|Year : 2019 | Volume
| Issue : 1 | Page : 11-16
Correlation of dysoxia metabolism markers with trauma scoring systems in multiple trauma patients admitted to the emergency department: A cross-sectional observational study
Reza Nikfarjam1, Zahra Khazaeipour2, Alireza Baratloo3, Seyed Mojtaba Aghili4
1 Department of Emergency Medicine, Imam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran
2 Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran
3 Prehospital and Hospital Emergency Research Center; Department of Emergency Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
4 Department of Emergency Medicine, Imam Khomeini Hospital; Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran, Iran
|Date of Submission||11-Nov-2018|
|Date of Acceptance||06-Feb-2019|
|Date of Web Publication||2-Aug-2019|
Dr. Seyed Mojtaba Aghili
Prehospital and Hospital Emergency Research Center, Tehran University of Medical Sciences, Tehran; Department of Emergency Medicine, Imam Khomeini Complex Hospital, Tehran University of Medical Sciences, Tehran
Source of Support: None, Conflict of Interest: None
Background: All the trauma scoring systems (TSSs) have some limitations, and none is useful for patient monitoring. Recently, investigators have tried to modify the TSSs to improve their use. Aims: This study was conducted to determine whether any correlation exists between dysoxia metabolism markers (DMMs), including venous base deficit (BD) and HCO3level with different TSSs. Materials and Methods: In this cross-sectional study, all multiple trauma patients admitted to the emergency department were eligible. Blood samples for venous blood gas analysis were taken at the onset of resuscitation process. TSSs, including trauma index (TI), abbreviated injury score (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma Score-ISS (TRISS), were calculated for the patients. Spearman's rank correlation coefficient test was applied to find the association between the independent variables. Results: A total of 285 patients with a mean age of 33.37 ± 15.29 fulfilled the inclusion criteria, of which, 211 cases (74.0%) were male. Statistical analysis revealed that there was a correlation between TI and HCO3level (P = 0.0001, r = −0.37) and also TI and BD (P = 0.0001, r = −0.47). Furthermore, there was an indirect correlation between AIS and ISS with HCO3and BD levels and the direct correlation between RTS and TRISS with HCO3and BD levels. Conclusion: It is likely that there is a statistical correlation, although weak, between TSSs with DMMs, including HCO3and BD level.
Keywords: Acid-base imbalance, correlation of data, hemodynamic monitoring, trauma severity indices
|How to cite this article:|
Nikfarjam R, Khazaeipour Z, Baratloo A, Aghili SM. Correlation of dysoxia metabolism markers with trauma scoring systems in multiple trauma patients admitted to the emergency department: A cross-sectional observational study. Arch Trauma Res 2019;8:11-6
|How to cite this URL:|
Nikfarjam R, Khazaeipour Z, Baratloo A, Aghili SM. Correlation of dysoxia metabolism markers with trauma scoring systems in multiple trauma patients admitted to the emergency department: A cross-sectional observational study. Arch Trauma Res [serial online] 2019 [cited 2019 Oct 19];8:11-6. Available from: http://www.archtrauma.com/text.asp?2019/8/1/11/263974
| Introduction|| |
Trauma is the most common cause of mortality in young and middle-aged patients worldwide.,,, Several trauma scoring systems (TSSs) have been developed for the classification of trauma patients, grading the severity of the injury, and predicting their outcomes. However, all these scoring systems have some limitations and none is useful for patient monitoring.,, It is also well established that systolic blood pressure (SBP), heart rate (HR), shock index (SI), and urine output measurement are not adequate, although useful for appropriate monitoring.,,,,
