Original scientific article
Hemodynamic Patterns of Blunt and Penetrating Injuries

https://doi.org/10.1016/j.jamcollsurg.2006.08.004Get rights and content

Background

The aims of this prospective observational study were to describe early hemodynamic patterns of blunt and penetrating truncal injury and to evaluate outcomes prediction using noninvasive hemodynamic monitoring with a mathematical model tested against actual in-hospital outcomes. The hypothesis was that traumatic shock is a circulatory disorder that can be monitored by noninvasive hemodynamic parameters that reflect cardiac, pulmonary, and tissue perfusion functions.

Study design

The cardiac index (CI), heart rate (HR), mean arterial pressure (MAP), pulse oximetry (SapO2), transcutaneous oxygen tension indexed to FiO2 (PtcO2/FiO2), and carbon dioxide (PtcCO2) tensions were monitored beginning shortly after emergency department admission in 657 emergency patients with severe blunt and penetrating chest, abdominal, and extremity trauma. Of these, 113 patients had associated head injury, and these patients also were analyzed separately. A search and display mathematical model, with a decision support program, was based on continuous online, real-time, noninvasive hemodynamic monitoring.

Results

There were similar patterns in the blunt and penetrating injuries; the cardiac index, mean arterial pressure, pulse oximetry, transcutaneous oxygen tension indexed to FiO2, and survival probability values of the survivors were significantly higher (p < 0.01) than the corresponding values of those who died, although heart rate and carbon dioxide tension were higher in the nonsurvivors during the first 24 hours after their emergency department admission. These patterns occurred more rapidly in patients with penetrating injuries. After initial resuscitation in the emergency department, results were correlated with actual outcomes at hospital discharge and found to be 88% correct.

Conclusions

Early noninvasive hemodynamic monitoring with a computerized information system provided a feasible pattern recognition program for outcomes prediction and therapeutic decision support.

Section snippets

Clinical series

We studied 657 consecutive noninvasively monitored blunt and penetrating trauma patients. Of these, 221 patients had chest injuries, 266 had abdominal trauma, 175 had both chest and abdominal trauma, 57 had extremity injuries, and 113 had head injuries associated with their truncal trauma. Patients with severe head injury and those with brain death were evaluated separately because they had different hemodynamic patterns.22, 23 In addition, hemodynamic patterns of this series were calculated

Continuous noninvasive hemodynamic patterns from the time of ED admission

Table 2 summarizes the mean hemodynamic values ± SD for all trauma survivors compared with all nonsurvivors. Hemodynamic values included CI, HR, MAP, SapO2, PtcO2/FiO2, and the calculated SP. The CI, MAP, SapO2, PtcO2/FiO2, and SP values of the survivors were significantly higher than the corresponding values of those who died, although the HR and PtcCO2 were higher in the nonsurvivors during the first 24 hours after ED admission. Figure 2 illustrates the time course of survivors’ and

Discussion

The proposed mathematical representation of circulatory status defines the patient’s clinical-circulatory state by specific diagnostic categories; clinical covariates; and the patterns of hemodynamic variables, their first and second derivatives, and their integrals. Simply stated, the program picks out the patterns of patients in the database who have the closest clinical and hemodynamic patterns to the newly admitted study patient. These are statistically referred to as “nearest neighbors”

References (32)

  • O. Boyd et al.

    Enhancement of perioperative tissue perfusion as a therapeutic strategy for major surgery

    New Horiz

    (1996)
  • J.W. Kern et al.

    Meta-analysis of hemodynamic optimization in high-risk patients

    Crit Care Med

    (2002)
  • O. Boyd et al.

    The oxygen trail: the goal

    Brit Med Bull

    (1999)
  • O. Boyd et al.

    Preoperative increase of oxygen delivery reduces mortality in high risk surgical patients

    JAMA

    (1993)
  • J. Wilson et al.

    Reducing the risk of major elective surgery: randomized control trial of preoperative optimization of oxygen delivery

    Brit Med J

    (1999)
  • A.F. Conners et al.

    The effectiveness of right heart catheterizaion in the initial care of critically ill patients

    JAMA

    (1996)
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    • Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study

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      We therefore used regression models that accounted for the correlation of patient characteristics and outcome within hospitals using a mixed-effects logistic-regression model. We excluded patients with blunt injuries as it has been suggested that the cardiovascular response in patients with blunt trauma is different from those with penetrating trauma, and because we wanted to conduct a study on penetrating trauma exclusively, as all previous studies of this type had been conducted on mixed trauma.14,15,20,26 Patients suffering from concomitant brain injury (AIS ≥ 3) were excluded as data suggest that this might also influence the cardiovascular response.27

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    Competing Interests Declared: None.

    Supported in part by DOD BAA99-1, Award Number DAMD 17-01-2-0070 by the US Army Medical Research Acquisition Activity, Fort Detrick, MD. The content of the information does not necessarily reflect the position or the policy of the US government, and no official endorsement should be inferred.

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