J. O. Hwabejire1,2, B. A. Adesibikan2, T. A. Oyetunji3, M. Williams2, S. M. Siram2, E. Cornwell III2, W. R. Greene4 1Massachusetts General Hospital,Division Of Trauma, Emergency Surgery, And Surgical Critical Care/Department Of Surgery,Boston, MA, USA 2Howard University College Of Medicine,Surgery,Washington, DC, USA 3Children’s Mercy Hospital- University Of Missouri Kansas City,Surgery,Kansas City, MO, USA 4Emory University School Of Medicine,Surgery,Atlanta, GA, USA
Introduction: Major thoracic injury is one of the causes of hemorrhagic shock in patients who suffer severe blunt trauma. The goal of this study is to determine the factors that contribute to increased mortality in blunt traumatic hemorrhagic shock necessitating a thoracic surgical procedure.
Methods: The Glue Grant database was retrospectively examined. Patients aged ≥ 16 years and had either a thoracotomy, sternotomy or video-assisted thoracoscopic surgery (VATS) were included in the analysis. Univariate analysis was used to compare survivors and non-survivors, while multivariable analysis was used to ascertain predictors of mortality.
Results: A total of 205 patients were included in the analysis. Their average age was 43 years (SD=18), 72% were males, and 87% were White. This subset had an in-hospital mortality of 37 %. When compared to non-survivors, survivors had a higher BMI (28.0 ±6.7 vs. 22.3 ±12.4 kg/m2, p<0.001), higher emergency room (ER) systolic BP (104±36 mmHg vs. 90 ±36 p=0.010), lower ER lactate (5.1 ±3.0 vs. 8.0 ±3.8 mg/dL, p<0.001), were less coagulopathic (ER INR: 1.4 ±0.5 vs. 2.0±1.9, p=0.002 ), and received a lower volume of blood products within 12 hours of presentation (3599±3249 vs. 8470±6978 mL, p<0.001). There were no differences in age, gender, race, Injury Severity Score (ISS), multiple organ dysfunction score, volume of crystalloids received within 12 hours of presentation, and pre-injury comorbidities between the two groups. About half of survivors (53.4%) underwent a laparotomy compared to 73.7% of non-survivors (p=0.004). In the multivariable analysis, ER lactate (OR: 1.21, CI 1.07-1.37, p=0.002) was the only independent predictor of mortality. Higher BMI appeared to be protective against mortality (OR: 0.951, CI 0.905-0.998, p=0.043).
Conclusion: In blunt traumatic hemorrhagic shock requiring a thoracic surgical procedure, the degree of tissue hypoperfusion as represented by the serum lactate on presentation in the ER is an independent predictor of mortality.