On the other hand, it was believed that acid–base balance may better reveal the ongoing situation of hemodynamic of such patients. As recent studies have reported, dysoxia (abnormal tissue oxygen utilization) metabolism markers (DMMs), including serum bicarbonate (HCO3) and base deficit (BD) levels, could be considered as valuable markers to evaluate the actual tissue perfusion in shock state, although some controversies still exist.,,,, BD refers to a deficit in the amount of base existing in blood, with positive numbers indicating an excess of base and negative a deficit. The normal values for BD are −2 to +2 mEq/L. It should also be mentioned that the typical reference range for HCO3 is 22–26 mmol/L. The severity of metabolic acidosis is to predict the occurrence of organ failure, length of hospital stay, transfusion requirements, and mortality; normalization of them plays the role of an end-point in therapy or resuscitation.,,
Recently, investigators have tried to modify the TSSs to improve their use.,,
It was believed that major trauma may cause hypoperfusion could lead to tissue hypoxemia that is indicated as metabolic acidosis. HCO3 and BD are the markers to measure the tissue hypoxemia and metabolic acidosis. We have a hypothesis that adding DMMs to the current TSSs and developing modified scoring systems would be helpful in better monitoring of traumatic patients. For the first step in evaluating this hypothesis, we had a challenge whether there is a correlation between DMMs and TSSs or not. Although various studies addressed this subject, the controversial results necessitate further studies. Therefore, this study was designed and conducted to determine whether any correlation exists between DMMs, including venous BD and HCO3 level with different TSSs.
| Materials and Methods|| |
Study design and population
This cross-sectional observational study was conducted between September 2014 and June 2015 in the emergency department (ED) of a level-1 trauma center in Tehran, Iran. All multiple trauma patients admitted to the ED over the age of 5 years were eligible. A diagnosis of “multiple trauma” implies the presence of two or more separate injuries, at least one or a combination of which endangers the patient's life.
Lack of required data for calculating TSSs or not requesting blood gas analysis by in-charge physicians was considered as excluding criteria. Patients with a major head injury, known acid–base disturbances, and those who received exogenous NaHCO3 before laboratory analysis or were pronounced dead on arrival were also excluded from this study. Based on the results of previous studies, assuming a 0.2 correlation between DMMs and TSSs in multiple trauma patients, and considering α = 0.05, β = 0.2 for assessing this correlation, based on the correlation study formula, the least sample size was calculated as 250.
The utility of vital signs, metabolic parameters, and different trauma grading systems to detect major injury was evaluated. All patients underwent initial triage using emergency severity index version-4 (ESI-4) and advanced trauma life support (ATLS) was applied for all. A 3rd postgraduate year emergency medicine resident was responsible for data gathering and not interfering with patients' management. Patients' demographic information (age and sex), triage level, the mechanism of injury, physical exam findings, on-arrival vital signs (SBP, diastolic blood pressure [BP], HR, respiratory rate (RR), O2-saturation, and calculated SI [defined as a ratio of HR to SBP]), whether transferred by emergency medical service (EMS) or not, and on-arrival Glasgow Coma Scale (GCS), were all documented in a preprepared checklist.
All vital signs were evaluated automatically using a monitoring device (SAADAT/ALBORZ-B9 [based on the device catalog, accuracy in measuring vital signs were as HR: −1% or 2 BPM; BP: 2% or 2 mmHg; T: −0.2 C; RR: ±2% or 2 BrPM]).
Computed tomography scans pathologic findings, and report of performed surgery, if done, were all also reviewed. Thereafter, TSSs, including trauma index (TI), abbreviated injury score (AIS), Injury Severity Score (ISS), Revised Trauma Score (RTS), and Trauma Score-ISS (TRISS) were calculated for the patients. The exact score range of each scale and method of calculation are available through the link “http://www.trauma.org/archive/scores/index.html.”
A blood sample was obtained by the in-charge nurse from the patient for venous blood gas (VBG) analysis, and measured parameters (PH, HCO3, PCO2, and BD) were also recorded in the checklist. VBG analyses were performed by an automated device (GEM Premier 4000 [with the accuracy of 99.2%]).
