End-tidal CO2 on admission is associated with hemorrhagic shock and predicts the need for massive transfusion as defined by the critical administration threshold: A pilot study☆
Section snippets
Background
Uncontrolled hemorrhage accounts for the majority of deaths in the first hour of trauma admissions and is responsible for almost 50% of deaths in the first 24 h [1], [2], [3]. A significant number of these patients, up to 40%, will present on admission with an acute coagulopathy of trauma shock [4], [5]. Early implementation of a massive transfusion (MT) protocol consisting of high ratios of plasma and platelets to packed red blood cells has been shown to improve survival in hemorrhaging trauma
Study patients
Following approval from the Institutional Review Board, we performed a prospective observational study where data were collected on patients presenting to our urban Level I trauma center between November 2012 and May 2015. Inclusion criteria included patients ≥ 18 years of age requiring the highest level of trauma team activation, and who had capnography and venous lactate measured. Exclusion criteria included patients with missing ET CO2 data; patients already intubated on arrival to trauma bay;
Results
Of 131 patients enrolled during the study period, 67 patients remained eligible for analysis following exclusion criteria (Fig. 1). Table 1 shows baseline demographics. The mean age of the study group was 41.2 years, where the majority (76%) of the patients were male. Blunt mechanism of injury comprised about half (49%) of the study group. The median ISS was nine and there were six (9%) patient deaths overall. Two patients died within 24 h of admission. More than half of the patients (60%)
Discussion
Expeditious activation of MT consisting of high ratios of plasma and platelets to PRBC’s improves survival in the hemorrhaging trauma patient [6], [7]. Therefore, early identification of those patients in the trauma bay who will need MT remains a top priority. For those patients who present with obvious signs of hemorrhagic shock, e.g. hypotension, identifying their need for MT is somewhat straightforward. On the other hand, given that trauma patients can present with normal vital signs yet
Conclusion
Our results demonstrate a significant and intriguing association between ET CO2 < 35 mmHg and established markers for shock that include SBP, SI and venous lactate for patients in the trauma bay. ET CO2 was found to be independently associated with CAT+ status when adjusting for age, ISS > 15, HR and SBP, however, the confidence intervals were large due to the small sample size. Given the small sample size of this study, although compelling, these results are preliminary and this should be
Authorship statement
MS—study design, data acquisition, analysis, interpretation of data, manuscript preparation.
SK—data acquisition, analysis, interpretation of data, manuscript preparation.
AL—analysis, interpretation of data, manuscript preparation.
ZA—data acquisition, analysis.
SY—data acquisition, analysis.
EC—intepretation of data, manuscript preparation.
SR—intepretation of data, manuscript preparation.
MJ—intepretation of data, manuscript preparation.
CV—data acquisition, interpretation of data.
ST—intepretation
Conflicts of interest
All authors declare that there are no conflicts of interest with regards to this study. The work was not funded by any outside institution.
Acknowledgement
The authors would like to thank Nicholas D. Caputo MD, our colleague and neighbor in the Bronx, for help in inspiring the use of capnograpy in the Jacobi Medical Center Emergency Department trauma bay.
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Cited by (23)
Sensitive assessment of ETCO<inf>2</inf> on circulatory function in critical ill patient — A narrative review
2024, Trends in Anaesthesia and Critical CareLow initial in-hospital end-tidal carbon dioxide predicts poor patient outcomes and is a useful trauma bay adjunct
2022, American Journal of Emergency MedicineCitation Excerpt :The triage utility of end-tidal capnography is not as well known since most studies focus on main-stream ETCO2 in the setting of intubation or cardiopulmonary arrest [11,13]. Past analyses corroborate the diagnostic value of ETCO2 in detecting hemorrhagic shock [6-8]. However, the bulk of literature on end-tidal capnography in critical care and major trauma has not differentiated between those values obtained immediately upon arrival and those obtained hours afterwards.
Prehospital end-tidal CO2 as an early marker for transfusion requirement in trauma patients
2021, American Journal of Emergency MedicineCitation Excerpt :Below normal ETCO2 has been shown to be associated with worse outcomes in sepsis and trauma patients as compared to patients with normal ETCO2 [12-17]. ETCO2 less than 35 has been shown to have a strong association with hemorrhagic shock and massive transfusion protocol initiation in trauma patients independent of injury severity score (ISS), age, and/or systolic blood pressure (SBP) < 90 [18]. Patients with ETCO2 of 30 or less are more likely to have more severe traumatic injuries and more likely to require ICU stay [19].
Whole Blood in Trauma: A Review for Emergency Clinicians
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2017, Journal of Emergency MedicineCitation Excerpt :Capnography levels < 30 mm Hg may be associated with increased risk of severe injury in trauma, though it does not change decision making when combined with blood pressure, age, or Glasgow Coma Scale (97). A recent study released in Injury finds capnography levels < 35 mm Hg are associated with mortality and need for blood transfusion (98). Capnography in trauma requires additional study, but it holds promise for determining those critically ill if used in conjunction with clinical assessment, as well as need for transfusion.
Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion
2020, Prehospital and Disaster Medicine
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Poster presentation at the 29th EAST Annual Scientific Assembly January 12–16, 2016 San Antonio, Texas