J. Carney1, A. Strumwasser1, K. Matsushima1, D. Grabo1, D. Clark1, K. Inaba1, E. Benjamin1, L. Lam1, D. Demetriades1 1University Of Southern California,Surgery – Trauma/Acute Care Surgery,Los Angeles, CA, USA
Introduction: The triage of hemodynamically abnormal trauma patients is debated. Controversial data suggests that hemodynamically abnormal patients can safely undergo CT prior to definitive therapy. We wished to investigate outcomes for hemodynamically abnormal thoracoabdominal trauma undergoing CT.
Methods: All hemodynamically abnormal (HR≥120, SBP<90 mmHg) patients arriving at our Level I trauma center in 2014 were reviewed. Inclusion criteria were thoracoabdominal trauma patients that achieved hemodynamic normalization (SBP≥90 mmHg) and were eligible for CT. Pregnant patients, pediatric patients (age<18), patients undergoing resuscitative thoracotomy, and isolated head, neck and extremity injuries were excluded. Variables abstracted from the registry included patient demographics, injury mechanism, injury severity score (ISS), physical exam, E-FAST results, laboratory data, CT scan findings and operative details. Primary outcomes included hospital length-of-stay (HLOS), ICU LOS, ventilator days and mortality. Secondary outcomes included intraoperative data (procedure duration, fluids, blood loss), transfusion burden, incidence of venous thromboembolism (VTE), infectious complications, need for additional procedures, and total hospital cost. Data was analyzed by unpaired Student’s t-test for continuous variables and Chi Square analysis for categorical variables with significance denoted at a p value of 0.05 or less.
Results: A total of 201 patients met inclusion criteria. Thirty-five (17%) went directly to the OR at triage, 117 (59%) went to CT, and 49 (24%) were spared an operation. The CT and non-CT groups were well matched at baseline for age (34±2.0 vs. 38±1.2 years, p=0.1), injury burden (mean ISS-CT=18±2.7 vs. ISS-non-CT=18±0.9) and total resuscitation time (81±43.0 vs. 67±9.4 minutes, p=0.7). No difference in time-to-normalization of lactate, HLOS, ICU LOS or mortality was observed (p>0.1 for each). Patients undergoing CT prior to OR had increased recognition of intraabdominal injuries (89 vs. 74%, p=0.05), a significant reduction in negative explorations (2.3 vs. 8.6%, p<0.01) and a decreased need for PRBCs (2±0.6 vs. 7±2.5 units, p<0.01), FFP (1±0.3 vs. 4±1.3, p<0.01) and platelets (0.3±0.1 vs. 1±0.4 units, p=0.03) throughout admission. Moreover, patients in the non-CT group had an increased need for surgical procedures (37.1 vs. 12.1%, p<0.01) after the index operation. No differences were noted in any secondary outcome (p>0.1 for each).
Conclusion: Hemodynamically abnormal thoracoabdominal trauma achieving a SBP≥90 during resuscitation should undergo CT scanning prior to definitive therapy. Imaging increases the identification of intraabdominal injuries, decreases negative explorations, decreases transfusion burden and decreases the need for additional surgical procedures without affecting morbidity, mortality or hospital cost.