- Email: [email protected]
Severity assessment in trauma patient
Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
Monothematic meeting of Sfar
Severity assessment in trauma patient§,§§ E´valuation de la gravite´ chez le traumatise´ M. Raux a,*,d, B. Vivien b, J.-P. Tourtier c, O. Langeron a a
Salle de surveillance post-interventionnelle et d’accueil des polytraumatise´s, de´partement d’anesthe´sie re´animation, groupe hospitalier Pitie´-Salpeˆtrie`re, Assistance publique–hoˆpitaux de Paris, 47–83, boulevard de l’Hoˆpital, 75651 Paris cedex, France b Samu de Paris, universite´ Paris Descartes Paris-V, hoˆpital Necker–Enfants malades, Assistance Publique–hoˆpitaux de Paris, 75015 Paris, France c Service me´dical d’urgence, brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France d Universite´ Pierre-et-Marie-Curie, UPMC Paris 6, 75013 Paris, France
A R T I C L E I N F O
A B S T R A C T
Keywords: Trauma Severity Triage
Severity assessment in trauma patients is mandatory. It started during initial phone call that alerts emergency services when a trauma occurred. On-call physician assesses severity based on witnessprovided information, to adapt emergency response (paramedics, emergency physicians). Initial severity assessment is subsequently improved based on first-responder provided informations. Whenever information comes, it helps providing adequate therapeutics and orientating the patient to the appropriate hospital. Severity assessment is based upon pre-trauma medical conditions, mechanism of injury, anatomical lesions and their consequences on physiology. Severity information can be summarized using scores, yet those are not used in France, except for post-hoc scientific purposes. Triage is usually performed using algorithms. Whatever the way triage is performed, triage tools are based on mortality as main judgement criterion. Other criteria should be considered, such as therapeutics requirements. The benefit of biomarkers of ultrasonography at prehospital setting remains to be assessed. ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. R E´ S U M E´
Mots cle´s: Traumatise´ Se´ve´rite´ Triage
L’e´valuation de la gravite´ d’un patient traumatise´ fait partie des missions des moyens de secours implique´s dans sa prise en charge. Elle commence de`s la communication te´le´phonique entre l’appelant signalant l’accident et le centre de secours, au cours de laquelle elle permet au me´decin re´gulateur d’adapter les moyens de secours (secouristes, me´dicalisation pre´hospitalie`re). Cette e´valuation est secondairement e´toffe´e par le bilan transmis par les moyens de secours sur place. A` ce stade, elle guide la the´rapeutique et l’orientation du traumatise´ vers un hoˆpital adapte´ a` son e´tat, c’est-a`-dire disposant des moyens humains et mate´riels ne´cessaires a` sa prise en charge. Cette e´valuation repose actuellement sur le terrain du patient, le me´canisme le´sionnel, les le´sions et leur retentissement physiologique. Les scores sont peu utilise´s en France, ou` le triage se fait pre´fe´rentiellement au moyen d’un algorithme construit sur la base des algorithmes de triage nord-ame´ricains. Quels qu’ils soient, les moyens de cette e´valuation ont e´te´ construits autour de la mortalite´ comme crite`re de jugement principal. D’autres e´le´ments du devenir du patient, contribuant a` sa survie, rentrent en ligne de compte dans la de´cision d’orientation (besoins the´rapeutiques par exemple). Le be´ne´fice informatif de biomarqueurs ou de techniques e´chographiques pour e´valuer la gravite´ a` la phase pre´hospitalie`re reste a` e´valuer. ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Publie´ par Elsevier Masson SAS. Tous droits re´serve´s.
§
Article presented at Monothematic meeting of Sfar (Socie´te´ franc¸aise d’anesthe´sie et de re´animation): ‘‘Severe trauma: the first 24 hours’’, Paris, May 29th, 2013. This article is published under the responsibility of the Scientific Committee of the ‘‘Journe´e Monothe´matique 2013 de la Sfar’’ (http://www.jmtsfar.com). The editorial board of the Annales franc¸aises d’anesthe´sie et de re´animation was not involved in the conception and validation of its content. * Corresponding author. E-mail address: [email protected] (M. Raux). §§
0750-7658/$ – see front matter ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.annfar.2013.07.004
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
473
1. Introduction
3.1. Clinical approach
Trauma is the third cause of death after cancer and cardiovascular diseases in the overall population, but the leading cause in young people (below 35). It accounts for 60 deaths out of 100 000 inhabitants in France, thus 37 415 patients in 2010. Eighty percent of dead patients died within the first 24 hours. They mainly died from massive hemorrhage or traumatic brain injury [1]. Teixera et al. [2] reported a 2.5% rate of preventable death, mainly related to massive bleeding. Of interest, the incidence of hemorrhage as a cause of death decreased through time during the last 30 years [3]. The type of trauma varies across countries, but in France, remains mainly related to blunt trauma in young males [4].
