J. O. Hwabejire1, C. E. Nembhard1, T. A. Oyetunji3, W. R. Greene2, M. Williams1, E. E. Cornwell III1, S. M. Siram1 1Howard University College Of Medicine,Surgery,Washington, DC, USA 2Emory University Hospital,Surgery,Atlanta, GEORGIA, USA 3Northwestern University Feinberg School Of Medicine,Surgery,Chicago, ILLINOIS, USA
Introduction: The combination of acidosis, coagulopathy and hypothermia in a trauma patient is a harbinger of death. Resuscitation and control of bleeding are two key tenets of trauma care designed to halt this vicious cycle. We examine clinical variables that contribute to mortality in blunt traumatic shock patients presenting with this triad.
Methods: The Inflammation and the Host Response to Injury database was analyzed. Patients who, on presentation to the emergency room (ER), had the triple combination of severe hyperlactatemia (serum lactate >4 mg/dL), coagulopathy (INR >1.5) and hypothermia (body temperature ≤ 36 °C) were included. Univariate analyses were used to compare survivors and non-survivors while multivariable analysis was used to determine predictors of mortality.
Results: A total of 172 patients met all three criteria. The mean age of the cohort was 39 years, 70% were male, and 90% were White. Their overall mortality was 30.8%. There was no difference in pre-injury comorbidities, body mass index, Injury Severity Score, multiple organ dysfunction score, ER systolic BP, ER heart rate, ER body temperature, crystalloid volume administered within 12 hours, WBC count, and platelet count between survivors and non-survivors. Compared to survivors, non-survivors were older (46±22 vs. 37±18 years, p=0.005), more coagulopathic (ER INR 2.6±1.5 vs. 2.1±1.2, p=0.021), had higher ER lactate (7.8±3.2 vs. 6.5±2.2 mg/dL, p=0.002), higher APACHE II score (37±6 vs. 31±5, p<0.001), larger volume of transfused blood within 12 hours (6848±5574 vs. 3232±2779 mL, p<0.001) and were more likely to have a cardiac arrest (50.9% vs. 2.5%, p<0.001) or myocardial infarction (7.5% vs. 0.8%, p=0.032). Non-survivors were more likely to undergo angiographic embolization (37.7% vs. 14.3%, p=0.001) or an operative thoracic procedure (thoracotomy, sternotomy, or VATS, 26.4% vs. 7.6%, p=0.01), although they had similar laparotomy rates (52.8 % vs. 49.6%, p=0.694). Independent predictors of mortality in this cohort include APACHE II score (OR: 1.15, CI: 1.04-1.28, p=0.005), cardiac arrest (OR: 21.21, CI: 5.06-88.87, p<0.001), and angioembolization (OR: 4.31, CI: 1.45-12.83, p=0.009). For patients who underwent angiographic embolization, mortality was 54.1%, and for those who suffered a cardiac arrest, mortality was 90%.
Conclusion: In blunt trauma patients with hemorrhagic shock who met criteria for the lethal triad on presentation to the ER, angiographic embolization, APACHE II score, and cardiac arrest independently predict mortality. The exact role of angiographic embolization, which should be a life-saving procedure, deserves further study.