Following the established clinical practice guideline in the studied ED, the blood samples for VBG analysis were taken at the onset of the resuscitation process. The mentioned data were collected prospectively by an emergency medicine resident who is one of the coauthors of the present study.
Values were expressed as frequency (number and percentage), mean and median (standard deviation [SD], and interquartile range) as appropriate. Shapiro–Wilks test and Q-Q plot were used to check the normality assumption for the variable; thus according to the establishment of assumptions, parametric or nonparametric test was done. Mann–Whitney U and Kruskal–Wallis tests were used to compare the numerical variables. Spearman's rank correlation coefficient test was applied to find the association of independent variables. P < 0.05 was considered as statistically significant. Statistical analyses were performed using the IBM SPSS software package, version 22.0, (SPSS Inc., Chicago, IL, USA).
The study methodology was approved by the Institutional Review Board and Ethical Committee of Tehran University of Medical Sciences and code IR.TUMS.REC.1394.2213 was assigned. The investigators did not interfere with patients' management, and all required data were extracted from their files.
| Results|| |
A total of 285 patients with a mean age of 33.37 ± 15.29 fulfilled the inclusion criteria, of whom, 74.0% were male. The demographic and baseline characteristics of studied patients are reported in [Table 1]. Based on the findings, motor vehicle collisions were the most prevalent cause of trauma (n = 109, 38.2%). The majority of patients (n = 202, 71.0%) were delivered to the hospital by the EMSs. The majority of patients had a GCS of 14–15 (n = 248, 87.0%) and most of them were classified as level 3 triage (n = 111, 38.9%). The majority of patients were discharged from ED (n = 144, 50.52%).
|Table 1: The demographic and baseline characteristics of studied multiple trauma patients|
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The mean ± SD of each calculated TSSs and measured DMMs in studied patients are reported in [Table 2]. In all participants, the mean of TI was 9.15 ± 4.36. Calculated TSSs were not significantly different based on sex, mechanism of trauma, and transfer by EMS (P > 0.05).
|Table 2: The mean±standard deviation of each calculated trauma scoring systems and measured dysoxia metabolism markers in studied multiple trauma patients|
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[Figure 1] contains 15 graphs in five rows related to each TSS and three columns related to triage level, GCS, and outcomes of the studied patients. Based on the findings revealed in the graphs, calculated TSSs significantly differed based on the triage level, on-arrival GCS, and outcome (P < 0.001); therefore, TI was expected to be higher in triage level 1, GCS <9 and dead patients.
|Figure 1: Distribution of trauma scoring systems in triage level, on-arrival Glasgow Coma Scale, and outcome in studied multiple trauma patients|
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Statistical analysis revealed that there was a correlation between TI and HCO3 level (P = 0.0001, r = −0.37) and also TI and BD (P = 0.0001, r = −0.47). Furthermore, there were indirect correlations between AIS and ISS with HCO3 and BD levels, and the direct correlation between RTS and TRISS with HCO3 and BD levels [Table 3].
|Table 3: Correlation of trauma scoring systems and measured venous blood gas analysis components in studied multiple trauma patients|
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Although weak, there was a statistical correlation between ESI and HCO3 level (P = 0.02, r = 0.19) and ESI and BD (P = 0.0001, r = 0.32). In addition, a correlation was detected between ESI and length of hospital stay (P = 0.0001, r = −0.42) and hospitalization costs (P = 0.0001, r = −0.52). A correlation was also found between TI and length of hospital stay (P = 0.0001, r = 0.33) and hospitalization costs (P = 0.0001, r = 0.44).
| Discussion|| |
This study was conducted to determine the correlation between DMMs, including venous BD and HCO3 level with different TSSs. The results of this study showed a relative correlation between TSSs with measured DMMs.
