Comparison of the previous and current trauma-related shock classifications – The more the better? – A retrospective cohort study from a level I trauma centre

Abstract

Background: The aim was to compare the predictive performance of the current, extended (VS+BD) Advanced Trauma Life Support (ATLS) classification for hypovolaemic shock over the previous, vital sign (VS)-based classification with respect to mortality outcomes. We also studied the prognostic values of heart rate (HR), systolic blood pressure (SBP), Glasgow Coma Scale (GCS) and base deficit (BD).Methods: The present study is a retrospective analysis at a level I trauma centre between 11 July 2014 and 11 September 2019. Trauma patients (inclusion criteria: trauma team activation, transport directly from scene, no need for resuscitation on scene, precise and detailed medical documentation, age ≥16, 30-day follow-up, complete dataset for HR, SBP, GCS and BD) were allocated to shock classes (I–IV) based on the VS and VS+BD criteria. The predictive values for the classifications were compared with a two-proportion Z-test, while individual parameters were examined with receiver operating characteristic (ROC) analyses.Results: A total of 156 patients met the inclusion criteria out of 60,037 trauma admissions. Both the VS and VS+BD classifications have shown a strong relation to mortality (P=0.0001 vs. P=0.000009). There was no significant difference in their predictive performance. According to the statistical analysis, GCS, BD and SBP showed significant prognostic values (AUCGCS=0.799 [CI: 0.722, 0.875]; AUCBD=0.683, [CI: 0.576, 0.790]; AUCSBP=0.633, [CI: 0.521, 0.744]). HR was found ineffective in predicting mortality. Conclusions: The current ATLS classification for hypovolaemic shock did not appear to be superior to the previous, VS-based classification in our study setting. GCS, BD and SBP were proven to be useful parameters in prognosticating outcome. The role of HR should be reconsidered, since it does not seem to reflect the clinical condition accurately.

Predictive value of tachycardia for mortality in trauma-related haemorrhagic shock: a systematic review and meta-regression

“…However, the question remains if it is effective enough to be taken into consideration when we can also rely on parameters with higher sensitivity and specificity for bleeding—such as base deficit (BD). Multiple studies have presented the inferiority of HR as compared with other predictors included in the ATLS criteria such as systolic blood pressure, Glasgow Coma Scale and BD 27 28. Based on these concerns, the role of HR in the classification of hypovolaemic shock and the initial management of the severely injured should be re-evaluated.…”