Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members
Definition of hemodynamic stability in blunt trauma patients: a systematic review and assessment amongst Dutch trauma team members
S. A. I. Loggers 0 1
T. W. A. Koedam 0 1
G. F. Giannakopoulos 0 1
E. Vandewalle 0 1
M. Erwteman 0 1
W. P. Zuidema 0 1
0 Department of Anesthesiology, VU University Medical Center , Amsterdam , The Netherlands
1 Department of Emergency Medicine, VU University Medical Center , Amsterdam , The Netherlands
Introduction Trauma is a great contributor to mortality worldwide. One of the challenges in trauma care is early identification and management of bleeding. The circulatory status of blunt trauma patients in the emergency room is evaluated using hemodynamic (HD) parameters. However, there is no consensus on which parameters to use. In this study, we evaluate the used terms and definitions in the literature for HD stability and compare those to the opinion of Dutch trauma team members. Method A systematic review was performed to collect the definitions used for HD stability. Studies describing the assessment and/or treatment of blunt trauma patients in the emergency room were included. In addition, an online survey was conducted amongst Dutch trauma team members. Results Out of a total of 222, 67 articles were found to be eligible for inclusion. HD stability was defined in 70% of these articles. The most used parameters were systolic blood pressure and heart rate. Besides the variety of parameters, a broad range of corresponding cut-off points is noted. Despite some common ground, high inter- and intra-variability is seen for the physicians that are part of the Dutch trauma teams.
Hemodynamic instability; Hypovolemic shock; Primary survey; Blunt trauma; Triage; Trauma team
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Trauma is a global phenomenon. In 2008, 5.1 million
people (9% of total deaths) died worldwide as a result of
injury. Injuries also account for 17% of the disease burden
in adults aged 15–59 years in 2004 [1, 2].
Most deaths are caused by unintentional injuries
including blunt trauma such as falls or road accidents. Blunt
trauma accounts for an estimated 50% of the mechanism of
injury proportion [1].
The assessment of the hemodynamic (HD) status in
blunt trauma patients is vital for early identification and
timely management of a potential hemorrhage to keep the
time between injury and intervention to a minimum. In
order to improve trauma care furthermore, evidence-based
practice guidelines are designed and implemented in every
hospital. These management schemes are often based on
the presence or absence of HD stability, proposed by the
American College of Surgeons Advanced Trauma Life
Support (ATLS) guidelines [3].
When the patient is unstable, time is a luxury and
immediate surgical intervention in combination with
resuscitation is mandatory [4, 5]. When the patient is stable, more
time is available for the assessment of the patient’s injuries.
Systolic blood pressure (SBP) and heart rate (HR) have
traditionally been used for recognition of the shock state in
ATLS and Prehospital Trauma Life Support (PTLS)
guidelines [3, 6]. However, the value of these vital signs and
their cut-off points have been disputed by some [7–12].
Despite the importance of the HD status of blunt trauma
patients, several hemodynamic parameters [e.g., HR,
respiratory rate (RR), blood pressure (BP), SPB and Revised
Trauma Score (RTS)] with different cut-off points are used
without general consensus about the best evidence-based
practice. A combination of the traditional signs BP and HR,
named Shock Index (SI) (calculated by HR/SBP), has been
shown to identify beginning hemorrhage [13], need for
massive transfusion [14] and predicting mortality [11, 15]
more early and better than the vital signs apart.
As the initial assessment of a trauma patient concerns
a multidisciplinary approach by the examining
anesthesiologist, trauma surgeon and the emergency physician in the
emergency room, it is important for everyone to speak the
same language. Different specialities, however, bring
different opinions about the best treatment if there is no clear
consensus about the interpretation of all parameters. The
meaning of HD instability in trauma patient is still very
wide with unclear borders and lacks a clear validated
definition that states which indicative parameters to use to
initially assess the circulatory status.
This study assesses the definitions used for HD
stability in a systematic review of the literature combined with
a survey of the interpretations of HD instability in blunt
trauma patients in the ER amongst Dutch trauma team
members in order to establish the level of consensus about
HD stability for blunt trauma patients.
Review of the literature
A systematic search of the literature was conducted using
the computerized bibliographic database MEDLINE and
Embase. Both were searched for English and Dutch
articles published from 2005 to 2015 concerning the
diagnostics and/or treatment of adult patients suffering exclusively
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