3.1.1. Physiological variables Various physiological items help determining prognosis of trauma patients. Age older than 65 is associated with worst prognosis than younger people [12]. This is mainly related to agerelated comorbidities. Glasgow Coma Scale, that is collected on scene, helps identifying severe patients among those with trauma brain injury: the lower the Glasgow Coma Scale, the lower the prognosis. Of major interest, Glasgow ranging between 9 and 12 is associated with worst outcome than patients with Glasgow between 4 and 8 [13]. This could be related to the undertriage process that is associated with intermediate Glasgow Coma Scale values. Although Glasgow Coma Scale is informative, it suffers from poor reliability in drunk patients. Adnet et al. reported that beside neurologic prognosis, Glasgow Coma Scale was associated with a probability of aspiration pneumonia: the lower the Glasgow Coma Scale, the higher the probability of aspiration pneumonia [14]. Systolic arterial pressure is among the variables that are collected in every trauma patients, as Glasgow Coma Scale. Systolic arterial pressure lower than 65 mmHg is associated with a very poor prognosis (mortality reaches 74% in this group of patients) [15]. Unfortunately, systolic arterial pressure may remain within normal ranges at the initial phase of acute hemorrhagic process. This is related to sympathetic compensatory mechanisms. Respiratory rate is barely recorded on scene in France. Peripheral oxygen saturation (SpO2) is preferred. SpO2 lower than 90% is associated with a 27% mortality. This rises up to 76% with SpO2 lower than 80% or non measurable SpO2 [16].
2. Why should severity be assessed in trauma patients? Severity assessment helps classifying trauma patients to determine the priority of need and proper place of treatment. It started with the phone call that alerts a trauma occurred. Phone assessment of severity allows appropriate prehospital emergency medical services response team activation (mobile intensive care unit [MICU]). On scene severity assessment allows to provide the patient with adequate therapeutics. In France, MICU administer venous line in almost all trauma patients. Half of them are intubated after sedation, and receive medical ventilation [5]. Eleven percent of these patients receive on scene norepinephrine [5]. Such an aggressive approach is associated with a better prognosis [5,6]. Eventually, severity assessment helps orientating the trauma patient to the appropriate trauma center. Severe patients should be referred to experienced and high volume trauma centers. Yet mortality decreases with volume activity in severe patients [7]. Such benefit disappears in less severe patients [8]. The non normal distribution of the probability to survive complicates the triage process [13]. Inappropriate orientation of a severe patient to an inexperienced trauma center impairs his/her prognosis. This is referred to ‘‘undertriage’’. Subsequent transfer to a level-I trauma center remains insufficient to limit detrimental effect of initial mis-orientation [9]. Undertriage should remain below 5% of the overall trauma population. Various factors are associated with undertriage: age between 45 and 54, injury severity score (ISS) above 16, Glasgow Coma Score between 13 and 15, night shift, head injury as well as pelvic injuries [10]. As mentioned above, inappropriate orientation of a non-severe trauma patient to a level-I trauma center will not affect his/her prognosis [8]. Since this ‘‘over-triage’’ leads to trauma center jamming and increases related cost, it may affect subsequent patients prognosis. Under and over-triage are interdependent. The lower the over-triage, the higher the undertriage. Accordingly, over-triage should remain between 25 and 50% to ensure undertriage remains below 5%. 3. How can severity be assessed in trauma patients? Severe trauma patients are usually defined in the literature as patients with at least one criteria in several categories that are defined based on whole-body CT-scan results [11]. Such definition precludes identifying major trauma patients before CT-scan is performed. It is thus inappropriate. A pragmatic approach leads to define severe trauma patient as a patient who sustained major trauma that might have caused lesions of poor prognosis.
3.1.2. Mechanism of injury Patients may have poor prognosis despite normal physiological assessment, especially those who experienced high velocity injury. This depends on kinetic energy that the patient receives when bumping the ground (falls) or a vehicle (road accidents). Accordingly, severity assessment should focus on injury mechanism, all the more as physiological variables are normal. Any falls higher than 6 m impairs prognosis. Following road accident, any of the following conditions is associated with masked lesions, and requires to pay attention to the patient: impact speed above 40 km/h when involving pedestrian or motorcycle, intrusion greater than 30 cm, ejection, death in the same passenger compartment [17]. 3.1.3. Anatomic lesions Trauma patients may have normal physiology, but may have anatomical lesions that requires a high level of care. Among these lesions are torso, abdominal or pelvic penetrating trauma (as well as proximal extremities penetrating trauma or amputation), chest wall instability such as flail chest, pelvic fractures, burn, paralysis, degloving trauma, ischemic lesion (now refereed to as timesensitive injury) [17]. 3.2. Score based severity assessment 3.2.1. Prehospital scores With the view toward standardizing severity assessment in trauma, various authors defined scores that are to be calculated based on physiologic variables and/or anatomic lesions. Initial Revised Trauma Score (RTS) aimed at identifying severity based on systolic arterial pressure, Glasgow Coma Scale and respiratory rate [18]. Difficulties to calculate RTS lead to build up a simplified version, refereed to as ‘‘Triage-RTS’’. It ranges from 0 to 12 (with better prognosis with elevated values). A Triage-RTS lower than 11 is known as being associated with lower prognosis. Raux et al., [16]
474
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