It was well demonstrated that major disturbances in acid–base balance should be diagnosed and managed immediately in critically ill or injured patients; and it was assumed that major traumatic events could start a process of physical and electrochemical functions that may result in acute changes of acid–base balance. Accordingly, here, we discussed the current challenges regarding hemodynamic monitoring in multiple trauma patients and the possible role of HCO3 and BD further in this regard.
Multiple variables such as evaluation of BD, lactate, anion gap and mixed venous oxygen saturation, and also the efficiency of modalities such as sublingual capnometry, gastric tonometry, transcutaneous oxygen, or carbon dioxide monitoring have been studied to determine the occurrence of tissue hypoperfusion and/or the acidosis.,,, But obviously, some of them do not apply to patients with trauma and some are more feasible to use. Albeit, there is continuing debate regarding the relative advantages and feasibility of each technique, especially in trauma patients.
The best marker must be precise, reliable, and cost-effective in terms of time and equipment and must be easily obtained. Modalities, such as orthostatic vital signs, capillary refill, and central venous oxygen saturation, have been used to identify low circulating blood volume, but several criteria, including age or gender may influence the results.,
A direct measure of systemic oxygen delivery and consumption had been conventionally evaluated through central cannulation as an invasive monitoring method. Central arterial/venous oxygen saturation and lactate are superior to BP, HR, and central venous pressure in evaluating and monitoring after trauma. However, central venous cannulation is not always practical and is not commonly performed in patients with normal vital signs.,,, On the other hand, pH and BD are the most frequently applied markers considered as indicators of anaerobic metabolism that have been used as an endpoint of resuscitation could easily and repetitively be available with a simple peripheral blood sampling for VBG analysis. By applying VBG evaluation, the risk of local arterial-related complications from arterial manipulation such as hand ischemia was eliminated.,
Several studies have demonstrated that the admission BD is a prognostic marker of morbidity and mortality in trauma patients and the normalization of which correlates with enhanced outcomes. According to the study of Paladino et al., BD and lactate increase the ability to differentiate major from minor trauma if being added to triage vital signs. The results of the study of Mutschler et al. revealed that BD may be superior to the current ATLS classification of hypovolemic shock in identifying the need for early blood product transfusion in patients with hypovolemic shock. Similar results were obtained in the study of Kincaid et al. suggesting the correlation between a steadily high arterial BD and distorted oxygen utilization, elevated risk of multiple organ failure, and mortality in trauma patients. Accordingly, it was recommended that serial monitoring of BD may be a practical method in evaluating the sufficiency of resuscitation. Mofidi et al. suggested that BD can be applied as an early accessible indicator of intra-abdominal injury and a high transfusion requirement in patients with blunt abdominal trauma. Schmelzer et al. demonstrated that central venous BD was a more accurate predictor of survival compared to arterial BD that may be due to the fact that venous blood reflects systemic effects of shock; whereas the arterial BD imitates ventilation and oxygenation deficits. Similarly, VBG analysis was performed in the current study to evaluate acid–base parameters and different trauma scores.
Serum HCO3 measurement may be an accurate and reliable substitute for the arterial BD evaluation. The study conducted by Martin et al. showed that serum HCO3 assessment provides an equal information to the arterial BD and may be applied as a substitute marker. In the present study, admission parameters that may affect the outcome of trauma patients were evaluated and showed that TSSs were statistically but weakly correlated with HCO3 level.
The TSSs may be applied as important determinants of clinical outcome in critically injured patients and may be safely and reliably substituted with previously applied measurement techniques for trauma patients. However, considering the fact that trauma is multi-factorial in origin, these modalities should not be replaced with a total evaluation of the critically traumatized patient. HCO3 alternation may precisely identify metabolic acidosis that demands prompt assessment and immediate interventions. There is a strong correlation between a steadily altered BD and altered oxygen consumption, extravascular fluid appropriation, and an increased risk of mortality in severely injured trauma patients. Therefore, an insight into the sufficiency of therapy may be provided by serial monitoring of BD. Along with a total assessment of the trauma patient, correction of BD may be associated with improved cellular oxygen applied that may be one of the suitable goals of resuscitation.
