Preoperative indications
|
Overall injury burden
|
High ISS
|
0
|
BD, temperature
|
Survival
|
BD, temperature OR per ISS ↑, 1.12 (95% CI, 1.03 to 1.23) [54]
|
100
|
None
|
Survival
|
↑ mean ISS in non-survivors vs. survivors (38 vs. 29, p < 0.05) [58]
|
Volume and/or type of resuscitation provided
|
Transfusion of a large volume of PRBCs
|
100
|
None
|
Survival
|
↑ mean U PRBCs transfused in non-survivors vs. survivors (20 vs. 14, p < 0.01) [58]
|
Degree of physiologic insult
|
Prolonged duration of hypotension
|
100
|
None
|
Survival
|
↑ mean duration of preoperative hypotension in non-survivors vs. survivors (90 vs. 50 min., p < 0.05) [58]
|
Hypothermia (min temperature)
|
0
|
BD, ISS
|
Survival
|
OR per min temperature ↓ in °C, 0.32 (95% CI, 0.15 to 0.64) [54]
|
Temperature < 35 °C
|
100
|
Age, BD, pH
|
Survival
|
↓ temperature not independently associated with survival [44]
|
Elevated BD (max BD)
|
0
|
ISS, temperature
|
Survival
|
OR per max BD ↑, 0.66 (95% CI, 0.56 to 0.78) [54]
|
BD > 10.5 mEq/L
|
100
|
Age, pH, temperature
|
Survival
|
↑ BD not independently associated with survival [44]
|
Decreased pH
|
100
|
None
|
Survival
|
↓ mean pH in non-survivors vs. survivors (7.1 vs. 7.3, p < 0.05) [58]
|
pH < 7.20
|
100
|
Age, BD, temperature
|
Survival
|
↑ pH independently associated with ↓ survival (p = 0.001) [44]
|
Decreased platelet count
|
100
|
None
|
Survival
|
↓ mean platelet count in non-survivors vs. survivors (179,000 vs. 229,000 mm3) [58]
|
Laboratory-confirmed coagulopathy
|
100
|
None
|
Survival
|
↑ mean PT (22 vs. 14 sec) and PTT (69 vs. 42 sec.) in non-survivors vs. survivors (p < 0.05 for both) [58]
|
PT ≥ 16 sec
|
100
|
None
|
Survival
|
OR, 0.11 (p < 0.05) [60]
|
PTT ≥ 50 sec
|
100
|
None
|
Survival
|
OR, 0 (survival, 0% vs. 71% with PTT < 50 sec; p < 0.05) [60]
|
A model included highest ED BD, lowest ED temperature, and ISS
|
0
|
BD, lowest ED temperature, ISS
|
Survival
|
Model Se, 83%; model Sp, 93% [54]
|
A model predicting that survival was possible only when the Eq. 0.012(age) − 0.707(lowest preoperative pH) − 0.032(lowest preoperative temperature in °C) + 6.002 = < 0.5
|
100
|
None
|
Survival
|
Model Se, 25%; model PPV, 100% [46]
|
Intraoperative indications
|
Injury pattern identified during operation
|
Combined abdominal vascular and pancreas gunshot injuries
|
20
|
12 variables*
|
Survival
|
OR, 0.12 (95% CI, 0.041–0.36) [41]
|
20
|
11 variables*
|
Complicat-ions
|
OR, 3.59 (95% CI, 1.10-11.68) [41]
|
Iliac vessel injury and prolonged duration of hypotension
|
22
|
None
|
Survival
|
↑ mean duration of hypotension in non-survivors vs. survivors who underwent definitive (95 vs. 65 min, p-value NR) and DC (40 vs. 85 min, p < 0.05) laparotomy [55]
|
Iliac vessel injury and initial temperature < 34 °C
|
17
|
None
|
Survival
|
OR, 0.27 (95% CI, 0.072-1.0) [56]
|
Iliac vessel injury and final temperature < 35 °C
|
17
|
None
|
Survival
|
OR, 0.025 (95% CI, 0.0028-0.23) [56]
|
Iliac vessel injury and initial BD > 15 mEq/L
|
17
|
None
|
Survival
|
OR, 0.037 (95% CI, 0.0072-0.19) [56]
|
Iliac vessel injury and final BD > 6 mEq/L
|
17
|
None
|
Survival
|
OR, 0.091 (95% CI, 0.019–0.45) [56]
|
Iliac vessel injury and initial pH < 7.1
|
17
|
None
|
Survival
|
OR, 0.032 (95% CI, 0.0055-0.19) [56]
|
Iliac vessel injury and final pH < 7.3
|
17
|
None
|
Survival
