Reliable variables in the exsanguinated patient which indicate damage control and predict outcome

doi:10.1016/S0002-9610(01)00809-1

The American Journal of Surgery

Volume 182, Issue 6, December 2001, Pages 743-751

Presented at the 53rd Annual Meeting of the Southwestern Surgical Congress, Cancun, Mexico, April 29–May 2, 2001.

https://doi.org/10.1016/S0002-9610(01)00809-1 Get rights and content

Abstract

Background: Exsanguination as a syndrome is ill defined. The objectives of this study were to investigate the relationship between survival and patient characteristics—vital signs, factors relating to injury and treatment; determine if threshold levels of pH, temperature, and highest estimated blood loss can predict survival; and identify predictive factors for survival and to initiate damage control.

Material and methods: A retrospective 6-year study was conducted, 1993 to 1998. In all, 548 patients met one or more criteria: (1) estimated blood loss ≥2,000 mL during trauma operation; (2) required ≥1,500 mL packed red blood cells (PRBC) during resuscitation; or (3) diagnosis of exsanguination. Analysis was made in two phases: (1) death versus survival in emergency department (ED); (2) death versus survival in operating room (OR). Statistical methods were Fisher’s exact test, Student’s t test, and logistic regression.

Results: For 548 patients, mean Revised Trauma Score 4.38, mean Injury Severity Score 32. Penetrating injuries 82% versus blunt injuries 18%. Vital statistics in emergency department: mean blood pressure 63 mm Hg, heart rate 78 beats per minute. Mean OR pH 7.15 and temperature 34.3°C. Mortality was 379 of 548 (69%). Predictive factors for mortality (means): pH ≤7.2, temperature <34°C, OR blood replacement >4,000 mL, total OR fluid replacement >10,000 mL, estimated blood loss >15 mL/minute (P <0.001). Analysis 1: death versus survival in ED, logistic regression. Independent risk factors for survival: penetrating trauma, spontaneous ventilation, and no ED thoracotomy (P <0.001; probability of survival 0.99613). Analysis 2: death versus survival in OR, logistic regression. Independent risk factors for survival: ISS ≤20, spontaneous ventilation in ED, OR PRBC replacement <4,000 mL, no ED or OR thoracotomy, absence of abdominal vascular injury (P <0.001, max R² 0.55, concordance 89%).

Conclusions: Survival rates can be predicted in exsanguinating patients. “Damage control” should be performed using these criteria. Knowledge of these patterns can be valuable in treatment selection.

Section snippets

Methods

Over a 6-year period (January 1993 to December 1998) all patients admitted to the Los Angeles County-University of Southern California (LAC+USC) Medical Center, that met one or more of the following criteria: estimated blood loss of ≥2,000 mL during trauma operation, required ≥1,500 mL of packed red blood cells (PRBC) during resuscitation, and met the trauma registry diagnosis of exsanguination were retrospectively reviewed. Data collected included demographics, age, mechanism of injury,

Results

Over the span of this 72-month study (January 1993 to December 1998) there were 548 patients meeting entry criteria for the study. Their mean age was 30 ± 13 years (range 2 to 94). There were 484 males (88%) and 64 females (12%); 449 patients (82%) were admitted with penetrating injuries: 352 (78%) gunshot wounds, 88 (20%) stabwound (SW), and 9 (2%) shotgun wound (STW). Ninety-nine (18%) were admitted with blunt trauma: 52 (53%) motor vehicle accidents, 36 (36%) pedestrians struck by vehicles,

Comments

Although trauma surgeons recognize exsanguination as a syndrome [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12], [13], [14], its multifactorial effects on the cell, microcirculation, inflammatory cascades, and temperature dependent enzymatic functions of both platelets and the coagulation pathways remain to be defined [1], [2], [4], [7], [11]. Shock causing cardiopulmonary arrest or massive injuries responsible for blood losses exceeding more than 40% to 50% with ongoing

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^∗: Asensio JA, Britt LD, Borzotia A et al. Multiinstitutional experience with the management of superior mesenteric artery injuries. Journal of the American College of Surgeons Vol 193, No 4, p 354–366 October 2001.

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Reliable variables in the exsanguinated patient which indicate damage control and predict outcome

Abstract

Section snippets

Methods

Results

Comments

Am J Surg

Am J Surg

Am J Surg

Exsanguination from penetrating injuries

Trauma Q

Exsanguination

Emerg Care Q

Major abdominal vascular trauma—a unified approach

J Trauma

Management of the major coagulopathy with onset during laparotomy

Ann Surg