[Lethality and outcome in multiple injured patients after severe abdominal and pelvic trauma. Influence of preclinical volume replacement - an analysis of 604 patients from the trauma registry of the DGU]

Abstract

Background: Uncontrollable hemorrhaging after blunt trauma and the resulting hemorrhagic shock is still one of the main causes of death in trauma patients. Starting volume replacement before admission to hospital is one of the main pillars of immediate treatment. The statements concerning the quantity of the preclinically administered fluid are still controversial and have a low level of evidence in the literature. Massive abdominal trauma and unstable pelvic fractures belong to the most relevant causes of hemorrhagic shock. The aim of this study was to analyze the influence of the quantity of the preclinically administered fluid on the posttraumatic course of patients with massive abdominal and pelvic injuries.

Patients and methods: All patients of the trauma registry of the DGU (German Society for Trauma Surgery) who met the following criteria were included: injury severity score ≥16 points, primary admission to hospital, age ≥16 years, initial blood pressure <100 mmHg and transfusion of erythrocyte concentrate (EC). Out of this collective patients with an AIS abdomen ≥4 or an AIS pelvis ≥4 were analyzed. Both groups were divided into 4 subgroups subject to the preclinically infused volume (<1000 ml, 1000-2000 ml, 2001-3000 ml and >3000 ml).

Results: Of the 375 patients with abdominal trauma and 229 patients with pelvic trauma were consistent with the inclusion criteria. In both groups an increasing volume replacement was associated with an increased need for transfusion and a reduction of the coagulation ability (Quick 61% in the case of <1000 ml versus 49.1% in the case of >3000 ml). The rescue time had a relevant influence on the quantity of preclinically infused volume (62 min for <1000 ml versus 88 min for >3000 ml). On admission to hospital the blood pressure values were on average the same in all patients (~ 95 mmHg). With an increasing volume a slight elevation of lethality was found as well as a significant increase of the transfused erythrocyte concentrates, a significant deterioration of coagulation and an increase of patients with mass transfusions.

Conclusion: In the case of a preclinical relevant bleeding after blunt pelvic or abdominal trauma moderate volume replacement (<1000 ml) results in an enhancement of the initial coagulation situation and in a reduction in the need for transfusion. The results of this study support the concept of a restrained volume therapy after massive trauma with and bleeding requiring transfusion.