Air Medical Journal xxx (2016) 1e5

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Air Medical Journal

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Critical Care Update Toward Zero Preventable Deaths

Kelsey S. Berndt, MD, David J. Dries, MSE, MD

Recent military conflicts have led to attributed to advances in hemorrhage con- As Donald Berwick, MD, Chair of the enhanced civilian trauma care through trol, improved resuscitation techniques, and National Academies of Science, Engineering, lessons learned. Because of concerns aggressive neurocritical care interventions. and Medicine Committee on Military regarding the maintenance of civilian and Many of these advances were made via Trauma Care's Learning Health System and military trauma care preparedness, a continuous performance improvement and Its Translation to the Civilian Sector stated, recent conference proposed reinvigorated focused empiricism. Questions have arisen “Both the military and civilian sectors collaboration between the civilian and regarding the use of knowledge gained in have made impressive progress and military trauma systems. A synopsis of the military during combat by the civilian important innovations in trauma care, these comments is provided in this article. sector and how to maintain military trauma but there are serious limitations in the The release of the statement favoring readiness for future combat operations. The diffusion of these gains from location to collaboration between military and civilian National Academies of Science, Engineering, location…the successes have saved trauma programs coincides with multiple and Medicine Committee on Military many lives; the disparities have cost published summaries of recent military Trauma Care's Learning Health System and many lives. With the decrease in com- trauma research. Articles selected from this Its Translation to the Civilian Sector released bat and the need to maintain readiness collection, published in Shock, are sum- a report this spring calling for the develop- for trauma care between wars, a win- marized here. ment of a national trauma system with the dow of opportunity now exists to inte- aim of achieving zero preventable deaths Berwick DM, Downey AS, Cornett EA. grate military and civilian trauma after injury and minimizing trauma-related A national trauma care system to achieve systems and view them not separately, disability. The complete document, cited zero preventable deaths after injury, but as one.” earlier, calls for coordination between recommendations from a National trauma provider organizations, the Secre- Academies of Sciences, Engineering, and tary of Defense, the Defense Health Agency, Recently, Shock published a supplement Medicine report. JAMA. 2016;316:927-928. and the US Department of Health and Hu- containing military trauma research. Stewart RM, Jenkins DH, Winchell RJ, man Services to establish stable, long-term Studies include a range of basic science and Rotondo MF. ACS Committee on Trauma support of a national trauma system from clinical research. Some of that work is pledges to make zero preventable deaths point of injury to rehabilitation and post- highlighted here, focusing on improved a reality. Bulletin of the American College of acute care. parameters for the early recognition of Surgeons. 2016;101:23-28. Elements needed for an effective hemorrhage and initial treatment with learning trauma care system include 1) junctional tourniquets and hemostatic The National Academies of Sciences, leadership and a culture of learning via the agents. The optimal use of blood products Engineering, Medicine. A National integration of military and civilian trauma also continues to be of widespread interest Trauma System: Integrating Military and care, 2) examination of the entire patient to civilian and military investigators. Civilian Trauma Systems to Achieve Zero experience from prehospital resuscitation to Preventable Deaths After Injury. Washing- Joseph B, Haider A, Ibraheem K, et al. long-term outcomes, 3) coordinated per- ton, DC: The National Academies Revitalizing vital signs: the role of the formance improvement and research to Press; 2016. delta shock index. Shock. 2016;46(suppl generate best trauma care practices, 4) 1):50-54. In the United States, trauma is the third timely dissemination of trauma knowledge leading cause of death and accounts for with real-time access to high-quality infor- The trimodal distribution of trauma more years of life lost than any other cause. mation, 5) transparency and incentives for deaths has been well described, with the During the most recent military conflicts in quality trauma care with provider access to majority of preventable early trauma Afghanistan and Iraq, the percentage of performance data, and 6) systems for deaths attributed to hemorrhage. Early wounded service members who died of ensuring an expert trauma care workforce identification of hemorrhagic shock is their injuries reached an all-time low of by integrating military and civilian trauma essential for survival; however, standard 9.3% compared with 23% during the Viet- centers as a platform to train and sustain the vital sign monitoring with heart rate (HR) nam War. This improvement has been trauma care provider community. and systolic blood pressure (SBP) may be

