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Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®.

Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Fabian T, Paffrath T, Bouillon B, Maegele M, TraumaRegister D - Crit Care (2013)

Bottom Line: Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality.With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (±11.9) in class I to 36.7 (±17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%.The number of blood units transfused increased from 1.5 (±5.9) in class I patients to 20.3 (±27.3) in class IV patients.

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ABSTRACT

Introduction: The recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival.

Methods: Between 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU® database, classified into four strata of worsening BD [class I (BD≤2 mmol/l), class II (BD>2.0 to 6.0 mmol/l), class III (BD>6.0 to 10 mmol/l) and class IV (BD>10 mmol/l)] and assessed for demographics, injury characteristics, transfusion requirements and fluid resuscitation. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock.

Results: With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (±11.9) in class I to 36.7 (±17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes. The number of blood units transfused increased from 1.5 (±5.9) in class I patients to 20.3 (±27.3) in class IV patients. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p<0.001).

Conclusions: BD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

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Transfusion requirements and mortality in patients classified according to either admission base deficit (BD) or the ATLS classification of hypovolemic shock. (a) Percentage of patients with at least one blood product. (b) Percentage of patients with massive transfusion, defined as at least 10 blood units until intensive care unit (ICU) admission. (c) Mortality (percentage). ***P < 0.001; n = 16,305. ATLS, Advanced Trauma Life Support; n.s., not significant.
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Figure 2: Transfusion requirements and mortality in patients classified according to either admission base deficit (BD) or the ATLS classification of hypovolemic shock. (a) Percentage of patients with at least one blood product. (b) Percentage of patients with massive transfusion, defined as at least 10 blood units until intensive care unit (ICU) admission. (c) Mortality (percentage). ***P < 0.001; n = 16,305. ATLS, Advanced Trauma Life Support; n.s., not significant.

Mentions: When the two approaches to classify the extent of hypovolemic shock upon ED admission were compared, the new BD-based classification displayed a higher accuracy for discriminating the need for early blood products than the current ATLS classification of hypovolemic shock (Figure 2). Through groups II to IV, the percentage of patients who had received at least 1 blood unit during early ED resuscitation was significantly higher compared with patients classified according to ATLS (Figure 2a). A similar pattern was noted for the frequency of MTs (Figure 2b). If patients were classified by BD, MT rates increased from 5% in class I (BD of not more than 2 mmol/L) to 52% in class IV (BD of more than 10 mmol/L). In contrast, when patients were classified according to ATLS, 4% of group I and only 25% of group IV patients received MT until ICU admission (Figure 2b). Furthermore, BD distinguished more precisely between patients at risk of dying than the current ATLS classification of hypovolemic shock (Figure 2c). If classified by BD, 7.4% of class I and 51.5% of class IV patients, on average, died during in-hospital stay. In contrast, patients classified according to ATLS showed mortality rates of 2% in class I and 31% in class IV patients.


Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®.

Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Fabian T, Paffrath T, Bouillon B, Maegele M, TraumaRegister D - Crit Care (2013)

Transfusion requirements and mortality in patients classified according to either admission base deficit (BD) or the ATLS classification of hypovolemic shock. (a) Percentage of patients with at least one blood product. (b) Percentage of patients with massive transfusion, defined as at least 10 blood units until intensive care unit (ICU) admission. (c) Mortality (percentage). ***P < 0.001; n = 16,305. ATLS, Advanced Trauma Life Support; n.s., not significant.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3672480&req=5

Figure 2: Transfusion requirements and mortality in patients classified according to either admission base deficit (BD) or the ATLS classification of hypovolemic shock. (a) Percentage of patients with at least one blood product. (b) Percentage of patients with massive transfusion, defined as at least 10 blood units until intensive care unit (ICU) admission. (c) Mortality (percentage). ***P < 0.001; n = 16,305. ATLS, Advanced Trauma Life Support; n.s., not significant.
Mentions: When the two approaches to classify the extent of hypovolemic shock upon ED admission were compared, the new BD-based classification displayed a higher accuracy for discriminating the need for early blood products than the current ATLS classification of hypovolemic shock (Figure 2). Through groups II to IV, the percentage of patients who had received at least 1 blood unit during early ED resuscitation was significantly higher compared with patients classified according to ATLS (Figure 2a). A similar pattern was noted for the frequency of MTs (Figure 2b). If patients were classified by BD, MT rates increased from 5% in class I (BD of not more than 2 mmol/L) to 52% in class IV (BD of more than 10 mmol/L). In contrast, when patients were classified according to ATLS, 4% of group I and only 25% of group IV patients received MT until ICU admission (Figure 2b). Furthermore, BD distinguished more precisely between patients at risk of dying than the current ATLS classification of hypovolemic shock (Figure 2c). If classified by BD, 7.4% of class I and 51.5% of class IV patients, on average, died during in-hospital stay. In contrast, patients classified according to ATLS showed mortality rates of 2% in class I and 31% in class IV patients.

Bottom Line: Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality.With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (±11.9) in class I to 36.7 (±17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%.The number of blood units transfused increased from 1.5 (±5.9) in class I patients to 20.3 (±27.3) in class IV patients.

View Article: PubMed Central - HTML - PubMed

ABSTRACT

Introduction: The recognition and management of hypovolemic shock still remain an important task during initial trauma assessment. Recently, we have questioned the validity of the Advanced Trauma Life Support (ATLS) classification of hypovolemic shock by demonstrating that the suggested combination of heart rate, systolic blood pressure and Glasgow Coma Scale displays substantial deficits in reflecting clinical reality. The aim of this study was to introduce and validate a new classification of hypovolemic shock based upon base deficit (BD) at emergency department (ED) arrival.

Methods: Between 2002 and 2010, 16,305 patients were retrieved from the TraumaRegister DGU® database, classified into four strata of worsening BD [class I (BD≤2 mmol/l), class II (BD>2.0 to 6.0 mmol/l), class III (BD>6.0 to 10 mmol/l) and class IV (BD>10 mmol/l)] and assessed for demographics, injury characteristics, transfusion requirements and fluid resuscitation. This new BD-based classification was validated to the current ATLS classification of hypovolemic shock.

Results: With worsening of BD, injury severity score (ISS) increased in a step-wise pattern from 19.1 (±11.9) in class I to 36.7 (±17.6) in class IV, while mortality increased in parallel from 7.4% to 51.5%. Decreasing hemoglobin and prothrombin ratios as well as the amount of transfusions and fluid resuscitation paralleled the increasing frequency of hypovolemic shock within the four classes. The number of blood units transfused increased from 1.5 (±5.9) in class I patients to 20.3 (±27.3) in class IV patients. Massive transfusion rates increased from 5% in class I to 52% in class IV. The new introduced BD-based classification of hypovolemic shock discriminated transfusion requirements, massive transfusion and mortality rates significantly better compared to the conventional ATLS classification of hypovolemic shock (p<0.001).

Conclusions: BD may be superior to the current ATLS classification of hypovolemic shock in identifying the presence of hypovolemic shock and in risk stratifying patients in need of early blood product transfusion.

Show MeSH
Related in: MedlinePlus