reported respiratory rate could be neutralized (meaning a normal value can be implemented when crud respiratory rate is missing) without impairing score performances. This score has been developed in a population without prehospital medical care. It is thus inappropriate to use it in such setting. In an attempt to create a score that assesses severity in patients with medical prehospital care, Sartorius et al. identified four items that should be pooled: mechanism (blunt + 4 points), Glasgow Come Scale (1 point per GCS value), age (below 60 + 5 points) and Pressure (systolic arterial pressure above 120 mmHg + 5 points, between 60 and 120 + 3 points) [19]. This allowed building the MGAP score, ranging from 3 (poor prognosis) to 29 (good prognosis). The c-index is fair (0,90 with 95% confidence interval [0,88–0,92]). It allows an undertriage rate below 5%. 3.2.2. Hospital scores In a way to standardize lesion description, the Abbreviated Injury Severity Score (AIS) has been developed. It is based on the topography and severity of each lesion. Every anatomical lesion is described using a six-digit number (topography and nature) followed by a single digit number (severity). The latter ranges from 1 (minor) to 6 (lethal). The AIS helps calculating the Injury Severity Score (ISS) [20]. The ISS is the sum of the square of the three highest AIS within separate body area1. Patient with an ISS above 15 is considered as severe trauma patient. Any lesion with an AIS of 6 will automatically lead to a ISS of 75. Triage-RTS, ISS and age help calculating the Trauma Related Injury Severity Score (TRISS). This score assesses the probability to survive of a group of patients, rather than of a single patient. As mentioned, it requires an extensive assessment of anatomical lesions performed. It is thus not appropriate for patient triage. 3.2.3. Scores information All the above-mentioned scores have been developed to predict mortality. However, other judgment criteria should be considered. Indeed, surviving patients may suffer from handicap related to severity. Moreover, on scene physician is interested in the score capacity to predict subsequent care requirement. Of interest, on top of mortality, Triage-RTS, MGAP and ISS all predict intensive care unit length of stay, lesions severity, ongoing hemorrhagic process [21]. Unfortunately, none of them helps identifying patients that would require emergent procedure at hospital arrival (emergent surgery, chest tube placement, embolisation). 3.3. Toward triage algorithms 3.3.1. Definition Each of the above-mentioned approaches (variables, scores. . .) suffers from weaknesses that preclude their use as single ways to assess severity in trauma patients. Accordingly, severity assessment (and subsequent triage) moved toward an algorithm approach that encompasses some of above mentioned ones. The American College of Surgeons Committee on Trauma (ACS-COT) published their first algorithm in 1986. It has been updated six times, the last update being published in 2011 [17]. French algorithm has been adapted in 2002 during the ‘‘Journe´es scientifiques du Samu’’ in Vittel, from the 1999 version of the American algorithm. This French five-step algorithm (Fig. 1) defines criteria that require trauma patient being referred to a trauma center. Since French ‘‘trauma centers’’ are not defined on an administrative basis (as in the United States), these are referred to ‘‘specialized hospital’’. Specialized hospital encompasses hospital 1 Body is divided in six main area: head and neck, torso, abdomen, pelvis, extremities and skin.
with facilities that allow to provide adequate care to any severe trauma patient (emergency room, intensive care unit, operating room, surgeons, anesthetists, intensivists, radiology, CT-scan, endovascular procedures, blood products, biology . . .). Step-one item assesses severity on a physiological basis: Glasgow Coma Scale below 13, SpO2 below 90%, systolic arterial pressure below 90 mmHg. Any patient with one of these criteria should be referred to specialized hospital. The lack of physiological criterion for severity lead to step-two item: mechanism of injury suggesting high-energy trauma. Any criterion for high-energy trauma (depicted above) should orientate the patient to a specialized hospital. In the absence of step-two criterion, physician should seek for step-three (anatomical lesions) items. Step-four does not exist in the original 1999 algorithm. It has been added to account for French physician based prehospital settings. Step-four thus encompasses any criterion for prehospital resuscitation (tracheal intubation, mechanical ventilation, fluid loading above 1000 mL, catecholamine and G-suit). Eventually, step-five items aim at defining high-risk patients based on personal medical conditions. Among those criteria is pregnancy (second and third trimesters, coagulopathy, cardiac, respiratory or renal insufficiency). Whatever the occurrence of step-one to -five items, emergency medical services provider judgment should be taken into account for adequate triage. 3.3.2. Performances Overall performance of the above-mentioned algorithm has never been assessed in France. Over-triage has been reported to be within normal range (38% in Pitie´-Salpeˆtrie`re Hospital, 42% for Beaujon Hospital, both from Assistance publique–Hoˆpitaux de Paris, France). However, undertriage rate remains unknown. Assessing undertriage requires initiating epidemiological research at the time first-responder arrives on-scene, irrespective of medical categorization (paramedics, physicians). 4. Perspectives As previously mentioned, French triage algorithm is based on the 1999 version of the ASC-COT algorithm. It should thus benefit from implementations as in 2006, 2009 and 2011 in the American versions. Among new ways to assess severity is telemetry. Vehicle collision data, stored in vehicle computer, can be sent using GSM network to emergency services. Irrespective of information transmission to facilitate severity assessment and emergency services alert, on scene severity can be assessed on a biological or radiological basis. 4.1. Biology Haemorrhage is responsible for tissue hypoxia and anaerobic metabolism, which produces lactate. Lactate has prognosis value in trauma patients, as in sepsis. Lactate level at hospital arrival is associated with survival [4]. Lactate level is not affected by venous or arterial site the sample is drawn [22]. On top of predicting day28 mortality, trauma severity, occurrence of haemorrhage and ICU stay, initial lactate predicts the requirement for emergent surgery, chest tube insertion or arterial embolization [4]. Initial lactate level provides additional information to RTS, MGAP and TRISS scores. However, it does not provide additive information in normotensive patients at hospital arrival. Of interest, lactate clearance2, provides additional information to initial lactate value. Cut-off value for lactate clearance is –20% per hour. This means any decrease of less than 20% per hour of the initial value is associated with poor outcome [4]. Relevant 2
Lactate clearance = (lactateHN–lactateH0)/lactateH0/(delay HN-H0) 100.