1067-991X/$36.00 Copyright © 2016 by Air Medical Journal Associates http://dx.doi.org/10.1016/j.amj.2016.11.003 2 K.S. Berndt, D.J. Dries / Air Medical Journal xxx (2016) 1e5 falsely reassuring in a compensating pa- that may be used to identify occult hypo- require admission to the intensive care unit tient. The shock index (SI), a ratio of HR and volemic shock and those trauma patients at (100% vs. 15.6%, P < .001). Bleeding patients SBP, has been proposed as a better predic- higher risk of death. were more likely to receive blood trans- tor of hemorrhagic shock than HR or SBP fusions within the first hour (25% vs. 3.1%, Stewart CL, Mulligan J, Grudic GZ, alone. A normal SI value is less than 0.7, P ¼ .03) and received higher volumes of Talley ME, Jurkovich GJ, Moulton SL. The with an SI greater than 1 considered a crystalloid (2.3 vs. 1.3 L, P ¼ .007). The early Compensatory Reserve Index following predictor of hemodynamic instability. identification of bleeding patients and their injury: results of a prospective clinical However, there are subsets of patients in magnitude of reserve to compensate for trial. Shock. 2016;46(suppl 1):61-67. whom hypovolemia may not elevate the SI, blood loss provides an opportunity to namely, those with pseudohypertension Photoplethysmographic waveforms improve and expedite care in critically and those who present with relative have been shown to change shape in the injured and bleeding patients. bradycardia. In these patients, a change setting of acute volume loss before changes This work with the CRI represents from the field SI to the emergency depart- in traditional vital sign measurements. a long-standing interest of military ment (ED) SI may better identify hemor- Waveform data were collected during researchers. The use of computational re- rhage. It was hypothesized that a rise in the simulated hemorrhage models and used to sources makes this work attractive. How- SI or a positive delta SI would predict a create a smart algorithm, the Compensatory ever, the usefulness of a data-intensive higher mortality than an unchanged or Reserve Index (CRI). The value of CRI is approach to patient management requires negative (decreasing) delta SI. defined as 1 (BLV/BLVHDD) where BLV validation in remote settings and as a part The authors performed a 2-year review represents current blood loss volume and of standard urban trauma care. (2011-2012) of the National Trauma Data BLV is the volume of blood loss at which HDD Gerhardt RT, Glassberg E, Holcomb JB, Bank. Trauma patients aged 18 to 85 years a patient will experience hemodynamic Mabry RL, Schreiber MB, Spinella PC. with an Injury Severity Score (ISS) of 16 or decompensation (defined as systolic blood Tactical Study of Care Originating in the above were included. Field and ED SI pressure < 80 mm Hg, changes in vision, or Prehospital Environment (TACSCOPE): values were calculated based on docu- discomfort resulting in termination of a acute traumatic coagulopathy on the mented emergency medical services and testing protocol used to generate calibra- contemporary battlefield. Shock. ED measurements of HR and SBP. The delta tion data). The CRI can be thought of as the 2016;46(suppl 1):104-107. SI was calculated by subtracting the field percentage of physiologic reserve and is SI from the ED SI. A total of 95,088 patients estimated by analyzing waveforms over a Along with hemorrhage control, recent were included with a mean age of 46.2 30-beat window. The algorithm has previ- evidence supports the expanded use of years and a median ISS of 22. Seventy-two ously been validated in healthy volunteers blood products and procoagulant pharma- percent were male. Patients with a posi- donating blood. ceuticals in prehospital combat care to tive delta SI were more likely to be hypo- The CRI was evaluated in 47 trauma prevent or delay the onset of acute trau- tensive and tachycardic in the ED and less patients presenting to the Denver Health matic coagulopathy (ATC). A retrospective likely to have been tachycardic and