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Gorski JK, Chaudhari PP, Spurrier RG, Goldstein SD, Zeineddin S, Martin-Gill C, Sepanski RJ, Stey AM, Ramgopal S. Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma. JAMA Netw Open 2024; 7:e2356472. [PMID: 38363566 PMCID: PMC10873773 DOI: 10.1001/jamanetworkopen.2023.56472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 12/26/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
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Affiliation(s)
- Jillian K. Gorski
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Pradip P. Chaudhari
- Division of Emergency and Transport Medicine, Department of Pediatrics, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Ryan G. Spurrier
- Division of Pediatric Surgery, Department of Surgery, Children’s Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles
| | - Seth D. Goldstein
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Suhail Zeineddin
- Department of Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Robert J. Sepanski
- Department of Quality and Safety, Children’s Hospital of The King’s Daughters, Norfolk, Virginia
- Department of Pediatrics, Eastern Virginia Medical School, Norfolk
| | - Anne M. Stey
- Department of Surgery, Northwestern Memorial Hospital, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Sanchez T, Coisy F, Grau-Mercier L, Occelli C, Ajavon F, Claret PG, Markarian T, Bobbia X. Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets. Am J Emerg Med 2024; 75:59-64. [PMID: 37922831 DOI: 10.1016/j.ajem.2023.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 10/01/2023] [Accepted: 10/06/2023] [Indexed: 11/07/2023] Open
Abstract
INTRODUCTION The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase. METHODS We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly. RESULTS The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively. CONCLUSIONS In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.
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Affiliation(s)
- Thomas Sanchez
- University of Montpellier, Research Unit IMAGINE, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France.
| | - Fabien Coisy
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Laura Grau-Mercier
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Céline Occelli
- University of Côte d'Azur, Faculty of Medecine, Transporter in Imaging and Radiotherapy in Oncology Laboratory, Basic Research Direction - Department of Emergency Medicine, Nice University Hospital, Nice, France
| | - Florian Ajavon
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Pierre-Géraud Claret
- University of Montpellier, Research Unit IMAGINE, Division of Anesthesiology, Critical Care, Pain and Emergency Medicine, Nîmes University Hospital, Nîmes, France
| | - Thibaut Markarian
- University of Aix-Marseille, UMR 1263 Center of Cardiovascular and Nutrition Research (C2VN), INSERM, INRAE - Department of Emergency Medicine, Timone University Hospital, Marseille, France
| | - Xavier Bobbia
- University of Montpellier, Research Unit IMAGINE, Department of Emergency Medicine, Montpellier University Hospital, Montpellier, France
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Steins K, Goolsby C, Grönbäck AM, Charlton N, Anderson K, Dacuyan-Faucher N, Prytz E, Andersson Granberg T, Jonson CO. Recommendations for Placement of Bleeding Control Kits in Public Spaces-A Simulation Study. Disaster Med Public Health Prep 2023; 17:e527. [PMID: 37852924 DOI: 10.1017/dmp.2023.190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
OBJECTIVE Bleeding control measures performed by members of the public can prevent trauma deaths. Equipping public spaces with bleeding control kits facilitates these actions. We modeled a mass casualty incident to investigate the effects of public bleeding control kit location strategies. METHODS We developed a computer simulation of a bomb exploding in a shopping mall. We used evidence and expert opinion to populate the model with parameters such as the number of casualties, the public's willingness to aid, and injury characteristics. Four alternative placement strategies of public bleeding control kits in the shopping mall were tested: co-located with automated external defibrillators (AEDs) separated by 90-second walking intervals, dispersed throughout the mall at 10 locations, located adjacent to 1 exit, located adjacent to 2 exits. RESULTS Placing bleeding control kits at 2 locations co-located with AEDs resulted in the most victims surviving (18.2), followed by 10 kits dispersed evenly throughout the mall (18.0). One or 2 kit locations placed at the mall's main exits resulted in the fewest surviving victims (15.9 and 16.1, respectively). CONCLUSIONS Co-locating bleeding control kits with AEDs at 90-second walking intervals results in the best casualty outcomes in a modeled mass casualty incident in a shopping mall.
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Affiliation(s)
- Krisjanis Steins
- Department of Science and Technology, Linköping University, Sweden
| | - Craig Goolsby
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nathan Charlton
- Department of Emergency Medicine, University of Virginia, Charlottesville, VA, USA
| | - Kevin Anderson
- F. Edward Hebert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Nicole Dacuyan-Faucher
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
- The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Erik Prytz
- Department of Computer and Information Science, Linköping University, Sweden
- Center for Disaster Medicine and Traumatology, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
| | | | - Carl-Oscar Jonson
- Center for Disaster Medicine and Traumatology, and Department of Biomedical and Clinical Sciences, Linköping University, Sweden
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Tucker C, Winner A, Reeves R, Cooper ES, Hall K, Schildt J, Brown D, Guillaumin J. Resuscitation Patterns and Massive Transfusion for the Critical Bleeding Dog-A Multicentric Retrospective Study of 69 Cases (2007-2013). Front Vet Sci 2022; 8:788226. [PMID: 35071385 PMCID: PMC8766795 DOI: 10.3389/fvets.2021.788226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/17/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To describe resuscitation patterns of critically bleeding dogs, including those receiving massive transfusion (MT). Design: Retrospective study from three universities (2007-2013). Animals: Critically bleeding dogs, defined as dogs who received ≥ 25 ml/kg of blood products for treatment of hemorrhagic shock caused by blood loss. Measurements and Main Results: Sixty-nine dogs were included. Sources of critical bleeding were trauma (26.1%), intra/perioperative surgical period (26.1%), miscellaneous (24.6%), and spontaneous hemoabdomen (23.1%). Median (range) age was 7 years (0.5-18). Median body weight was 20 kg (2.6-57). Median pre-transfusion hematocrit, total protein, systolic blood pressure, and lactate were 25% (10-63), 4.1 g/dl (2-7.1), 80 mm Hg (20-181), and 6.4 mmol/L (1.1-18.2), respectively. Median blood product volume administered was 44 ml/kg (25-137.4). Median plasma to red blood cell ratio was 0.8 (0-4), and median non-blood product resuscitation fluid to blood product ratio was 0.5 (0-3.6). MT was given to 47.8% of dogs. Survival rate was 40.6%. The estimated odds of survival were higher by a factor of 1.8 (95% CI: 1.174, 3.094) for a dog with 1 g/dl higher total protein above reference interval and were lower by a factor of 0.6 (95% CI: 0.340, 0.915) per 100% prolongation of partial thromboplastin time above the reference interval. No predictors of MT were identified. Conclusions: Critical bleeding in dogs was associated with a wide range of resuscitation patterns and carries a guarded to poor prognosis.
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Affiliation(s)
- Claire Tucker
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States.,TetraMed, Fort Collins, CO, United States
| | - Anna Winner
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Ryan Reeves
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States
| | - Edward S Cooper
- Department of Clinical Sciences, The Ohio State University, Columbus, OH, United States
| | - Kelly Hall
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States.,TetraMed, Fort Collins, CO, United States
| | - Julie Schildt
- Department of Clinical Sciences, The University of Tennessee, Knoxville, Knoxville, TN, United States
| | - David Brown
- Department of Statistics, Colorado State University, Fort Collins, CO, United States
| | - Julien Guillaumin
- Department of Clinical Sciences, Colorado State University, Fort Collins, CO, United States.,TetraMed, Fort Collins, CO, United States
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