Hemodynamic stability of trauma patients

Medical Negligence

Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters.

Trauma is a global phenomenon. In 2008, 5.1 million people (9% of total deaths) died worldwide as a result of injury. Injuries also account for 17% of the disease burden in adults aged 15–59 years in 2004.

Most deaths are caused by unintentional injuries including blunt trauma such as falls or road accidents. Blunt trauma accounts for an estimated 50% of the mechanism of injury proportion .

The assessment of the hemodynamic (HD) status in blunt trauma patients is vital for early identification and timely management of a potential hemorrhage to keep the time between injury and intervention to a minimum. In order to improve trauma care furthermore, evidence-based practice guidelines are designed and implemented in every hospital. These management schemes are often based on the presence or absence of HD stability, proposed by the American College of Surgeons Advanced Trauma Life Support (ATLS) guidelines .

When the patient is unstable, time is a luxury and immediate surgical intervention in combination with resuscitation is mandatory . When the patient is stable, more time is available for the assessment of the patient’s injuries.

Systolic blood pressure (SBP) and heart rate (HR) have traditionally been used for recognition of the shock state in ATLS and Prehospital Trauma Life Support (PTLS) guidelines. However, the value of these vital signs and their cut-off points have been disputed by some .

Despite the importance of the HD status of blunt trauma patients, several hemodynamic parameters [e.g., HR, respiratory rate (RR), blood pressure (BP), SPB and Revised Trauma Score (RTS)] with different cut-off points are used without general consensus about the best evidence-based practice. A combination of the traditional signs BP and HR, named Shock Index (SI) (calculated by HR/SBP), has been shown to identify beginning hemorrhage, need for massive transfusion and predicting mortality more early and better than the vital signs apart.

As the initial assessment of a trauma patient concerns a multidisciplinary approach by the examining anesthesiologist, trauma surgeon and the emergency physician in the emergency room, it is important for everyone to speak the same language. Different specialities, however, bring different opinions about the best treatment if there is no clear consensus about the interpretation of all parameters. The meaning of HD instability in trauma patient is still very wide with unclear borders and lacks a clear validated definition that states which indicative parameters to use to initially assess the circulatory status.

This study assesses the definitions used for HD stability in a systematic review of the literature combined with a survey of the interpretations of HD instability in blunt trauma patients in the ER amongst Dutch trauma team members in order to establish the level of consensus about HD stability for blunt trauma patients.

Source: US National Library of Medicine National Institutes of Health

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