Southwestern Surgical Congress
Time is the enemy: Mortality in trauma patients with hemorrhage from torso injury occurs long before the “golden hour”

https://doi.org/10.1016/j.amjsurg.2016.08.018Get rights and content

Highlights

  • Risk of death increased with longer prehospital times, most prominent within the first 30 min.

  • Mortality risk was more significant with higher Torso Abbreviated Injury Scale (AIS) scores.

  • Need to develop strategies to increase the window of survival in the prehospital environment.

Abstract

Introduction

The concept of the “Golden Hour” has been a time-honored tenet of prehospital trauma care, despite a paucity of data to substantiate its validity. Non-compressible torso hemorrhage has been demonstrated to be a significant cause of mortality in both military and civilian settings. We sought to characterize the impact of prehospital time and torso injury severity on survival. Furthermore, we hypothesized that time would be a significant determinant of mortality in patients with higher Abbreviated Injury Scale (AIS) grades of torso injury (AIS ≥ 4) and field hypotension (prehospital SBP ≤ 110 mmHg) as these injuries are commonly associated with hemorrhage.

Methods

Data for this analysis was generated from a registry of 2,523,394 injured patients entered into the National Trauma Data Bank Research Data Set from 2012 to 2014. Patients with torso injury were identified utilizing Abbreviated Injury Scale (AIS) for body regions 4 (Thorax) and 5 (Abdomen). Specific inclusion criteria for this study included pre-hospital time, prehospital SBP ≤110 mmHg, torso injury qualified by AIS and mortality. Patients with non-survivable torso injury (AIS = 6), severe head injuries (AIS ≥ 3), no signs of life in the field (SBP = 0), interfacility transfers, or those with any missing data elements were excluded. This classification methodology identified a composite cohort of 42,135 adult patients for analysis.

Results

The overall mortality rate of the study population was 7.9% (3326/42,135); Torso AIS and prehospital time were noted to be strong independent predictors of patient mortality in all population strata of the analysis (P < 0.05). The data demonstrated a profound incremental increase in mortality in the early time course after injury associated with torso AIS ≥4.

Conclusion

In patients with high-grade torso injury, AIS grades ≥4, the degree anatomic disruption is associated with significant hemorrhage. In our study, a precipitous rise in patient mortality was exhibited in this high-grade injury group at prehospital times <30 min. Our data highlight the critical nature of prehospital time in patients with non-compressible torso hemorrhage. However, realizing that evacuation times ≤30 min may not be realistic, particularly in rural or austere environments, future efforts should be directed toward the development of therapies to increase the window of survival in the prehospital environment.

Section snippets

Background

In 1966, the National Academy of Sciences (NAS) published “Accidental Death and Disability: The Neglected Disease of Modern Society” perceiving injury to be one of the most significant public health problems faced by our nation.1 At the same point in history, the surgical community was taking note of significant successes in trauma care on the battlefields of Vietnam such as advanced resuscitation practices and refined aeromedical evacuation capabilities.2 The timely coevolution of these

Methods

This was a retrospective study of 2,523,394 patient records derived from the National Trauma Data Bank Research Datasets (NTDB-RDS) 2012 to 2014. The NTDB is compiled annually from participating trauma centers nationwide and is the largest aggregation of U.S. trauma registry data.

Patients with torso injury were identified utilizing Abbreviated Injury Scale (AIS) for body regions 4 (Thorax) and 5 (Abdomen). Torso injury morphology was ascribed utilizing the six digit pre dot AIS code. Injury

Results

The mean age of our sample population was 37.4 years, median ISS was 14, 67.6% of the patients were male, and 73.3% of patients sustained blunt trauma. Motor vehicle collisions (MVC) accounted for 75.6% of blunt injuries, while firearm related injuries accounted for 55.2% of penetrating trauma.

The overall mortality in this analysis was 7.9% (3326/42,135); 7.4% (2371/32,077) with blunt mechanisms, 3.3% (143/4325) with stab wounds, and 14.2% (812/5733) with firearm injuries. Of the 3, 326

Discussion

The basic tenets of trauma care and trauma systems have highlighted the need for rapid transport of the trauma patient. Improving our ability to temporize or definitively control hemorrhage in a timely fashion before the onset of shock represents a perpetual major challenge in reducing trauma mortality.15

Mortality studies from conflicts in Iraq and Afghanistan by Eastridge et al. found non-compressible torso hemorrhage (NCTH) to account for the majority of potentially survivable deaths. The

Conclusion

In patients with high-grade torso injury, AIS grades ≥4, the degree anatomic disruption is often associated with significant hemorrhage. In our study, a precipitous rise in patient mortality was exhibited in this high-grade injury group at prehospital times <30 min. Our data highlight that the critical nature of prehospital time in patients with non-compressible torso hemorrhage. However, realizing that evacuation times <30 min may not be realistic, particularly in rural or austere

Funding source

None.

Financial disclosure

The authors have no relevant financial relationships or conflicts of interest in relation to the presentation or publication of this work.

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