Emergency Department. Patients were cohort study was performed to analyze US hypotensive in the field. They were also categorized on arrival as actively bleeding, combat casualties from the Department of more likely to require exploratory lapa- indeterminate bleeding, or not actively Defense Trauma Registry to determine the rotomy. The mortality rate for all patients bleeding. For simplicity of comparison, the incidence, epidemiologic and clinical was 11.9%, with patients with a positive 3 patients classified as indeterminate were characteristics, and the effect of ATC on deltaSIhavingahighermortalitythan excluded, leaving 44 patients for analysis. survival outcomes. The data set included all those with an unchanged or negative delta The average initial CRI was calculated over casualties from October 1, 2007, to June 30, SI (P < .001). Patients with a delta SI the first 5 minutes and compared with 2011. Data were collected on de- greater than 0.1 had a mortality rate of prehospital HR and BP, initial HR and BP in mographics, mechanism of injury, vital 16.6% versus 9.5% in patients with a delta the trauma bay, initial SI, and initial labo- signs, ISS, complete blood count, pro- SI of 0.1 or less (P < .001). After stratifying ratory data. The initial CRI for bleeding thrombin time, international normalized patients based on blunt versus pene- patients was 0.17 (95% confidence interval ratio (INR), serum pH, and quantities of trating injury, a delta SI more than 0.1 was [CI], 0.13-0.22) and on average decreased blood transfused. ATC was defined as an still associated with an increased hazard the hour after administration of each liter INR greater than or equal to 1.5. Massive ratio of death. This association remained of crystalloid (CRI ¼0.02; 95% CI, 0.05 to transfusion (MT) was defined as 10 or more after stratifying patients based on age, sex, 0.01) or unit of blood (CRI ¼0.04; 95% units of packed red blood cells (PRBCs) ISS, and Glasgow Coma Score. CI, 0.08 to 0.01). In nonbleeding pa- administered in the first 24 hours after This study shows that delta SI may be a tients, the initial CRI was higher (0.56; 95% presentation. Eight thousand nine hundred helpful tool for the identification of subtle CI, 0.49-0.62; P < .001) and increased in the twelve cases were available for analysis. Of hemodynamic instability that may be hour after each liter of crystalloid (0.05; these, 4,543 (51%) had complete data missed using traditional vital signs. This is 95% CI, 0.05 to 0.14) or after each unit of available for analysis. Of the excluded particularly important in patients who blood. The average change in CRI after fluid cases, 98.9% survived, the average ISS was have apparently normal hemodynamics and blood administration had a narrower 7, and less than 1% received MT. In the because of pseudohypertension or range in bleeding patients compared with 4,543 included cases, 98.5% survived, the medication-induced bradycardia but are nonbleeding patients and did not reach average ISS was 10, the average INR was suffering from occult hypoperfusion. There significance (P ¼ .06). Bleeding patients 1.16, and 2.7% received MT. A total of 383 are limitations of this study as a retro- were more likely to have long bone frac- cases (8.4%) met criteria for ATC with an spective review, particularly missing data tures and pelvic fractures (33% vs. 0%, P ¼ INR > 1.5. ATC cases had a higher ISS (15 vs. regarding prehospital treatment and the .001), have a positive Focused Assessment 9, P < .01) and were more likely to die than use of medications that could affect vital with Sonography in Trauma examination non-ATC cases (odds ratio ¼ 28; 95% CI, 16- sign response. However, this article shows (41.7% vs. 3.1%, P ¼ .001), require urgent 48). ATC cases were more likely to be vic- a novel and easy to calculate parameter operation (91.7% vs. 15.6%, P < .001), and tims of blast and penetrating injuries and Download English Version: https://daneshyari.com/en/article/8555373

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