|
OR, 0.069 (95% CI, 0.014–0.36) [56]
|
Penetrating iliac vessel injury and final pH < 7.2
|
22
|
None
|
Survival
|
↓ mean final pH in non-survivors vs. survivors who underwent definitive (7.11 vs. 7.29, p-value NR) and DC (7.20 vs. 7.32, p-value < 0.05) [55]
|
Penetrating iliac vessel injury and final PT > 20 sec
|
22
|
None
|
Survival
|
↑ final PT in non-survivors vs. survivors who underwent definitive (25.2 vs. 17.8 sec, p-value NR) and DC (20.2 vs. 15.9 sec, p < 0.05) laparotomy [55]
|
Penetrating iliac vessel injury and final PTT > 70 sec
|
22
|
None
|
Survival
|
↑ final PTT in non-survivors vs. survivors who underwent definitive (86.1 vs. 59.2 sec, p-value NR) and DC (66.2 vs. 47.8 sec, p < 0.05) laparotomy [55]
|
Iliac vessel injury and shock, hypothermia, acidosis, or coagulopathy (timing of measurement not specified)
|
18
|
≤ 14 variables†
|
Survival
|
Shock, hypothermia, acidosis, and coagulopathy not independently associated with survival [51]
|
Volume and/or type of resuscitation provided
|
Transfusion > 4 L PRBCs
|
100
|
23 variables‡
|
Survival
|
Independently associated with ↓ survival [53]
|
Transfusion > 5 L PRBCs and whole blood
|
100
|
None
|
Survival
|
↑ mean volume of PRBCs and whole blood in non-survivors vs. survivors (8.2 vs. 5.6 L, p < 0.001) [53]
|
Administration > 12 L PRBCs and/or whole blood, other blood products, and crystalloids
|
100
|
None
|
Survival
|
↑ mean volume of these fluids in non-survivors vs. survivors (15.0 vs. 12.4 L, p < 0.001) [53]
|
Degree of physiologic insult
|
Temperature ≤ 34 °C
|
100
|
None
|
Survival
|
↓ mean min temperature in non-survivors vs. survivors (33.9 vs. 35.0, p < 0.001) [53]
|
Serum [HCO3−] ≤ 15 mEq/L
|
100
|
None
|
Survival
|
Serum [HCO3−] ≤ 15 mEq/L associated with ↓ survival [53]
|
pH < 7.2
|
100
|
None
|
Survival
|
↓ mean initial (7.1 vs. 7.4), max (7.2 vs. 7.4), and min (7.0 vs. 7.2) pH in non-survivors vs. survivors (p < 0.001 for all) [53]
|
Elevated ACT
|
23
|
Unclear for logistic regression
|
Clinical coagulo-pathy§
|
The mean of 2 ACT measurements (taken within the first 10 min of beginning surgery and repeated ~ 15 min later) was 180 sec in patients with coagulopathy versus 118 sec in those without (p < 0.001) [50] The 1st, 2nd, and mean ACT values were independently associated with coagulopathy using logistic regression (p-value NR) [50]
|
Systolic BP < 90 mmHg, BD > 7.5 mEq/L, and/or temperature < 35.5 °C at the start of surgery
|
100
|
None
|
Survival
|
OR for survival was 0.13 (95% CI, 0.021–0.77) among patients who presented with all 3 vs. <3 variables. There was also a stepwise ↓ in survival as the no. of variables present ↑ [45]
|
A model predicted that survival was only possible when patients lie below and to the right of a diagonal discriminant line given by the equation PRBC transfusion rate (U/h) = 35.7(arterial pH) − 242 (for an arterial pH = 7.2, transfusion rate = 15 U/h)
|
100
|
PRBC transfusion rate, pH
|
48 h survival
|
Model Se, 77% [62]
|
Pre- or intraoperative indications (or indications for which the setting was unclear or not specified)
|
Volume and/or type of resuscitation provided
|
Transfusion > 15 U PRBCs
|
100
|
None
|
Coagulo-pathy**
|
OR, 6.0 (95% CI, 0.67–75.61) [63]
|
Transfusion > 10 U PRBCs in the first 24 h and an ISS > 25
|
31
|