The current study has several limitations. In spite of strong and reliable correlation found between TI with HCO3 level and BD in the whole population, this relationship may be varied or even invalid on an unidentified subgroup of patients. For example, considering the age limit and some other baseline characteristics would be interfering with the results. This article would be suitable as a pilot study on this challenging topic to attract the attention of other researchers to make better studies on this topic.
| Conclusion|| |
Based on our findings, it is likely that there is a statistical correlation between TSSs with DMMs, including HCO3 and BD level. There was an indirect correlation between TI, AIS, and ISS with HCO3 and BD levels and the direct correlation between RTS and TRISS with HCO3 and BD levels.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Rhee P, Joseph B, Pandit V, Aziz H, Vercruysse G, Kulvatunyou N, et al.
Increasing trauma deaths in the United States. Ann Surg 2014;260:13-21.
Tyson AF, Varela C, Cairns BA, Charles AG. Hospital mortality following trauma: An analysis of a hospital-based injury surveillance registry in Sub-Saharan Africa. J Surg Educ 2015;72:e66-72.
Moore L, Evans D, Hameed SM, Yanchar NL, Stelfox HT, Simons R, et al.
Mortality in Canadian trauma systems: A multicenter cohort study. Ann Surg 2017;265:212-7.
Baratloo A, Mirbaha S, Bahreini M, Banaie M, Safaie A. Outcome of trauma patients admitted to emergency department based on full outline of unresponsiveness score. Adv J Emerg Med 2017;1:e2.
de Munter L, Polinder S, Lansink KW, Cnossen MC, Steyerberg EW, de Jongh MA. Mortality prediction models in the general trauma population: A systematic review. Injury 2017;48:221-9.
Lecky F, Woodford M, Edwards A, Bouamra O, Coats T. Trauma scoring systems and databases. Br J Anaesth 2014;113:286-94.
Champion HR. Trauma scoring. Scand J Surg 2002;91:12-22.
Kuster M, Exadaktylos A, Schnüriger B. Non-invasive hemodynamic monitoring in trauma patients. World J Emerg Surg 2015;10:11.
Strumwasser A, Frankel H, Murthi S, Clark D, Kirton O; American Association for the Surgery of Trauma Committee on Critical Care. Hemodynamic monitoring of the injured patient: From central venous pressure to focused echocardiography. J Trauma Acute Care Surg 2016;80:499-510.
Cecconi M, De Backer D, Antonelli M, Beale R, Bakker J, Hofer C, et al.
Consensus on circulatory shock and hemodynamic monitoring. Task force of the European society of intensive care medicine. Intensive Care Med 2014;40:1795-815.
Antonelli M, Levy M, Andrews PJ, Chastre J, Hudson LD, Manthous C, et al.
Hemodynamic monitoring in shock and implications for management. International consensus conference, Paris, France, 27-28 april 2006. Intensive Care Med 2007;33:575-90.
Pinsky MR. Functional haemodynamic monitoring. Curr Opin Crit Care 2014;20:288-93.
Rahim-Taleghani S, Fatemi A, Alavi Moghaddam M, Shojaee M, Abushouk AI, Forouzanfar MM, et al.
Correlation of central venous pressure with venous blood gas analysis parameters; a diagnostic study. Turk J Emerg Med 2017;17:7-11.
Kushimoto S, Akaishi S, Sato T, Nomura R, Fujita M, Kudo D, et al.
Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients. Acute Med Surg 2016;3:293-7.
Soller B, Zou F, Prince MD, Dubick MA, Sondeen JL. Comparison of noninvasive pH and blood lactate as predictors of mortality in a swine hemorrhagic shock with restricted volume resuscitation model. Shock 2015;44 Suppl 1:90-5.
