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Goal-directed resuscitation in the prehospital setting: A propensity-adjusted analysis

Brown, Joshua B. MD; Cohen, Mitchell J. MD; Minei, Joseph P. MD; Maier, Ronald V. MD; West, Michael A. MD; Billiar, Timothy R. MD; Peitzman, Andrew B. MD; Moore, Ernest E. MD; Cuschieri, Joseph MD; Sperry, Jason L. MD, MPH; The Inflammation and the Host Response to Injury Investigators

Journal of Trauma and Acute Care Surgery:
doi: 10.1097/TA.0b013e31828c44fd
AAST 2012 Plenary Papers
Editor's Choice
Abstract

BACKGROUND: The scope of prehospital (PH) interventions has expanded recently—not always with clear benefit. PH crystalloid resuscitation has been challenged, particularly in penetrating trauma. Optimal PH crystalloid resuscitation strategies remain unclear in blunt trauma as does the influence of PH hypotension. The objective was to characterize outcomes for PH crystalloid volume in patients with and without PH hypotension.

METHODS: Data were obtained from a multicenter prospective study of blunt injured adults transported from the scene with ISS > 15. Subjects were divided into HIGH (>500 mL) and LOW (≤500 mL) PH crystalloid groups. Propensity-adjusted regression determined the association of PH crystalloid group with mortality and acute coagulopathy (admission International Normalized Ratio, >1.5) in subjects with and without PH hypotension (systolic blood pressure [SBP], <90 mm Hg) after controlling for confounders.

RESULTS: Of 1,216 subjects, 822 (68%) received HIGH PH crystalloid and 616 (51%) had PH hypotension. Initial base deficit and ISS were similar between HIGH and LOW crystalloid groups in subjects with and without PH hypotension. In subjects without PH hypotension, HIGH crystalloid was associated with an increase in the risk of mortality (hazard ratio, 2.5; 95% confidence interval [95% CI], 1.3–4.9; p < 0.01) and acute coagulopathy (odds ratio [OR], 2.2; 95% CI, 1.01–4.9; p = 0.04) but not in subjects with PH hypotension. HIGH crystalloid was associated with correction of PH hypotension on emergency department (ED) arrival (OR, 2.02; 95% CI, 1.06–3.88; p = 0.03). The mean corrected SBP in the ED was 104 mm Hg. Each 1 mm Hg increase in ED SBP was associated with a 2% increase in survival in subjects with PH hypotension (OR, 1.02; 95% CI, 1.01–1.03; p < 0.01).

CONCLUSION: In severely injured blunt trauma patients, PH crystalloid more than 500 mL was associated with worse outcome in patients without PH hypotension but not with PH hypotension. HIGH crystalloid was associated with corrected PH hypotension. This suggests that PH resuscitation should be goal directed based on the presence or absence of PH hypotension.

LEVEL OF EVIDENCE: Therapeutic study, level III.

Author Information

From the Department of Surgery (J.B.B., T.R.B., A.B.P., J.L.S.), Division of General Surgery and Trauma, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Department of Surgery (M.J.C., M.A.W.), University of California, San Francisco, California; Department of Surgery (J.P.M.), Division of Burn, Trauma, Critical Care, University of Texas Southwestern Medical Center, Dallas, Texas; Division of General Surgery and Trauma, Harborview Medical Center and the Department of Surgery (R.V.M., J.C.), University of Washington, Seattle, Washington; and Department of Surgery (E.E.M.), Denver Health Medical Center and The University of Colorado Health Sciences Center, Denver, Colorado.

Submitted: August 30, 2012, Revised: January 4, 2013, Accepted: January 22, 2013.

This article was presented as an oral presentation at the annual meeting of the American Association for the Surgery of Trauma in Kauai, Hawaii, September 12–15, 2012.

Address for reprints: Jason L. Sperry, MD, MPH, Department of Surgery, Division of General Surgery and Trauma, University of Pittsburgh Medical Center, 200 Lothrop St, Pittsburgh, PA 15213; email: sperryjl@upmc.edu.

© 2013 Lippincott Williams & Wilkins, Inc.