Early Predictors of the Need for Emergent Surgery to Control Hemorrhage in Hypotensive Trauma Patients

Scand J Trauma Resusc Emerg Med

Fenwick

Smith

et al. 2021

Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies. Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012 to 2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p < 0.001). Spinal cord injuries were rare (0.71% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were trapped (p < 0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10–29) vs 13 (IQR 9–22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow Coma Scale, GCS (all p < 0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p < 0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p < 0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for < 0.7% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.

Section: Discussionmentioning

confidence: 99%

A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to those patients who are not trapped

Scand J Trauma Resusc Emerg Med

Fenwick

Smith

et al. 2021

“…It has been suggested that rapid extrication, minimising the time the patient is trapped, may offer signi cant bene ts. Kaiser et al reinforce this need in their report on 446 traumatically injured patients where they performed a regression analysis to predict the need for urgent surgery (19). They identi ed that prolonged extrication (> 30 minutes) was associated with an increased need for emergency surgery (odds ratio 2.3 (1.2-4.6)).…”

Section: Injuries In Context Of Intervention When the Patient Remainsmentioning

confidence: 96%

A Comparison of the Demographics, Injury Patterns and Outcome Data for Patients Injured in Motor Vehicle Collisions Who Are Trapped Compared to Those Patients Who Are Not Trapped

Fenwick²,

Smith³

et al. 2020

Preprint

Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. Understanding the outcomes and injuries of those trapped following an MVC will help guide meaningful patient-focused interventions and future extrication strategies.Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients who were admitted to an English hospital following an MVC from 2012-2018. Patients were excluded when their outcomes were not known or if they were secondary transfers.Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p<0.001). Spinal cord injuries were rare (0.29% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were not trapped (p<0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10-29) vs 13 (IQR 9-22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow comas Scale, GCS (all p<0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p<0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p<0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for <0.3% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.

“…It has been suggested that rapid extrication, minimising the time the patient is trapped, may offer signi cant bene ts. Kaiser et al reinforce this need in their report on 446 traumatically injured patients where they performed a regression analysis to predict the need for urgent surgery (16). They identi ed that prolonged extrication (> 30 minutes) was associated with an increased need for emergency surgery (odds ratio 2.3 (1.2-4.6)).…”

Section: Do Patients With Spinal Injuries Have Other Injuries Which Mmentioning

confidence: 96%

A comparison of the demographics, injury patterns and outcome data for patients injured in motor vehicle collisions who are trapped compared to patients who are not trapped

Fenwick

Smith³

et al. 2020

Preprint

Background Motor vehicle collisions (MVCs) are a common cause of major trauma and death. Following an MVC, up to 40% of patients will be trapped in their vehicle. Extrication methods are focused on the prevention of secondary spinal injury through movement minimisation and mitigation. This approach is time consuming and patients may have time-critical injuries. The purpose of this study is to describe the outcomes and injuries of those trapped following an MVC: this will help guide meaningful patient-focused interventions and future extrication strategies.Methods We undertook a retrospective database study using the Trauma Audit and Research Network database. Patients were included if they were admitted to an English hospital following an MVC from 2012-2018. Patients were excluded when their outcomes were not known or if they were secondary transfers. Results This analysis identified 426,135 cases of which 63,625 patients were included: 6983 trapped and 56,642 not trapped. Trapped patients had a higher mortality (8.9% vs 5.0%, p<0.001). Spinal cord injuries were rare (0.29% of all extrications) but frequently (50.1%) associated with other severe injuries. Spinal cord injuries were more common in patients who were not trapped (p<0.001). Injury Severity Score (ISS) was higher in the trapped group 18 (IQR 10-29) vs 13 (IQR 9-22). Trapped patients had more deranged physiology with lower blood pressures, lower oxygen saturations and lower Glasgow comas Scale, GCS (all p<0.001). Trapped patients had more significant injuries of the head chest, abdomen and spine (all p<0.001) and an increased rate of pelvic injures with significant blood loss, blood loss from other areas or tension pneumothorax (all p<0.001). Conclusion Trapped patients are more likely to die than those who are not trapped. The frequency of spinal cord injuries is low, accounting for <0.3% of all patients extricated. Patients who are trapped are more likely to have time-critical injuries requiring intervention. Extrication takes time and when considering the frequency, type and severity of injuries reported here, the benefit of movement minimisation may be outweighed by the additional time taken. Improved extrication strategies should be developed which are evidence-based and allow for the expedient management of other life-threatening injuries.