Francis X Guyette1, Eric N Meier, Craig Newgard, Barbara McKnight, Mohamud Daya, Eileen M Bulger, Judy L Powell, Karen J Brasel, Jeffery D Kerby, Debra Egan, Michael Sise, Raul Coimbra, Timothy C Fabian, David B Hoyt. 1. From the Department of Emergency Medicine (F.X.G.), University of Pittsburgh, Pittsburgh, Pennsylvania; Departments of Surgery (E.M.B.) and Biostatistics (E.N.M.), and Clinical Trials Center (J.L.P.), University of Washington, Seattle; Department of Surgery (K.J.B.), Medical College of Wisconsin, Milwaukee; Department of Emergency Medicine (M.D.), Emergency Medicine, Surgery and Public Health and Preventive Medicine (C.N.), Oregon Health and Science University, Portland, Oregon; Department of Surgery (J.D.K.), University of Alabama, Birmingham; Department of Surgery (M.S., R.C.), University of California, San Diego, California; Department of Surgery (T.C.F.), University of Tennessee, Memphis, Tennessee; National Heart, Lung, and Blood Institute (D.E.), National Institutes of Health, Bethesda, Maryland; and American College of Surgeons (D.B.H.), Chicago, Illinois.
Abstract
BACKGROUND: Reliance on prehospital trauma triage guidelines misses patients with serious injury. Lactate is a biomarker capable of identifying high-risk trauma patients. Our objective was to compare prehospital point-of-care lactate (P-LAC) with systolic blood pressure (SBP) for predicting the need for resuscitative care (RC) in trauma patients transported by ground emergency medical services. METHODS: This is a prospective observational study at nine sites within the Resuscitation Outcomes Consortium conducted from March 2011 to August 2012. Lactate was measured on patients with a prehospital SBP of 100 mm Hg or less who were transported by emergency medical services to a Level I or II trauma center. Patients were followed up for the need for RC, defined as any of the following within 6 hours of emergency department arrival: blood transfusion of 5 U or greater; intervention for hemorrhage including thoracotomy, laparotomy, pelvic fixation, or interventional radiology embolization; or death. RESULTS: A total of 387 patients had a lactate value and presented with SBP between 71 mm Hg and 100 mm Hg, and 70 (18%) required RC. With the use of a P-LAC decision rule (≥2.5 mmol/L) that yielded the same specificity as that of SBP of 90 mm Hg or less (48%), the observed sensitivities for RC were 93% (95% confidence interval [CI], 84-98%) for P-LAC of 2.5 mmol/L or greater and 67% (95% CI, 55-78%) for SBP of 90 mm Hg or less (McNemar's test, p < 0.001). P-LAC has an estimated area under the curve of 0.78 (95% CI, 0.73-0.83), which is statistically superior to that of SBP (0.59; 95% CI, 0.53-0.66) and shock index (heart rate / SBP) (0.66; 95% CI, 0.60-0.74). CONCLUSION: P-LAC obtained at the scene is associated with the need for RC. P-LAC is superior to other early surrogates for hypoperfusion (SBP and shock index) in predicting the need for RC in trauma patients with 70 mm Hg < SBP ≤ 100 mm Hg. LEVEL OF EVIDENCE: Prognostic study, level II.
BACKGROUND: Reliance on prehospital trauma triage guidelines misses patients with serious injury. Lactate is a biomarker capable of identifying high-risk traumapatients. Our objective was to compare prehospital point-of-care lactate (P-LAC) with systolic blood pressure (SBP) for predicting the need for resuscitative care (RC) in traumapatients transported by ground emergency medical services. METHODS: This is a prospective observational study at nine sites within the Resuscitation Outcomes Consortium conducted from March 2011 to August 2012. Lactate was measured on patients with a prehospital SBP of 100 mm Hg or less who were transported by emergency medical services to a Level I or II trauma center. Patients were followed up for the need for RC, defined as any of the following within 6 hours of emergency department arrival: blood transfusion of 5 U or greater; intervention for hemorrhage including thoracotomy, laparotomy, pelvic fixation, or interventional radiology embolization; or death. RESULTS: A total of 387 patients had a lactate value and presented with SBP between 71 mm Hg and 100 mm Hg, and 70 (18%) required RC. With the use of a P-LAC decision rule (≥2.5 mmol/L) that yielded the same specificity as that of SBP of 90 mm Hg or less (48%), the observed sensitivities for RC were 93% (95% confidence interval [CI], 84-98%) for P-LAC of 2.5 mmol/L or greater and 67% (95% CI, 55-78%) for SBP of 90 mm Hg or less (McNemar's test, p < 0.001). P-LAC has an estimated area under the curve of 0.78 (95% CI, 0.73-0.83), which is statistically superior to that of SBP (0.59; 95% CI, 0.53-0.66) and shock index (heart rate / SBP) (0.66; 95% CI, 0.60-0.74). CONCLUSION: P-LAC obtained at the scene is associated with the need for RC. P-LAC is superior to other early surrogates for hypoperfusion (SBP and shock index) in predicting the need for RC in traumapatients with 70 mm Hg < SBP ≤ 100 mm Hg. LEVEL OF EVIDENCE: Prognostic study, level II.
Authors: Lorilee S L Arakaki; Eileen M Bulger; Wayne A Ciesielski; David J Carlbom; Dana M Fisk; Kellie L Sheehan; Karin M Asplund; Kenneth A Schenkman Journal: Shock Date: 2017-05 Impact factor: 3.454
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Authors: Alexander E St John; Andrew M McCoy; Allison G Moyes; Francis X Guyette; Eileen M Bulger; Michael R Sayre Journal: West J Emerg Med Date: 2018-02-12
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