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A comparison of prehospital lactate and systolic blood pressure for predicting the need for resuscitative care in trauma transported by ground

Guyette, Francis X. MD, MPH; Meier, Eric N. MS; Newgard, Craig MD, MPH; McKnight, Barbara PhD; Daya, Mohamud MD, MS; Bulger, Eileen M. MD; Powell, Judy L.; Brasel, Karen J. MD; Kerby, Jeffery D. MD; Egan, Debra MS, MPH; Sise, Michael MD; Coimbra, Raul MD, PhD; Fabian, Timothy C. MD; Hoyt, David B. MDfor the ROC Investigators

Journal of Trauma and Acute Care Surgery: March 2015 - Volume 78 - Issue 3 - p 600–606
doi: 10.1097/TA.0000000000000549
Original Articles

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.

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.

Submitted: August 29, 2014, Revised: November 12, 2014, Accepted: November 24, 2014.

The content of this article is solely the responsibility of the authors and does not necessarily represent the official views of the National Heart, Lung and Blood Institute or the National Institutes of Health.

Address for reprints: Francis X. Guyette MD, MS, MPH, University of Pittsburgh School of Medicine, 3600 Forbes Ave, Suite 400A, Pittsburgh, PA 15261; email:

© 2015 Lippincott Williams & Wilkins, Inc.