PRBCs transfused in 24 h, lowest systolic BP < 70 mmHg, pH < 7.1, and temperature < 34 °C
|
PT & PTT > 2*control
|
OR, 7.7 (95% CI, 1.5–38.8) [57]¶
|
Transfusion > 10 U PRBCs in the first 6 h and an ISS > 25
|
NR
|
9 variables#
|
INR > 1.5 at 6 h
|
OR, 4.14 (95% CI, 0.57–3.18) [47]
|
Transfusion > 10 U PRBCs in the first 24 h and the lowest systolic BP < 70 mmHg
|
31
|
ISS > 25, PRBCs transfused in 24 h, pH < 7.1, and temperature < 34 °C
|
PT & PTT > 2*control
|
OR, 5.8 (95% CI, 1.2–28.2) [57]¶
|
Transfusion > 10 U PRBCs in the first 6 h and ED systolic BP < 70 mmHg
|
NR
|
9 variables#
|
INR > 1.5 at 6 h
|
OR, 0.48 (95% CI, 0.10–2.23) [47]
|
Transfusion > 10 U PRBCs in the first 24 h and lowest temperature < 34 °C
|
31
|
ISS > 25, PRBCs transfused in 24 h, lowest systolic BP < 70 mmHg, and pH < 7.1
|
PT & PTT > 2*control
|
OR, 8.7 (95% CI, 1.8–41.8) [57]¶
|
Transfusion > 10 U PRBCs in the first 6 h and ED temperature < 34 °C
|
NR
|
9 variables#
|
INR > 1.5 at 6 h
|
OR, 6.10 (95% CI, 1.54–24.19) [47]
|
Transfusion > 10 U PRBCs in the first 24 h and lowest pH < 7.1
|
31
|
ISS > 25, PRBCs transfused in 24 h, lowest systolic BP < 70 mmHg, and temperature < 34 °C
|
PT & PTT > 2*control
|
OR, 12.3 (95% CI, 2.4–64.0) [57]¶
|
Transfusion > 10 U PRBCs in the first 6 h and ED pH < 7.1
|
NR
|
9 variables#
|
INR > 1.5 at 6 h
|
OR, 1.69 (95% CI, 0.56–5.08) [47]
|
Degree of physiologic insult
|
Min temperature ≤ 33 °C
|
100
|
None
|
Survival
|
OR, 0.20 (p-value reported as NS) [60]
|
Elevated max BD in the first 24 h in blunt trauma patients without TBI
|
NR
|
Age ≥ 55 yr
|
Mortality
|
OR per max BD ↑, 1.39 (95% CI, 1.35 to 1.41) [61]
|
Elevated max BD in the first 24 h in penetrating trauma patients without TBI
|
NR
|
Age ≥ 55 yr
|
Mortality
|
OR per max BD ↑, 1.58 (95% CI, 1.44 to 1.75) [61]
|
Elevated max BD in the first 24 h in blunt trauma patients with TBI
|
NR
|
Age ≥ 55 yr
|
Mortality
|
OR per max BD ↑, 1.25 (95% CI, 1.14 to 1.38) [61]
|
Min pH ≤ 7.18
|
100
|
None
|
Survival
|
OR, 0.17 (p < 0.05) [60]
|
Miscellaneous
|
Transfusion ≥ 10 U PRBCs, lowest ED or intraoperative temperature ≤ 33 °C, pH ≤ 7.18, ED PT ≥ 16 sec, or ED PTT ≥ 50 sec
|
100
|
None
|
Survival
|
↓ survival when 4–5 (0% vs. 82%; p < 0.04) or 2–3 (17% vs. 82%; p < 0.003) vs. 0–1 of these indications were present [60]
|
A model including BD, penetrating MOI, TBI, age ≥ 55 year, and an interaction between BD and penetrating MOI and BD and TBI. This model predicted that the BD for which the probability of survival was 75% was 15 mmol/L for young patients without TBI versus 8 mmol/L for patients aged < 55 year with a TBI and older patients aged ≥ 55 yr
|
NR
|
BD, penetrating MOI, TBI, age ≥ 55 yr
|
75% survival
|
Model Se, 71%; model Sp, 89% [61]
|
Where ACT, activated coagulation time; BD, base deficit; BP, blood pressure; CI, confidence interval; DC, damage control; ED, Emergency Department; FFP, fresh frozen plasma; h, hours; HD, hemodynamic; INR, international normalized ratio; ISS, Injury Severity Scale score; max, maximum; min, minimum; MOI, mechanism of injury; NISS, New Injury Severity Scale score; NR, not reported; NS, not significant; OR, operating room; PPV, positive predictive value; PRBCs, packed red blood cells; PT, prothrombin time; PTT, partial thromboplastin time; pts, patients; U, unit(s); Se, sensitivity; Sp, specificity; ULN, upper limit of normal; and yr, years. |
