Citation

Meizoso JP, 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. J. Trauma Acute Care Surg. 2016; 81(4): 685-691.

Affiliation

1Ryder 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.

Copyright

(Copyright © 2016, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000001198

PMID

27488491

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.

Language: en