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Changes in vital signs of trauma victims from prehospital to hospital settings

07 October 2011
Features
02 October 2011
Volume 3 · Issue 10

Abstract

The objective of this article is to characterize changes in vital signs of trauma victims from prehospital to hospital settings, their associations with injury severity, and the need for an emergency operation. Methods: a prospective cohort included 601 patients admitted to a level one trauma centre from 1 July to 30 September 2007. All prehospital and hospital admission values of Glasgow coma score (GCS), systolic blood pressure (SBP), heart rate (HR), respiratory rate (Resp) and oxygen saturation (SpO2) were recorded. All urgent major surgical procedures were graded in real-time as: emergency, urgent, or not urgent. Injury severity score (ISS) was calculated following completion of all the diagnostic work-up. Patients were classified as major trauma victims if their calculated ISS was 16 or greater, and those who needed an urgent intervention or intensive care. Vital signs trends were analyzed using the students' T—test. Associations with injury severity and the need for an emergency operation were analyzed using chi-squared test. The statistical significance level was set at 5% (P ≤ 0.05). Results: 243(40%) patients were classified as major trauma. 39(6.5%) patients required an emergency operative intervention—29 for active bleeding and 10 for imminent cerebral herniation. The time from injury to hospital arrival was 44.8 ± 17.63 minutes (mean±standard deviation), the time did not differ for those needing an emergency operation. Prehospital GCS ≤12 and SBP ≤90 were associated with a severe injury (a relative risk(RR) of 4.95, 95% confidence interval(CI) 3.25–7.58 for low GCS and 4.60, 2.67–7.94 for low SBP) and emergency surgical procedures (RR, 95% CI 4.43, 2.28–8.58 for low GCS and 11.69, 5.85–23.36 for low SBP). These values changed significantly from the field to the hospital with the mean GCS increasing 1.65 points and the mean SBP decreasing 7.23 mmHg (p<0.001). One patient out of 473 with a GCS ≥14 in the field and no one out of 483 patients with a GCS ≥14 on admission needed a neurosurgical procedure. 15/533(2.8%) patients with a prehospital SBP >90, and only 2/542(0.4%) patients with a SBP >90 on admission required emergency bleeding control (P<0.005). HR ≥120 and changes in HR of 20 beats per minute (bpm) or more were not associated with injury severity. The respiratory rate and the SpO2 did not change significantly, and were not associated with injury severity. Conclusion: prehospital vital signs values are expected to change significantly over time. Prehospital GCS ≤12 and SBP ≤90 predict major trauma, while the HR is not a good indicator of haemodynamic status. When these parameters normalize on admission, an emergency operation is rarely needed.

Standard vital signs are monitored on scene, en route and upon arrival at hospital, and are considered to be important parameters in any triage system. Haemodynamic stability assessment is critical as patients who are stable are managed very differently from patients who are unstable (Jacoby and Wisner, 2008). In the prehospital setting, patients with injuries that require emergency surgical intervention are an evacuation priority. Haemodynamic stability is an important consideration in determining the destination and urgency of the evacuation process. However, standard vital signs are neither sensitive nor specific for haemodynamic instability and may be inadequate for early detection of a requirement to implement an intervention (Orlinsky et al, 2001).

Haemodynamic stability is a somewhat illusory concept and one for which there is no consensus definition (Scalea and Henry, 1992). Hypotension (systolic blood pressure (SPB) <90 mmHg in an adult) is generally considered to be worthy of concern and a high index of suspicion for ongoing haemorrhage should be maintained. However, patients sustaining severe trauma are at significant risk for haemorrhage, even if they are normotensive in the field. There is a special importance to define the indices that indicate the highest probability of such injuries (Cherry et al, 2007), but the best method to identify those patients is yet to be established (Bond et al, 1997).

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Emergency surgery
Major trauma
Triage
Vital signs