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
475
Fig. 1. French ‘‘Vittel’’ algorithm, based on the 1999 version of the ASC-COT American algorithm.
information of lactate clearance comes from the first two hours following hospital arrival. Prognosis value of prehospital lactate level has never been assessed in physician-based prehospital settings. Current multicentric French study aims at testing the hypothesis that prehospital lactate level provides additive information to MGAP score, thus could help prehospital triage of trauma patients.
4.2. Ultra-sonography As mentioned-above, lactate doe not convey any information in normotensive patients [4]. Recently, Corradi et al., [23] reported renal Doppler resistive index above 0,7 was associated with the occurrence of hemorrhagic shock in normotensive patients. This result should be interpreted with caution, since study population
476
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
was recruited in a ‘‘scoop and run’’ prehospital setting, without prehospital medicalization. Moreover, median trauma-to-hospital delay was far below French delays. To date, none of the available algorithms includes results from ultrasonography as criteria that could help orientating patients. Yet focused assessment with sonography for traumas is widely available, it remains to be implemented in triage algorithms. 5. Conclusion Severity assessment of trauma patient helps guiding therapeutic, as well as orientating the patient in an adequate hospital. This assessment is based on pre-trauma medical condition, physiological variables, mechanism of injury and anatomical lesions. Various authors aimed at calculating cores to summarize severity on a continuous scale. These scores are not used in clinic, but for scientific purposes. Algorithm-based triage has been proposed to account for all criteria that convey information on patient severity. Triage performance remains to be assessed. Recent studies reported biology or ultrasonography provides additive information. The benefit of prehospital implementation of these techniques remains to be assessed. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Fundings: Departmental sources. References [1] Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185–93. [2] Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center 2007;63:1338–46 [discussion: 1346–7]. [3] Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients – has anything changed? Injury 2009;40:907–11. [4] Re´gnier MA, Raux M, Le Manach Y, Asencio Y, Gaillard J, Devilliers C, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology 2012;117:1276–88. [5] Yeguiayan JM, Garrigue D, Binquet C, Jacquot C, Duranteau J, Martin C, et al. Medical prehospital management reduces mortality in severe blunt trauma: a prospective epidemiological study. Crit Care 2011;15:R34.
[6] Roudsari BS, Nathens AB, Cameron P, Civil I, Gruen RL, Koepsell TD, et al. International comparison of prehospital trauma care systems. Injury 2007;38: 993–1000. [7] Nathens AB, Brunet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. Lancet 2004;363:1794–801. [8] MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366–78. [9] Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM. Directness of transport of major trauma patients to a level-I trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma 2011;70: 1118–27. [10] Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J, et al. Predictive factors for undertriage among severe blunt trauma patients: what enables them to slip through an established trauma triage protocol? J Trauma 2010;68:1044–51. [11] A Propensity score analysis of prehospital factors and directness of transport of major trauma patients to a level-I trauma center. A propensity score analysis of prehospital factors and directness of transport of major trauma patients to a level-I trauma center. J Trauma 2011;70:120–9. [12] Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. J Trauma 2002;53: 407–14. [13] Riou B, Landais P, Vivien B, Stell P, Labbene I, Carli P. Distribution of the probability of survival is a strategic issue for randomized trials in critically ill patients. Anesthesiology 2001;95:56–63. [14] Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet 1996;348:123–4. [15] Vivien B, Raux M, Riou B. E´valuation pre´hospitalie`re de la gravite´ des traumatise´s. Ann Fr Med Urg 2010;1–10. http://dx.doi.org/10.1007/s13341-0100003-4. [16] Raux M, Thicoı¨pe´ M, Wiel E, Rancurel E, Savary D, David JS, et al. Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients. Intensive Care Med 2006;32:405–12. [17] Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Fiel Triage. MMWR Recomm Rep 2011;61(RR-1):1–20. [18] Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623–9. [19] Sartorius D, Le Manach Y, David JS, Rancurel E, Smail N, Thicoı¨pe´ M, et al. Glasgow Coma Scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients. Crit Care Med 2010;38:831–7. [20] Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96. [21] Raux M, Sartorius D, Le Manach Y, David JS, Riou B, Vivien B. What do prehospital trauma scores predict besides mortality? J Trauma 2011;71: 754–9. [22] Zakrison T, McFarlan A, Wu YY, Keshet I, Nathens A. Venous and arterial base deficits. J Trauma Acute Care Surg 2013;74:936–9. [23] Corradi F, Brusasco C, Vezzani A, Palermo S, Altomonte F, Moscatelli P, et al. Hemorrhagic shock in polytrauma patients: early detection with renal Doppler resistive index measurements. Radiology 2011;260:112–8.
