A transient response: a patient who will not stay up

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Not clinically reviewed. No clinician has signed this scenario.

• Clarke JR, Trooskin SZ, Doshi PJ, Greenwald L, Mode CJ. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma. 2002;52(3):420-5. Patients in the Pennsylvania Trauma Systems Foundation trauma registry with isolated abdominal vascular, solid organ, or wall injuries grade 3 to 6 and hypotension; 243 patients met the criteria, with systolic blood pressure ranging from 30 to 90 mmHg, time to the emergency department 7 to 185 minutes and time in the department 7 to 915 minutes; 98 patients died (40%). The risk ratio for time spent in the department before laparotomy increased until 90 minutes and then significantly decreased below all earlier values. Logistic regression on the 165 patients spending 90 minutes or less showed the probability of death increased with time in the department, by as much as 0.35% per minute — approximately 1% for each 3 minutes.
• Meizoso JP, Ray JJ, Karcutskie CA 4th, Allen CJ, Zakrison TL, Pust GD, Koru-Sengul T, Ginzburg E, Pizano LR, Schulman CI, Livingstone AS, Proctor KG, Namias N. Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes. J Trauma Acute Care Surg. 2016;81(4):685-91. Retrospective review of 309 hypotensive adults with torso gunshot wounds requiring immediate operation, January 2004 to September 2013, at a single centre; resuscitative thoracotomies, traumatic brain injury, transfers, and operations more than 1 hour after arrival excluded. Mean systolic blood pressure 81 ± 29 mmHg, Injury Severity Score 24 ± 15, overall mortality 27%, mean time to operation 19 ± 13 minutes. After controlling for organ injury, arrival in the operating room after 10 minutes carried a hazard ratio of 1.89 (95% CI 1.10-3.26; p=0.02), and 2.67 (95% CI 0.97-7.34; p=0.05) in those with systolic blood pressure of 70 mmHg or less. The time associated with 50% cumulative mortality was 16 minutes. Level of evidence IV; the paper’s own conclusion describes the 1.89 hazard ratio as an almost threefold increase.
• Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG; Working Group on Polytrauma of the German Trauma Society. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373(9673):1455-61. Retrospective multicentre study of 4,621 blunt trauma patients in the German Trauma Society registry, of whom 1,494 (32%) received whole-body CT; mean age 42.6 years, mean injury severity score 29.7. Standardised mortality ratio based on TRISS 0.745 (95% CI 0.633-0.859) with whole-body CT versus 1.023 (0.909-1.137) without (p<0.001); based on the RISC score 0.865 (0.774-0.956) versus 1.034 (0.959-1.109) (p=0.017); relative mortality reduction 25% (14-37) by TRISS and 13% (4-23) by RISC; number needed to scan 17 by TRISS and 32 by RISC. Multivariate adjustment for hospital level, year of trauma and centre effects confirmed whole-body CT as an independent predictor for survival (p<=0.002).