 ]Academy for Trauma Surgery, Luisenstr. 58/59, D-10117 Berlin, Germany

[4 ]Working Group on Polytrauma of the German Society for Trauma Surgery (DGU), Luisenstr. 58/59, D-10117 Berlin, Germany

Article

Publisher ID: cc12555

DOI: 10.1186/cc12555

PMC ID: 3672480

PubMed ID: 23497602

SO-VID: 4fa214f9-fc75-4124-932d-243b083013e9

License:

This is an open access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

History

Date received : 4 September 2012

Date revision received : 7 December 2012

Date accepted : 11 January 2013

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