Monothematic meeting of Sfar
Severity assessment in trauma patient§,§§ E´valuation de la gravite´ chez le traumatise´ M. Raux a,*,d, B. Vivien b, J.-P. Tourtier c, O. Langeron a a
Salle de surveillance post-interventionnelle et d’accueil des polytraumatise´s, de´partement d’anesthe´sie re´animation, groupe hospitalier Pitie´-Salpeˆtrie`re, Assistance publique–hoˆpitaux de Paris, 47–83, boulevard de l’Hoˆpital, 75651 Paris cedex, France b Samu de Paris, universite´ Paris Descartes Paris-V, hoˆpital Necker–Enfants malades, Assistance Publique–hoˆpitaux de Paris, 75015 Paris, France c Service me´dical d’urgence, brigade des sapeurs-pompiers de Paris, 1, place Jules-Renard, 75017 Paris, France d Universite´ Pierre-et-Marie-Curie, UPMC Paris 6, 75013 Paris, France
A R T I C L E I N F O
A B S T R A C T
Keywords: Trauma Severity Triage
Severity assessment in trauma patients is mandatory. It started during initial phone call that alerts emergency services when a trauma occurred. On-call physician assesses severity based on witnessprovided information, to adapt emergency response (paramedics, emergency physicians). Initial severity assessment is subsequently improved based on first-responder provided informations. Whenever information comes, it helps providing adequate therapeutics and orientating the patient to the appropriate hospital. Severity assessment is based upon pre-trauma medical conditions, mechanism of injury, anatomical lesions and their consequences on physiology. Severity information can be summarized using scores, yet those are not used in France, except for post-hoc scientific purposes. Triage is usually performed using algorithms. Whatever the way triage is performed, triage tools are based on mortality as main judgement criterion. Other criteria should be considered, such as therapeutics requirements. The benefit of biomarkers of ultrasonography at prehospital setting remains to be assessed. ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. R E´ S U M E´
Mots cle´s: Traumatise´ Se´ve´rite´ Triage
L’e´valuation de la gravite´ d’un patient traumatise´ fait partie des missions des moyens de secours implique´s dans sa prise en charge. Elle commence de`s la communication te´le´phonique entre l’appelant signalant l’accident et le centre de secours, au cours de laquelle elle permet au me´decin re´gulateur d’adapter les moyens de secours (secouristes, me´dicalisation pre´hospitalie`re). Cette e´valuation est secondairement e´toffe´e par le bilan transmis par les moyens de secours sur place. A` ce stade, elle guide la the´rapeutique et l’orientation du traumatise´ vers un hoˆpital adapte´ a` son e´tat, c’est-a`-dire disposant des moyens humains et mate´riels ne´cessaires a` sa prise en charge. Cette e´valuation repose actuellement sur le terrain du patient, le me´canisme le´sionnel, les le´sions et leur retentissement physiologique. Les scores sont peu utilise´s en France, ou` le triage se fait pre´fe´rentiellement au moyen d’un algorithme construit sur la base des algorithmes de triage nord-ame´ricains. Quels qu’ils soient, les moyens de cette e´valuation ont e´te´ construits autour de la mortalite´ comme crite`re de jugement principal. D’autres e´le´ments du devenir du patient, contribuant a` sa survie, rentrent en ligne de compte dans la de´cision d’orientation (besoins the´rapeutiques par exemple). Le be´ne´fice informatif de biomarqueurs ou de techniques e´chographiques pour e´valuer la gravite´ a` la phase pre´hospitalie`re reste a` e´valuer. ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Publie´ par Elsevier Masson SAS. Tous droits re´serve´s.
§
Article presented at Monothematic meeting of Sfar (Socie´te´ franc¸aise d’anesthe´sie et de re´animation): ‘‘Severe trauma: the first 24 hours’’, Paris, May 29th, 2013. This article is published under the responsibility of the Scientific Committee of the ‘‘Journe´e Monothe´matique 2013 de la Sfar’’ (http://www.jmtsfar.com). The editorial board of the Annales franc¸aises d’anesthe´sie et de re´animation was not involved in the conception and validation of its content. * Corresponding author. E-mail address: [email protected] (M. Raux). §§
0750-7658/$ – see front matter ß 2013 Socie´te´ franc¸aise d’anesthe´sie et de re´animation (Sfar). Published by Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.annfar.2013.07.004
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
473
1. Introduction
3.1. Clinical approach
Trauma is the third cause of death after cancer and cardiovascular diseases in the overall population, but the leading cause in young people (below 35). It accounts for 60 deaths out of 100 000 inhabitants in France, thus 37 415 patients in 2010. Eighty percent of dead patients died within the first 24 hours. They mainly died from massive hemorrhage or traumatic brain injury [1]. Teixera et al. [2] reported a 2.5% rate of preventable death, mainly related to massive bleeding. Of interest, the incidence of hemorrhage as a cause of death decreased through time during the last 30 years [3]. The type of trauma varies across countries, but in France, remains mainly related to blunt trauma in young males [4].
3.1.1. Physiological variables Various physiological items help determining prognosis of trauma patients. Age older than 65 is associated with worst prognosis than younger people [12]. This is mainly related to agerelated comorbidities. Glasgow Coma Scale, that is collected on scene, helps identifying severe patients among those with trauma brain injury: the lower the Glasgow Coma Scale, the lower the prognosis. Of major interest, Glasgow ranging between 9 and 12 is associated with worst outcome than patients with Glasgow between 4 and 8 [13]. This could be related to the undertriage process that is associated with intermediate Glasgow Coma Scale values. Although Glasgow Coma Scale is informative, it suffers from poor reliability in drunk patients. Adnet et al. reported that beside neurologic prognosis, Glasgow Coma Scale was associated with a probability of aspiration pneumonia: the lower the Glasgow Coma Scale, the higher the probability of aspiration pneumonia [14]. Systolic arterial pressure is among the variables that are collected in every trauma patients, as Glasgow Coma Scale. Systolic arterial pressure lower than 65 mmHg is associated with a very poor prognosis (mortality reaches 74% in this group of patients) [15]. Unfortunately, systolic arterial pressure may remain within normal ranges at the initial phase of acute hemorrhagic process. This is related to sympathetic compensatory mechanisms. Respiratory rate is barely recorded on scene in France. Peripheral oxygen saturation (SpO2) is preferred. SpO2 lower than 90% is associated with a 27% mortality. This rises up to 76% with SpO2 lower than 80% or non measurable SpO2 [16].
