Papers presented
Systemic hypotension is a late marker of shock after trauma: a validation study of Advanced Trauma Life Support principles in a large national sample

Presented at the 58th Annual Meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 3–7, 2006
https://doi.org/10.1016/j.amjsurg.2006.08.034Get rights and content

Abstract

Background

Systolic blood pressure is used extensively to triage trauma patients as stable or unstable, contrary to Advanced Trauma Life Support recommendations. We hypothesized that systemic hypotension is a late marker of shock.

Methods

The National Trauma Data Bank was queried (n = 115,830). Base deficit was used as a measure of circulatory shock. Systolic blood pressure was correlated with the presence and the severity of base-deficit derangement.

Results

Systolic blood pressure correlated poorly with base deficit (r = .28). There was wide variation in systolic blood pressure within each base-deficit group. The mean and median systolic blood pressure did not decrease to less than 90 mm Hg until the base deficit was worse than −20, with mortality reaching 65%.

Conclusions

We validated the Advanced Trauma Life Support principle that systemic hypotension is a late marker of shock. A normal blood pressure should not deter aggressive evaluation and resuscitation of trauma patients.

Section snippets

Methods

The National Trauma Data Bank (NTDB) of the American College of Surgeons, the largest nationwide database of trauma patients, with more than 400 participating trauma centers and more than 1 million individual records, was queried (NTDB, version 4.0, 2004; N = 1,130,581). We used base deficit in the emergency department as a marker of shock because it has been validated previously as a reliable marker of shock severity in injured patients [11], [14], [15], [16]. Base deficit was measured in a

Results

In the study population, 64% of patients were 15 to 44 years of age, 71% were male, 82% sustained a blunt injury, and 74% were treated at a level 1 trauma center. The mean GCS was 12 ± 5, the Injury Severity Score was 16 ± 13, and the base deficit was −2 ± 5. The overall mortality rate was 10%, with a mean length of stay of 9 ± 15 days. Systemic hypotension was noted in 7,910 patients (7%). Compared with patients with a higher SBP, hypotensive patients had a significantly higher mortality rate

Comments

This study shows that systemic hypotension in trauma patients does not occur until the degree of shock is profound, and, hence, is an unreliable means of detecting clinically significant shock. This study validates the long-standing ATLS principle that hypotension is a late marker of shock in a large national sample of trauma patients. Although the relationship between systemic hypotension and outcome is well documented, few studies have shown the magnitude of shock and degree of anaerobic

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