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Abstract & Commentary
Source: Sava J. All patients with truncal gunshot wounds deserve trauma team activation. J Trauma 2002;52:276-279.
The purpose of the study was to validate recently revised American College of Surgeons standards for trauma team activation.1 These new criteria add penetrating torso trauma (regardless of field vital signs) to traditionally cited physiologic variables. Eight and one-half years of registry data from two busy inner city Level I trauma centers (Los Angeles County and University of Southern California Medical Centers) with more than 7000 annual admissions were reviewed—4128 patients with gunshot wounds (GSW) to the chest, back, flank, abdomen, and pelvis formed the cohort for study. Traditional trauma team activation criteria (TTAC) included: unresponsiveness to painful stimuli, systolic blood pressure less than 90 mmHg, heart rate greater than 120 bpm, and physician judgment. Patients were identified as either meeting or not meeting these criteria on admission. Severe injury was defined as death, intensive care unit (ICU) admission, non-orthopedic operation within 24 hours of admission, or injury severity score (ISS) greater than 15.
Sixty-one percent of patients with traditional TTAC met the definition of severe injury, as did 46% of patients without them. The mortality among patients with TTAC was 17%, compared with 1% in patients not meeting TTAC. Thirteen percent of patients with TTAC were admitted to the ICU and 41% required surgery, compared with 9% and 29%, respectively, in the group without TTAC. Notably, 21% of the non-TTAC patients had an ISS of 15 or greater.
Commentary by Michael A. Gibbs, MD, FACEP
Emergency physicians are under constant pressure to deliver better care to more patients for less. The acute management of severely injured patients puts a tremendous drain on our very limited resources in terms of personnel, time, space, and equipment. Although we may be tempted to streamline care delivery to conserve, this should never come at the expense of good patient care.
This study reminds us of two simple facts: 1) patients shot in the torso often are critically ill; and 2) many of these patients are at substantial risk for death, ICU admission, early surgery, and high ISS, despite "normal" prehospital vital signs. The authors recommend including a history of torso GSW as an independent criterion for trauma team activation, regardless of field vitals signs. I strongly agree. An "abbreviated" trauma response may be perfectly reasonable in many injured patients, but not in this situation. Let us put our precious resources where they belong.
Dr. Gibbs, Residency Program Director, Medical Director, Medcenter Air, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, NC, is on the Editorial Board of Emergency Medicine Alert.
1. ACS Committee on Trauma. Revisions to: Resources for optimal care of the injured patient: 1999. Chicago: American College of Surgeons; 2000.