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Role of the Neutrophil-To-Lymphocyte Ratio at the Time of Arrival at the Emergency Room As a Predictor of Rhabdomyolysis in Severe Trauma Patients

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Role of the Neutrophil-To-Lymphocyte Ratio at the Time of Arrival at the Emergency Room As a Predictor of Rhabdomyolysis in Severe Trauma Patients ORIGINAL ARTICLE J Trauma Inj 2020;33(2):96-103 https://doi.org/10.20408/jti.2020.018 JOURNAL OF TRAUMA AND INJURY Role of the Neutrophil-to-Lymphocyte Ratio at the Time of Arrival at the Emergency Room as a Predictor of Rhabdomyolysis in Severe Trauma Patients Jin Chul Bae, M.D., Kyung Hoon Sun, M.D., Ph.D., Yong Jin Park, M.D., Ph.D. Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, Received: March 31, 2020 Korea Revised: May 25, 2020 Accepted: June 2, 2020 Purpose: In patients with trauma, rhabdomyolysis (RM) can lead to fatal complications resulting from muscle damage. Thus, RM must be immediately diagnosed and treated to prevent complications. Creatine kinase (CK) is the most sensitive marker for diag- nosing RM. However, relying on CK tests may result in delayed treatment, as it takes approximately 1 hour to obtain CK blood test results. Hence, this study investigated whether the neutrophil-to-lymphocyte ratio (NLR) could predict RM at an earlier time point in patients with trauma, since NLR results can be obtained within 10 minutes. Correspondence to Methods: This retrospective study included 130 patients with severe trauma who were Kyung Hoon Sun, M.D., Ph.D. admitted to the emergency room of a tertiary institution between January 2017 and Department of Emergency Medicine, April 2020. RM was defined as a CK level ≥1,000 U/L at the time of arrival. Patients Chosun University Hospital, 365 Philmun-daero, Dong-gu, Gwangju with severe trauma were categorized into non-RM and RM groups, and their charac- 61453, Korea teristics and blood test results were analyzed. Statistical analysis was performed using Tel: +82-62-220-3285 Fax: +82-62-224-3501 SPSS version 26.0 for Windows. E-mail: [email protected] Results: Of the 130 patients with severe trauma, 50 presented with RM. In the multi- variate analysis, the NLR (odds ratio [OR], 1.252; 95% confidence interval [CI], 1.130– 1.386), pH level (OR, 0.006; 95% CI, 0.000–0.198), presence of acute kidney injury (OR, 3.009; 95% CI, 1.140–7.941), and extremity Abbreviated Injury Scale score (OR, 1.819; 95% CI, 1.111–2.980) significantly differed between the non-RM and RM groups. A re- ceiver operating characteristic analysis revealed that a cut-off NLR value of 3.64 was the best for predicting RM. Conclusions: In patients with trauma, the NLR at the time of arrival at the hospital is a useful biochemical marker for predicting RM. Keywords: Rhabdomyolysis; Multiple trauma; Neutrophils; Lymphocytes; Acute kidney injury http://www.jtraumainj.org Copyright © 2020 The Korean Society of Trauma This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License eISSN 2287-1683 (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted noncommercial use, distribution, and pISSN 1738-8767 reproduction in any medium, provided the original work is properly cited. Jin Chul Bae, et al. Neutrophil/Lymphocyte as a Predictor of Rhabdomyolysis INTRODUCTION tained within 10 minutes via a complete blood count ex- amination, and it is used as an indicator of the inflamma- Rhabdomyolysis (RM) is caused by the breakdown of tory response [6]. The NLR has been used as a predictor Role of the Neutrophil-to-Lymphocyte skeletal muscle and subsequent leakage of its contents into of poor prognosis in various conditions, such as infection, the blood circulation [1]. Common causes of this condi- infarction, and tumors [7,8]. According to Sugama et al. Ratio at the Time of Arrival at the tion are trauma, overexertion, and drug use, and it can [9], muscle damage leads to neutrophil recruitment and lead to acute kidney injury (AKI), hyperkalemia, cardiac decreased lymphocyte levels during the acute phase. Based Emergency Room as a Predictor of arrhythmia, compartment syndrome, and disseminated on the abovementioned findings, this study aimed to intravascular coagulation [1,2]. The clinical features of determine whether the NLR could be utilized as an early Rhabdomyolysis in Severe Trauma RM include muscle pain, swelling, weakness, tea-colored predictor of RM in patients with acute trauma. urine, nausea, and malaise [1]. Creatine kinase (CK) is the Patients most sensitive biomarker of muscle injury, and a baseline CK value ≥1,000 U/L, which is five times the normal up- METHODS Jin Chul Bae, M.D., Kyung Hoon Sun, M.D., Ph.D., Yong Jin Park, M.D., Ph.D. per limit of CK in the blood, is used to diagnose RM [3]. The treatment of RM aims to minimize muscle damage, In this retrospective study, the data of patients with Department of Emergency Medicine, College of Medicine, Chosun University, Gwangju, Korea prevent AKI, and immediately correct life-threatening trauma who were admitted to the emergency room of a complications. In particular, proper