Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma

Morgan Schellenberg; Natthida Owattanapanich; Joelle Getrajdman; Kazuhide Matsushima; Kenji Inaba

doi:10.1016/j.jss.2021.06.051

Prehospital Narrow Pulse Pressure Predicts Need for Resuscitative Thoracotomy and Emergent Intervention After Trauma

J Surg Res. 2021 Dec;268:284-290. doi: 10.1016/j.jss.2021.06.051. Epub 2021 Aug 12.

Authors

Morgan Schellenberg¹, Natthida Owattanapanich², Joelle Getrajdman², Kazuhide Matsushima², Kenji Inaba²

Affiliations

¹ Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California. Electronic address: morgan.schellenberg@med.usc.edu.
² Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, Los Angeles, California.

PMID: 34392182
DOI: 10.1016/j.jss.2021.06.051

Abstract

Background: The pulse pressure (PP) is the difference between systolic and diastolic blood pressures. Narrow PP in the Emergency Department (ED) has recently been shown to predict hemorrhagic shock after trauma. This study examined the impact of prehospital narrow PP on outcomes after trauma.

Methods: Patients presenting to our ACS-verified Level I trauma center (2008-2020) were retrospectively screened. Exclusions were unrecorded prehospital/ED vitals, age <16 or >60, transfers, on-scene cardiac arrest, and missing discharge disposition. Prehospital blood pressure defined study groups: Narrow PP (<30 mmHg) vs. Hypotensive (SBP<90 mmHg) vs. Others (herein referred to as Normotensive). Univariable/multivariable analyses compared outcomes and determined independent predictors of mortality; resuscitative thoracotomy; emergent intervention; and need for trauma intervention (NFTI), a contemporary measure of major trauma.

Results: In total, 39,144 patients met inclusion/exclusion criteria: 5% (n=1,834) Narrow PP, 3% (n=1,062) Hypotensive, and 92% (n=36,248) Normotensive. Penetrating trauma was more frequent among Narrow PP and Hypotensive patients (23% vs. 32% vs. 14%, p<0.001). ISS was higher among Narrow PP and Hypotensive patients (5[1-14] vs. 10[2-21] vs. 4[1-9], p<0.001). Mortality was highest among the Hypotensive (n=130, 12%) followed by Narrow PP (n=92, 5%) and Normotensive patients (n=502, 1%) (p<0.001). On multivariable analysis, prehospital narrow PP was independently associated with resuscitative thoracotomy (OR 1.609, p=0.009), emergent intervention (OR 1.356, p=0.001), and NFTI (OR 1.237, p=0.009).

Conclusion: Prehospital narrow PP independently predicts severe trauma, resuscitative thoracotomy, and emergent intervention. Although prehospital narrow PP is not currently a TTA criterion, these patients have a mortality rate and ISS intermediate to those of hypotensive and normotensive patients. Prehospital narrow PP should be recognized as a proxy for major trauma in patients with heightened surgical and interventional needs so that appropriate in-hospital preparations may be made prior to patient arrival.

Keywords: Hypotension; Narrow pulse pressure; Pulse pressure; Severe trauma; Trauma team activation criteria.

MeSH terms

Blood Pressure
Emergency Medical Services*
Humans
Injury Severity Score
Resuscitation
Retrospective Studies
Thoracotomy
Trauma Centers
Wounds and Injuries* / diagnosis
Wounds and Injuries* / surgery