TY - JOUR
T1 - Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial
AU - Campion, Eric M
AU - Cralley, Alexis
AU - Sauaia, Angela
AU - Buchheit, Ron C
AU - Brown, Austin
AU - Spalding, M Chance
AU - LaRiccia, Aimee
AU - Moore, Scott
AU - Tann, Kimberly
AU - Leskovan, John
AU - Camazine, Maraya
AU - Barnes, Stephen L
AU - Otaibi, Banan
AU - Hazelton, Joshua P
AU - Jacobson, Lewis E
AU - Williams, Jamie
AU - Castillo, Roberto
AU - Stewart, Nakosi J
AU - Elterman, Joel B
AU - Zier, Linda
AU - Goodman, Michael
AU - Elson, Nora
AU - Miner, Jason
AU - Hardman, Claire
AU - Kapoen, Carolijn
AU - Mendoza, April E
AU - Schellenberg, Morgan
AU - Benjamin, Elizabeth
AU - Wakam, Glenn K
AU - Alam, Hasan B
AU - Kornblith, Lucy Z
AU - Callcut, Rachael A
AU - Coleman, Lauren E
AU - Shatz, David V
AU - Burruss, Sigrid
AU - Linn, Ann C
AU - Perea, Lindsey
AU - Morgan, Madison
AU - Schroeppel, Thomas J
AU - Stillman, Zachery
AU - Carrick, Matthew M
AU - Gomez, Mario F
AU - Berne, John D
AU - McIntyre, Robert C
AU - Urban, Shane
AU - Nahmias, Jeffry
AU - Tay, Erika
AU - Cohen, Mitchell
AU - Moore, Ernest E
AU - McVaney, Kevin
AU - Burlew, Clay Cothren
N1 - e been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers.
PY - 2022/2
Y1 - 2022/2
N2 - BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63–0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50–0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53–0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64–0.75), SBP (AUROC, 0.75; CI, 0.70–0.81), and SI (AUROC, 0.74; CI, 0.68–0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61–0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47–0.58) or SI (AUROC, 0.56; CI, 0.50–0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65–0.84), SBP (AUROC, 0.63; CI, 0.54–0.74), and SI (AUROC, 0.64; CI, 0.54–0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
AB - BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63–0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50–0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53–0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64–0.75), SBP (AUROC, 0.75; CI, 0.70–0.81), and SI (AUROC, 0.74; CI, 0.68–0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61–0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47–0.58) or SI (AUROC, 0.56; CI, 0.50–0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65–0.84), SBP (AUROC, 0.63; CI, 0.54–0.74), and SI (AUROC, 0.64; CI, 0.54–0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
UR - https://dx.doi.org/10.1097/TA.0000000000003447
U2 - 10.1097/TA.0000000000003447
DO - 10.1097/TA.0000000000003447
M3 - Article
VL - 92
JO - Journal of Trauma and Acute Care Surgery
JF - Journal of Trauma and Acute Care Surgery
ER -