2. Why should severity be assessed in trauma patients? Severity assessment helps classifying trauma patients to determine the priority of need and proper place of treatment. It started with the phone call that alerts a trauma occurred. Phone assessment of severity allows appropriate prehospital emergency medical services response team activation (mobile intensive care unit [MICU]). On scene severity assessment allows to provide the patient with adequate therapeutics. In France, MICU administer venous line in almost all trauma patients. Half of them are intubated after sedation, and receive medical ventilation [5]. Eleven percent of these patients receive on scene norepinephrine [5]. Such an aggressive approach is associated with a better prognosis [5,6]. Eventually, severity assessment helps orientating the trauma patient to the appropriate trauma center. Severe patients should be referred to experienced and high volume trauma centers. Yet mortality decreases with volume activity in severe patients [7]. Such benefit disappears in less severe patients [8]. The non normal distribution of the probability to survive complicates the triage process [13]. Inappropriate orientation of a severe patient to an inexperienced trauma center impairs his/her prognosis. This is referred to ‘‘undertriage’’. Subsequent transfer to a level-I trauma center remains insufficient to limit detrimental effect of initial mis-orientation [9]. Undertriage should remain below 5% of the overall trauma population. Various factors are associated with undertriage: age between 45 and 54, injury severity score (ISS) above 16, Glasgow Coma Score between 13 and 15, night shift, head injury as well as pelvic injuries [10]. As mentioned above, inappropriate orientation of a non-severe trauma patient to a level-I trauma center will not affect his/her prognosis [8]. Since this ‘‘over-triage’’ leads to trauma center jamming and increases related cost, it may affect subsequent patients prognosis. Under and over-triage are interdependent. The lower the over-triage, the higher the undertriage. Accordingly, over-triage should remain between 25 and 50% to ensure undertriage remains below 5%. 3. How can severity be assessed in trauma patients? Severe trauma patients are usually defined in the literature as patients with at least one criteria in several categories that are defined based on whole-body CT-scan results [11]. Such definition precludes identifying major trauma patients before CT-scan is performed. It is thus inappropriate. A pragmatic approach leads to define severe trauma patient as a patient who sustained major trauma that might have caused lesions of poor prognosis.
3.1.2. Mechanism of injury Patients may have poor prognosis despite normal physiological assessment, especially those who experienced high velocity injury. This depends on kinetic energy that the patient receives when bumping the ground (falls) or a vehicle (road accidents). Accordingly, severity assessment should focus on injury mechanism, all the more as physiological variables are normal. Any falls higher than 6 m impairs prognosis. Following road accident, any of the following conditions is associated with masked lesions, and requires to pay attention to the patient: impact speed above 40 km/h when involving pedestrian or motorcycle, intrusion greater than 30 cm, ejection, death in the same passenger compartment [17]. 3.1.3. Anatomic lesions Trauma patients may have normal physiology, but may have anatomical lesions that requires a high level of care. Among these lesions are torso, abdominal or pelvic penetrating trauma (as well as proximal extremities penetrating trauma or amputation), chest wall instability such as flail chest, pelvic fractures, burn, paralysis, degloving trauma, ischemic lesion (now refereed to as timesensitive injury) [17]. 3.2. Score based severity assessment 3.2.1. Prehospital scores With the view toward standardizing severity assessment in trauma, various authors defined scores that are to be calculated based on physiologic variables and/or anatomic lesions. Initial Revised Trauma Score (RTS) aimed at identifying severity based on systolic arterial pressure, Glasgow Coma Scale and respiratory rate [18]. Difficulties to calculate RTS lead to build up a simplified version, refereed to as ‘‘Triage-RTS’’. It ranges from 0 to 12 (with better prognosis with elevated values). A Triage-RTS lower than 11 is known as being associated with lower prognosis. Raux et al., [16]
474
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
reported respiratory rate could be neutralized (meaning a normal value can be implemented when crud respiratory rate is missing) without impairing score performances. This score has been developed in a population without prehospital medical care. It is thus inappropriate to use it in such setting. In an attempt to create a score that assesses severity in patients with medical prehospital care, Sartorius et al. identified four items that should be pooled: mechanism (blunt + 4 points), Glasgow Come Scale (1 point per GCS value), age (below 60 + 5 points) and Pressure (systolic arterial pressure above 120 mmHg + 5 points, between 60 and 120 + 3 points) [19]. This allowed building the MGAP score, ranging from 3 (poor prognosis) to 29 (good prognosis). The c-index is fair (0,90 with 95% confidence interval [0,88–0,92]). It allows an undertriage rate below 5%. 