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The trauma patient in hemorrhagic shock: how is the C-priority addressed between emergency and ICU admission?
Sigune Peiniger1, Thomas Paffrath, Manuel Mutschler
1Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Centre (CMMC), Cologne, Germany.
Insights
Early trauma care inadequately addresses circulation and coagulation in patients with hemorrhagic shock. Most patients still exhibit shock and coagulopathy upon ICU admission, indicating critical care gaps.
Area of Science:
- Trauma and Emergency Medicine
- Hemorrhagic Shock Management
- Coagulation Disorders in Trauma
Background:
- Trauma is a leading cause of death in young individuals, with early mortality often stemming from secondary complications like shock and hemorrhage.
- Effective management of airway, breathing, and circulation (ABC priorities) is critical in early trauma care.
- Hemorrhagic shock and associated coagulopathy require prompt and effective interventions.
Purpose of the Study:
- To evaluate the adherence to C-priority (Circulation with hemorrhage control) and coagulation management in early trauma care.
- To assess the control of shock and coagulopathy prior to Intensive Care Unit (ICU) admission in patients with moderate to severe hemorrhagic shock.
Main Methods:
- Retrospective analysis of 517 datasets from the German TraumaRegister (TR-DGU®).
- Inclusion of severely injured patients (ISS ≥ 25) in moderate or severe shock (BE -2 to -6 or BE < -6) with coagulopathy (Quick's value <70%).
- Analysis of clinical and laboratory parameters upon Emergency Room (ER) arrival and ICU admission.
Main Results:
- A significant proportion of patients remained in shock upon ICU admission (63.6% for moderate, 75% for severe shock).
- All patients presented with coagulation dysfunction on ER arrival, with 75% still exhibiting disturbed coagulation at ICU admission.
- Thrombocytopenia increased 5-6 fold between ER and ICU admission, highlighting worsening coagulopathy.
Conclusions:
- The C-priority, including coagulation management, was not sufficiently addressed in the initial resuscitation of severely injured trauma patients.
- There are critical gaps in managing hemorrhagic shock and coagulopathy between ER and ICU admission.
- Improvements in early trauma care protocols focusing on circulation and coagulation are urgently needed.
Background:
Trauma 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.
Methods:
A 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.
Results:
A 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.
Conclusion:
The 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.
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