*Variables reported to be entered into the logistic regression model for mortality included age; Revised Trauma Score; systolic BP < 90 mmHg on admission; need for a major transfusion and volume transfused; need for DC surgery; AAST grade III-V pancreas injury and proximal pancreas injury; associated colonic, duodenal, and vascular injuries; postoperative complications; ICU admission; and length of ICU stay. Variables reported to be entered into the logistic regression model for complications included age; Revised Trauma Score; systolic BP < 90 mmHg on admission; need for transfusion and volume of blood transfused; need for DC surgery; grade of pancreas injury; repeat laparotomy; second pancreatic surgery; associated duodenal or vascular injury; intensive care unit (ICU) admission; and length of ICU stay. |
†Variables reported to be entered into the regression model included those with associated with mortality (p < 0.20) that did not have > 10% missing data. These may have included, at a minimum, systolic BP and respiratory rate in the ED; Glasgow Coma Scale score, ISS, and Revised Trauma Scale score; preoperative hematocrit; crystalloids and blood given in the ED; estimated intraoperative blood loss; crystalloids and blood given in the OR; total fluids; and length of stay in the surgical intensive care unit and hospital. |
‡Variables reported to be entered into the logistic regression model included those associated with survival in bivariate analysis (p < 0.20). These appeared to at least include ISS > 20; RTS > 0; GCS ≤ 3 or < 9; MOI; absence of spontaneous ventilation, a palpable carotid pulse, or extremity movement; non-sinus rhythm on the electrocardiogram; systolic BP and respiratory rate as a 3-level or 2-level categorical variable; a pulmonary artery and vein, thorax, thoracic or abdominal vascular, or liver injury; thoracotomy or laparotomy in the OR; coagulopathy; dysrhythmia; and type of dysrhythmia. |
§Defined by the authors as the perceived need to initiate DC maneuvers by a surgical attending, which was reported to be subjective that usually occurred in the setting of major blood loss, hypothermia, acidosis, and the presence of multiple injuries [50]. |
**Defined by the authors as diffuse bleeding from all wounds without discrete bleeding vessels, absence of observable clots, prolonged PT and PTT along with decreased platelet count, or decreased platelet count alone [63]. |
¶In this study, the probability of developing coagulopathy (defined as a PT and PTT > 2 times that of normal laboratory control) in patients who had received a transfusion of > 10 Us PRBCs in the first 24 h was 10% for those with an ISS > 25; 39% for those with an ISS > 25 and lowest systolic BP < 70 mmHg; 58% for those with an ISS > 25 and lowest pH < 7.1; 49% for those with an ISS > 25 and lowest temperature < 34 °C; 85% for those with an ISS > 25 and lowest systolic BP < 70 mmHg and temperature < 34 °C; and 98% for those with an ISS > 25 and lowest systolic BP < 70 mmHg, pH < 7.1, and temperature < 34 °C. |
#Variables entered into the logistic regression model included FFP:PRBC ratio at 6 h; age > 55 year; ISS > 25; PRBC, FFP, and platelet U transfused at 6 h; crystalloids in 24 h; and ED systolic BP < 70 mmHg, temperature < 34 °C, and pH < 7.1. |