What is ‘hypotension’ in penetrating trauma?

October 6, 2012 by  
Filed under All Updates, EMS, Resus, Trauma

I previously noted an article demonstrating that a ‘lowish’ – as opposed to a low – systolic blood pressure is a reason to be vigilant in blunt trauma patients, as a significant increase in mortality has been demonstrated with a systolic blood pressure (SBP) < 110 mmHg.

The same researchers have found similar results in patients with penetrating trauma.
Compared with the reference group with SBP 110-129mmHg, mortality was doubled at SBP 90-109mmHg, was four-fold higher at 70-89mmHg and 10-fold higher at <70mmHg. SBP values ≥150mmHg were associated with decreased mortality.

Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study
Resuscitation. 2012 Apr;83(4):476-81


INTRODUCTION: Non-invasive systolic blood pressure (SBP) measurement is a commonly used triaging tool for trauma patients. A SBP of <90mmHg has represented the threshold for hypotension for many years, but recent studies have suggested redefining hypotension at lower levels. We therefore examined the association between SBP and mortality in penetrating trauma patients.

METHODS: We conducted a prospective cohort study in adult (≥16 years) penetrating trauma patients. Patients were admitted to hospitals belonging to the Trauma Audit and Research Network (TARN) between 2000 and 2009. The main outcome measure was the association between SBP and mortality at 30 days. Multivariate logistic regression models adjusted for the influence of age, gender, Injury Severity Score (ISS) and Glasgow Coma Score (GCS) on mortality were used. RESULTS: 3444 patients with a median age of 30 years (IQR 22.5-41.4), SBP of 126mmHg (IQR 107-142), ISS of 9 (IQR 9-14) and GCS of 15 (IQR 15-15), were analysed. Multivariable logistic regression analysis adjusted for age, gender, severity of injury and level of consciousness showed a cut-off for SBP at <110mmHg, after which increased mortality was observed. Compared with the reference group with SBP 110-129mmHg, mortality was doubled at SBP 90-109mmHg, was four-fold higher at 70-89mmHg and 10-fold higher at <70mmHg. SBP values ≥150mmHg were associated with decreased mortality.

CONCLUSION: We recommend that penetrating trauma patients with a SBP<110mmHg are triaged to resuscitation areas within dedicated, appropriately specialised, high-level care trauma centres.

Comments

2 Responses to “What is ‘hypotension’ in penetrating trauma?”

  1. Matthew on October 6th, 2012 21:25

    Cliff,

    Interesting article, would this put a spanner in the works of ‘permissive hypotension’ for you?
    It would be interesting to know some more about the different groups, i.e. fluid received, blood products etc. And whether the hospital treating the patients bought into the Mattox/Brohi theory. Possibly not and therefore perhaps the hypotensive group received more fluids and therefore did worse??
    Unfortunately I can’t access the article via my institution (damn you CIAP!)

  2. Minh Le Cong on October 7th, 2012 17:13

    this has always troubled me about permissive hypotensive theory. I regard the longer retrieval and evacuation to definitive care is, for trauma and even penetrating trauma, there is a requirement to maintain adequate perfusing pressure, How to measure this, attain and maintain it, all in the prehospital setting, remains at the frontier of our specialty.