3.2.2. Hospital scores In a way to standardize lesion description, the Abbreviated Injury Severity Score (AIS) has been developed. It is based on the topography and severity of each lesion. Every anatomical lesion is described using a six-digit number (topography and nature) followed by a single digit number (severity). The latter ranges from 1 (minor) to 6 (lethal). The AIS helps calculating the Injury Severity Score (ISS) [20]. The ISS is the sum of the square of the three highest AIS within separate body area1. Patient with an ISS above 15 is considered as severe trauma patient. Any lesion with an AIS of 6 will automatically lead to a ISS of 75. Triage-RTS, ISS and age help calculating the Trauma Related Injury Severity Score (TRISS). This score assesses the probability to survive of a group of patients, rather than of a single patient. As mentioned, it requires an extensive assessment of anatomical lesions performed. It is thus not appropriate for patient triage. 3.2.3. Scores information All the above-mentioned scores have been developed to predict mortality. However, other judgment criteria should be considered. Indeed, surviving patients may suffer from handicap related to severity. Moreover, on scene physician is interested in the score capacity to predict subsequent care requirement. Of interest, on top of mortality, Triage-RTS, MGAP and ISS all predict intensive care unit length of stay, lesions severity, ongoing hemorrhagic process [21]. Unfortunately, none of them helps identifying patients that would require emergent procedure at hospital arrival (emergent surgery, chest tube placement, embolisation). 3.3. Toward triage algorithms 3.3.1. Definition Each of the above-mentioned approaches (variables, scores. . .) suffers from weaknesses that preclude their use as single ways to assess severity in trauma patients. Accordingly, severity assessment (and subsequent triage) moved toward an algorithm approach that encompasses some of above mentioned ones. The American College of Surgeons Committee on Trauma (ACS-COT) published their first algorithm in 1986. It has been updated six times, the last update being published in 2011 [17]. French algorithm has been adapted in 2002 during the ‘‘Journe´es scientifiques du Samu’’ in Vittel, from the 1999 version of the American algorithm. This French five-step algorithm (Fig. 1) defines criteria that require trauma patient being referred to a trauma center. Since French ‘‘trauma centers’’ are not defined on an administrative basis (as in the United States), these are referred to ‘‘specialized hospital’’. Specialized hospital encompasses hospital 1 Body is divided in six main area: head and neck, torso, abdomen, pelvis, extremities and skin.
with facilities that allow to provide adequate care to any severe trauma patient (emergency room, intensive care unit, operating room, surgeons, anesthetists, intensivists, radiology, CT-scan, endovascular procedures, blood products, biology . . .). Step-one item assesses severity on a physiological basis: Glasgow Coma Scale below 13, SpO2 below 90%, systolic arterial pressure below 90 mmHg. Any patient with one of these criteria should be referred to specialized hospital. The lack of physiological criterion for severity lead to step-two item: mechanism of injury suggesting high-energy trauma. Any criterion for high-energy trauma (depicted above) should orientate the patient to a specialized hospital. In the absence of step-two criterion, physician should seek for step-three (anatomical lesions) items. Step-four does not exist in the original 1999 algorithm. It has been added to account for French physician based prehospital settings. Step-four thus encompasses any criterion for prehospital resuscitation (tracheal intubation, mechanical ventilation, fluid loading above 1000 mL, catecholamine and G-suit). Eventually, step-five items aim at defining high-risk patients based on personal medical conditions. Among those criteria is pregnancy (second and third trimesters, coagulopathy, cardiac, respiratory or renal insufficiency). Whatever the occurrence of step-one to -five items, emergency medical services provider judgment should be taken into account for adequate triage. 3.3.2. Performances Overall performance of the above-mentioned algorithm has never been assessed in France. Over-triage has been reported to be within normal range (38% in Pitie´-Salpeˆtrie`re Hospital, 42% for Beaujon Hospital, both from Assistance publique–Hoˆpitaux de Paris, France). However, undertriage rate remains unknown. Assessing undertriage requires initiating epidemiological research at the time first-responder arrives on-scene, irrespective of medical categorization (paramedics, physicians). 4. Perspectives As previously mentioned, French triage algorithm is based on the 1999 version of the ASC-COT algorithm. It should thus benefit from implementations as in 2006, 2009 and 2011 in the American versions. Among new ways to assess severity is telemetry. Vehicle collision data, stored in vehicle computer, can be sent using GSM network to emergency services. Irrespective of information transmission to facilitate severity assessment and emergency services alert, on scene severity can be assessed on a biological or radiological basis. 4.1. Biology Haemorrhage is responsible for tissue hypoxia and anaerobic metabolism, which produces lactate. Lactate has prognosis value in trauma patients, as in sepsis. Lactate level at hospital arrival is associated with survival [4]. Lactate level is not affected by venous or arterial site the sample is drawn [22]. On top of predicting day28 mortality, trauma severity, occurrence of haemorrhage and ICU stay, initial lactate predicts the requirement for emergent surgery, chest tube insertion or arterial embolization [4]. Initial lactate level provides additional information to RTS, MGAP and TRISS scores. However, it does not provide additive information in normotensive patients at hospital arrival. Of interest, lactate clearance2, provides additional information to initial lactate value. Cut-off value for lactate clearance is –20% per hour. This means any decrease of less than 20% per hour of the initial value is associated with poor outcome [4]. Relevant 2
Lactate clearance = (lactateHN–lactateH0)/lactateH0/(delay HN-H0) 100.