renal perfusion must tertiary institution in South Korea between January 2017 be maintained with early and aggressive fluid resuscitation and April 2020 were collected. This study was approved to prevent AKI [3]. A peak CK value ≥5,000 U/L (severe by the Institutional Review Board of Chosun University Purpose: In patients with trauma, rhabdomyolysis (RM) can lead to fatal complications RM) indicates severe muscle injury and an elevated risk Hospital (IRB No. CHOSUN 2020-03-004). All data were resulting from muscle damage. Thus, RM must be immediately diagnosed and treated to prevent complications. Creatine kinase (CK) is the most sensitive marker for diag- of developing AKI. However, since CK can reach its peak extracted from the electronic medical records of Chosun nosing RM. However, relying on CK tests may result in delayed treatment, as it takes level within 1–3 days, relying on peak CK levels can result University Hospital. This study was conducted on injured approximately 1 hour to obtain CK blood test results. Hence, this study investigated in delays in providing proper treatment [4]. A previous patients aged ≥18 years who met Chosun University whether the neutrophil-to-lymphocyte ratio (NLR) could predict RM at an earlier time study showed that when the initial CK value was below Hospital's criteria for severe trauma team activation, as point in patients with trauma, since NLR results can be obtained within 10 minutes. 900 U/L, the peak CK value did not exceed 5,000 U/L [5]. shown in Table 1, and the severe trauma team was ac- Methods: This retrospective study included 130 patients with severe trauma who were Therefore, the initial CK value is effective for predicting tivated when one or more of the criteria were met [10]. admitted to the emergency room of a tertiary institution between January 2017 and the peak CK value. It takes approximately 1 hour to ob- The exclusion criteria were patients aged <18 years, those April 2020. RM was defined as a CK level ≥1,000 U/L at the time of arrival. Patients tain CK values from a blood test. Hence, if RM can be for whom excessive time had passed after the accident with severe trauma were categorized into non-RM and RM groups, and their charac- predicted before obtaining the CK test result, appropriate because of transfer from another hospital, those who died teristics and blood test results were analyzed. Statistical analysis was performed using treatment can be provided immediately. within 24 hours of presenting to the hospital, those with SPSS version 26.0 for Windows. The neutrophil-to-lymphocyte ratio (NLR) can be ob- known chronic kidney disease, and those with incomplete Results: Of the 130 patients with severe trauma, 50 presented with RM. In the multi- variate analysis, the NLR (odds ratio [OR], 1.252; 95% confidence interval [CI], 1.130– Table 1. Criteria for severe trauma team activation 1.386), pH level (OR, 0.006; 95% CI, 0.000–0.198), presence of acute kidney injury (OR, 3.009; 95% CI, 1.140–7.941), and extremity Abbreviated Injury Scale score (OR, 1.819; Physiological parameters Injury patterns Mechanism of injury 95% CI, 1.111–2.980) significantly differed between the non-RM and RM groups. A re- Systolic blood pressure <90 mmHg after trauma Penetrating injuries of the neck and trunk Fall from height >3 m ceiver operating characteristic analysis revealed that a cut-off NLR value of 3.64 was the Glasgow Coma Scale score <9 after trauma Gunshot injuries of the neck and trunk Road traffic accident best for predicting RM. Breathing disturbance/need for intubation Fractures of at least two proximal bones Frontal collision with intrusion of more than 50 to Conclusions: In patients with trauma, the NLR at the time of arrival at the hospital is a after trauma 75 cm useful biochemical marker for predicting RM. Unstable thorax, unstable pelvic fracture Changes in velocity of delta >30 km/h Amputation proximal to heads/feet Pedestrian/motorcycle collision Keywords: Rhabdomyolysis; Multiple trauma; Neutrophils; Lymphocytes; Acute Injuries with neurological signs of paraplegia Death of a passenger kidney injury Open cranial injury Ejection of a passenger Burns >20% http://www.jtraumainj.org 97 Journal of Trauma and Injury Volume 33, Number 2, June 2020 medical records, including blood test results. A total of of parameters, including age, sex, Glasgow Coma Scale 228 patients who met the criteria for severe trauma team (GCS) score, blood pressure, heart rate, Acute Physiology activation were admitted to Chosun University Hospital and Chronic Health Evaluation II (APACHE II) score, emergency room during the study period. Finally, 130 pa- Injury Severity Score (ISS), Abbreviated Injury Scale (AIS) tients were enrolled and 98 were excluded. According to score, trauma mechanism, the presence of acute kidney the blood test results performed immediately upon arrival injury (AKI), continuous renal replacement therapy at the hospital, patients with CK levels ≥1,000 U/L were (CRRT), emergency surgery, mortality, and laboratory diagnosed with RM.
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