Tuma M, Canestrini S, Alwahab Z, Marshall J. Trauma and endothelial glycocalyx: The microcirculation helmet? Shock 2016;46:352-7.
Paladino L, Sinert R, Wallace D, Anderson T, Yadav K, Zehtabchi S. The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs. Resuscitation 2008;77:363-8.
Randolph LC, Takacs M, Davis KA. Resuscitation in the pediatric trauma population: Admission base deficit remains an important prognostic indicator. J Trauma 2002;53:838-42.
Davis BL, Schreiber MA. Endpoints of Resuscitation, in Surgical Critical Care Therapy. Berlin, Germany: Springer; 2018. p. 107-13.
McBeth PB, Chow L. Monitoring and end-points of trauma resuscitation. Curr Trauma Rep 2017;3:124-34.
Kim SC, Kim DH, Kim TY, Kang C, Lee SH, Jeong JH, et al.
The revised trauma score plus serum albumin level improves the prediction of mortality in trauma patients. Am J Emerg Med 2017;35:1882-6.
Weeks SR, Stevens KA, Haider AH, Efron DT, Haut ER, MacKenzie EJ, et al.
Amodified Kampala trauma score (KTS) effectively predicts mortality in trauma patients. Injury 2016;47:125-9.
Akay S, Ozturk AM, Akay H. Comparison of modified Kampala trauma score with trauma mortality prediction model and trauma-injury severity score: A national trauma data bank study. Am J Emerg Med 2017;35:1056-9.
Frink M, Lechler P, Debus F, Ruchholtz S. Multiple trauma and emergency room management. Dtsch Arztebl Int 2017;114:497-503.
Gunnerson KJ, Kellum JA. Acid-base and electrolyte analysis in critically ill patients: Are we ready for the new millennium? Curr Opin Crit Care 2003;9:468-73.
Smith I, Kumar P, Molloy S, Rhodes A, Newman PJ, Grounds RM, et al.
Base excess and lactate as prognostic indicators for patients admitted to intensive care. Intensive Care Med 2001;27:74-83.
Heard SO. Gastric tonometry: The hemodynamic monitor of choice (Pro). Chest 2003;123:469S-74S.
Boswell SA, Scalea TM. Sublingual capnometry: An alternative to gastric tonometry for the management of shock resuscitation. AACN Clin Issues 2003;14:176-84.
Shoemaker WC, Wo CC, Chan L, Ramicone E, Kamel ES, Velmahos GC, et al.
Outcome prediction of emergency patients by noninvasive hemodynamic monitoring. Chest 2001;120:528-37.
Shoemaker WC, Wo CC, Chan L, Ramicone E, Kamel ES, Velmahos GC, et al
. Detection of low-volume blood loss: Compensatory reserve versus traditional vital signs. J Trauma Acute Care Surg 2014;77:892-7.
Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Fabian T, Paffrath T, et al.
Renaissance of base deficit for the initial assessment of trauma patients: A base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the traumaRegister DGU®. Crit Care 2013;17:R42.
Kincaid EH, Miller PR, Meredith JW, Rahman N, Chang MC. Elevated arterial base deficit in trauma patients: A marker of impaired oxygen utilization. J Am Coll Surg 1998;187:384-92.
Mofidi M, Hasani A, Kianmehr N. Determining the accuracy of base deficit in diagnosis of intra-abdominal injury in patients with blunt abdominal trauma. Am J Emerg Med 2010;28:933-6.
Schmelzer TM, Perron AD, Thomason MH, Sing RF. A comparison of central venous and arterial base deficit as a predictor of survival in acute trauma. Am J Emerg Med 2008;26:119-23.
Martin MJ, FitzSullivan E, Salim A, Berne TV, Towfigh S. Use of serum bicarbonate measurement in place of arterial base deficit in the surgical intensive care unit. Arch Surg 2005;140:745-51.
[Table 1], [Table 2], [Table 3]