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
475
Fig. 1. French ‘‘Vittel’’ algorithm, based on the 1999 version of the ASC-COT American algorithm.
information of lactate clearance comes from the first two hours following hospital arrival. Prognosis value of prehospital lactate level has never been assessed in physician-based prehospital settings. Current multicentric French study aims at testing the hypothesis that prehospital lactate level provides additive information to MGAP score, thus could help prehospital triage of trauma patients.
4.2. Ultra-sonography As mentioned-above, lactate doe not convey any information in normotensive patients [4]. Recently, Corradi et al., [23] reported renal Doppler resistive index above 0,7 was associated with the occurrence of hemorrhagic shock in normotensive patients. This result should be interpreted with caution, since study population
476
M. Raux et al. / Annales Franc¸aises d’Anesthe´sie et de Re´animation 32 (2013) 472–476
was recruited in a ‘‘scoop and run’’ prehospital setting, without prehospital medicalization. Moreover, median trauma-to-hospital delay was far below French delays. To date, none of the available algorithms includes results from ultrasonography as criteria that could help orientating patients. Yet focused assessment with sonography for traumas is widely available, it remains to be implemented in triage algorithms. 5. Conclusion Severity assessment of trauma patient helps guiding therapeutic, as well as orientating the patient in an adequate hospital. This assessment is based on pre-trauma medical condition, physiological variables, mechanism of injury and anatomical lesions. Various authors aimed at calculating cores to summarize severity on a continuous scale. These scores are not used in clinic, but for scientific purposes. Algorithm-based triage has been proposed to account for all criteria that convey information on patient severity. Triage performance remains to be assessed. Recent studies reported biology or ultrasonography provides additive information. The benefit of prehospital implementation of these techniques remains to be assessed. Disclosure of interest The authors declare that they have no conflicts of interest concerning this article. Fundings: Departmental sources. References [1] Sauaia A, Moore FA, Moore EE, Moser KS, Brennan R, Read RA, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185–93. [2] Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, et al. Preventable or potentially preventable mortality at a mature trauma center 2007;63:1338–46 [discussion: 1346–7]. [3] Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in polytrauma patients – has anything changed? Injury 2009;40:907–11. [4] Re´gnier MA, Raux M, Le Manach Y, Asencio Y, Gaillard J, Devilliers C, et al. Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology 2012;117:1276–88. [5] Yeguiayan JM, Garrigue D, Binquet C, Jacquot C, Duranteau J, Martin C, et al. Medical prehospital management reduces mortality in severe blunt trauma: a prospective epidemiological study. Crit Care 2011;15:R34.
[6] Roudsari BS, Nathens AB, Cameron P, Civil I, Gruen RL, Koepsell TD, et al. International comparison of prehospital trauma care systems. Injury 2007;38: 993–1000. [7] Nathens AB, Brunet FP, Maier RV. Development of trauma systems and effect on outcomes after injury. Lancet 2004;363:1794–801. [8] MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006;354:366–78. [9] Garwe T, Cowan LD, Neas BR, Sacra JC, Albrecht RM. Directness of transport of major trauma patients to a level-I trauma center: a propensity-adjusted survival analysis of the impact on short-term mortality. J Trauma 2011;70: 1118–27. [10] Nakahara S, Matsuoka T, Ueno M, Mizushima Y, Ichikawa M, Yokota J, et al. Predictive factors for undertriage among severe blunt trauma patients: what enables them to slip through an established trauma triage protocol? J Trauma 2010;68:1044–51. [11] A Propensity score analysis of prehospital factors and directness of transport of major trauma patients to a level-I trauma center. A propensity score analysis of prehospital factors and directness of transport of major trauma patients to a level-I trauma center. J Trauma 2011;70:120–9. [12] Taylor MD, Tracy JK, Meyer W, Pasquale M, Napolitano LM. Trauma in the elderly: intensive care unit resource use and outcome. J Trauma 2002;53: 407–14. [13] Riou B, Landais P, Vivien B, Stell P, Labbene I, Carli P. Distribution of the probability of survival is a strategic issue for randomized trials in critically ill patients. Anesthesiology 2001;95:56–63. [14] Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia. Lancet 1996;348:123–4. [15] Vivien B, Raux M, Riou B. E´valuation pre´hospitalie`re de la gravite´ des traumatise´s. Ann Fr Med Urg 2010;1–10. http://dx.doi.org/10.1007/s13341-0100003-4. [16] Raux M, Thicoı¨pe´ M, Wiel E, Rancurel E, Savary D, David JS, et al. Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients. Intensive Care Med 2006;32:405–12. [17] Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Fiel Triage. MMWR Recomm Rep 2011;61(RR-1):1–20. [18] Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623–9. [19] Sartorius D, Le Manach Y, David JS, Rancurel E, Smail N, Thicoı¨pe´ M, et al. Glasgow Coma Scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients. Crit Care Med 2010;38:831–7. [20] Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187–96. [21] Raux M, Sartorius D, Le Manach Y, David JS, Riou B, Vivien B. What do prehospital trauma scores predict besides mortality? J Trauma 2011;71: 754–9. [22] Zakrison T, McFarlan A, Wu YY, Keshet I, Nathens A. Venous and arterial base deficits. J Trauma Acute Care Surg 2013;74:936–9. [23] Corradi F, Brusasco C, Vezzani A, Palermo S, Altomonte F, Moscatelli P, et al. Hemorrhagic shock in polytrauma patients: early detection with renal Doppler resistive index measurements. Radiology 2011;260:112–8.