Hypotensive GSW- door to OR under 10 minutes

September 27, 2016

Short Attention Span Summary

Sprint to the OR
We aim for 17-18 minutes in the trauma bay for most Level 1 traumas.  For hypotensive GSWs, the goal should be to get to the OR in <10 minutes.  The hazard ratio for death was 1.89.  In real life, this means patients are almost twice as likely to die if hypotensive and not in the OR in under 10 minutes.  There was 50% mortality if the time to OR was 16 minutes.

Spoon Feed
Hypotensive GSW should be like a STEMI alert.  Door to OR in < 10 minutes.
EMS crews know the “Platinum 10 Minutes” regarding scene time.  Here is a new 10 minute interval that may impact mortality.

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Abstract

J Trauma Acute Care Surg. 2016 Aug 3. [Epub ahead of print]

Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes.

Meizoso JP1, Ray JJ, Karcutskie CA, Allen CJ, Zakrison TL, Pust GD, Koru-Sengul T, Ginzburg E, Pizano LR, Schulman CI, Livingstone AS, Proctor KG, Namias N.

Author information:

11Ryder Trauma Center, DeWitt Daughtry Family Department of Surgery, University of Miami Miller School of Medicine, Miami, FL; 2Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL.

Abstract

INTRODUCTION:

Timely hemorrhage control is paramount in trauma, however a critical time interval from emergency department (ED) arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW.

METHODS:

Adults (n=309) with hypotension and GSW to the torso requiring immediate operation from 01/2004 – 09/2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring > 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. Statistical significance was considered at p≤0.05.

RESULTS:

The study population was age 32±12 years, 92% male, Injury Severity Score 24±15, SBP 81±29 mmHg, Glasgow Coma Scale 13±4. Overall mortality was 27%. Mean time to operation was 19±13 min. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared to those who arrived in 10 minutes or less (HR 1.89, 95% CI 1.10-3.26, p=0.02); this was also true in the severely hypotensive patients with SBP ≤70 mmHg (HR 2.67, 95% CI 0.97-7.34, p=0.05). The time associated with a 50% cumulative mortality (LT50) was 16 minutes.

CONCLUSIONS:

Delay to the operating room of >10 minutes increases the risk of mortality by almost three-fold in hypotensive patients with GSW. Protocols should be designed to shorten time in the ED. Further prospective observational studies are required to validate these findings.

LEVEL OF EVIDENCE:

Level III, outcomes.

PMID: 27488491 [PubMed – as supplied by publisher]