failure after multiple trauma: An analysis of 31154 patients from the Trauma Register DGU Overall inpatient mortality: 16.2% Mean age 48y 96% blunt Looked at predictors of MOF using multivariate analysis using stepwise logistic regression. (MOF as the dependent variable). Looked at demographics, injury patterns, transfusion requirments. SBP<90: 0.408 (1.504) BD 3-6: 0.331 (1.392) BD 6-15: 0.448 (1.565) BD >15: 0.931 (2.536) as GCS, transfused pRBCs and base deficit”. Paffrath T et al 2014 How to define severely injured patients? An injury severity score (ISS) based approach alone is not sufficient. Trauma Register DGU 1993-2011 Primary Admissions, 48 hour hospital stay, ISS>15 included. N = 45350 >90% blunt Examined various physiological factor that predict mortality with a view to improve definition of the “severely injured patient” Used five arbitrary defined physiological risk factors: Gender High age >70years Acidosis BD >6 Unconsciousness GCS 3-8 Hypotension SBP<90 Coagulopathy INR >1.4 or PTT ≥40s Risk factors not directly compared but: BD >6 increased mortality from 14.3% to 40.6% SBP <90mmHg increased mortality from 13.9% to 37.4% “Our suggested physiological risk factors have been shown to be precise predictors for mortality and are already available within the first hour” Mutschler M et al 2014 Assessment of hypovolaemic at the scene: is the PHTLS classification of hypovolaemic Trauma Register DGU 2002-11. >16 y Primary admission to a Trauma Register DGU affiliated hospital N = 46689 26.5% matched all 3. Selected values: HR <100: Mean SBP 125 HR >140: Mean SBP 111 “Based on a large cohort of severely injured patients…this study demonstrates that the PHTLS classification of hypovolaemic shock has substantial deficits in adequately risk-stratifying trauma patients.”
ROC curve for hospital admission BD vs mortality: AUROC 0.701 Using cut off of 6mmol/L: Sensitivity 48.4% Specificity 81.3% Comparing univariate significance for mortality prediction: Regression coefficients: BD 0.1368 GCS -0.2544 HR 0.0113 SBP -0.0218 Mutschler M et al 2014 The impact of severe traumatic injury on a novel base deficit based classification of hypovolaemic shock Trauma Register DGU 2002-11 >16 years Primary admission Complete dataset Severe TBI: AIS head ≥3 N=10201 Aim of study was to test the applicability of the BD classification in patients with severe TBI. Stratified into four BD groups of increasing shock – similar methodology to 2013 paper. Looked at vital signs, laboratory and clinical outcomes. signs: Mean HR 1 – 84 2 – 89 3 – 95 4 – 97 Mean SBP 1 – 132 2 – 124 3 – 113 4 – 96 Mortality: 1 – 16% 2 – 22% 3 – 36% 4 – 61% Quick’s value: 1 – 84% 2 – 78% 3 – 68% 4 – 55% “The BD classification of hypovolaemic shock is a useful clinical tool to early risk stratify patients and in need for early blood product transfusions” Mutschler M et al 2013 The shock index revisited – a fast guide to transfusion requirement? A TraumaRegister DGU N = 21853 (93% blunt trauma) Mean ISS >>15 Worsening index group was associated with significant increase in ISS, transfusion requirements and mortality. “In daily clinical practice the SI may be used to assess the presence of hypovolaemic shock if laboratory or POCT technology is not available.” 2011)
retrospective analysis on 21853 patients derived from the TraumaRegister DGU Testing classification of shock using four “strata” of worsening “shock index” as alternative to base deficit classification. Divided into 4 arbitrary strata of shock using SI (33/55/10/5% in each group) Looked at transfusion requirements/clotting (plts and days/MOF/sepsis. Compared SI and BD AUROC for predicting transfusion requirement (requirement for 1U or more blood). The only direct comparison made with BD classification system was to predict requirement for transfusion – AUROC was similar. Mutschler M et al 2013 Renaissance of base deficit for the initial assessment of trauma patients: a base classification for hypovolaemic shock developed on data from 16305 patients derived from the TraumaRegister DGU TraumaRegister DGU (2002 – N = Mean ISS >>15 Divided into four groups of worsening BD and compared vital signs, laboratory parameters, ISS, transfusion requirements and mortality between groups. Compared BD-classification to “ATLS classification” – based on worst vital sign from HR/SBP or GCS (used arbitrary values where values not explicitly stated by ATLS system) When classified by BD: SBP fell as shock group increased, HR increased as shock group increased: 1 (BD <2): SBP 132 HR 86 Group 4 (BD >10): SBP 95 HR 97 BD distinguished more precisely between patients at risk of dying than the current ATLS classification of hypovolaemic shock: BD: Class 1: 7% mortality Class 4: 51% mortality ATLS: Class 1: 2% mortality Class 4: 31% mortality “The new classification discriminates better the need for early blood product transfusion and mortality in severely injured patients than the current ATLS classification of hypovolaemic shock.” Mutschler et al 2013 A critical reappraisal of the ATLS classification of hypovolaemic TraumaRegister DGU (2002 – 2010) N = 36504 9.3% of patient had signs as suggested by ATLS classification. “The ATLS classification of hypovolaemic shock might be academically and didactical appealing as an easy and fast assessment of multiply injured