•The mean age was 37 yrs, and 76 % were male.
•69% of patients had CT done within 12 hrs of the trauma.
•The major cause of blunt trauma in our study was RTA (86%).
Hemodynamic status of Patients:
Of the various parameters used in evaluating the hemodynamic stability of the patients, shock index more than 0.9 was seen in 63% of the patients. 88 % of the patients had hemoglobin less than 10 gm%. PCV less than 30% was seen in 60% of the patients.
HEMOGLOBIN CORRELATION WITH HEMODYNAMIC STATUS:
•The mean Hb in hemodynamically unstable patients was 8.5 gm% which was statistically different from the mean Hb seen in stable patients (p < 0.0001). Hemoglobin less than 10 gm% showed high specificity in relation to presence of shock. The sensitivity was low correlating to the fact that the Hb less than 10gm% does not always imply presence of shock.
PCV CORRELATION WITH HEMODYNAMIC STATUS:
The mean PCV in hemodynamically unstable patients was 24.6 which was statistically different from the mean Hb seen in stable patients (p < 0.0001). In comparison to low hemoglobin, PCV showed better correlation with presence of shock , showing moderate sensitivity and high specificity in relation to shock index > 0.9.
FREE FLUID SCORE:
| Frequency | Percent % |
0 | 16 | 10.0 |
I | 36 | 22.5 |
II | 55 | 34.4 |
III | 53 | 33.1 |
Total | 160 | 100.0 |
Based on the presence of the free fluid was categorized on the basis of presence in various intraabdominal spaces and maximum no of cases (68%) had free fluid of grade II / > II. 10 % of the cases did not show free fluid on CT.
FACTORS GAURDING HEMODYNAMIC STATUS AND ITS VALUE IN PREDICTING HEMODYNAMIC INSTABILITY:
IVC:
| Frequency | Percent % |
NORMAL | 95 | 59.4 |
FLAT | 65 | 40.6 |
Total | 160 | 100.0 |
Flat IVC was seen in 40 % of the cases suggesting significant blood loss and hypovolemia.
FLAT IVC CORRELATION WITH HEMODYMANIC STABILITY:
| HEMO UNSTABLE | HEMO STABLE |
FLAT IVC | 46 | 19 |
NORMAL IVC | 17 | 78 |
Of the 63 hemodynamic unstable patients 73% had flat IVC. Only 20 % of the hemodynamically stable patients had flat IVC rest 80 % showed normal caliber IVC.
FREE FLUID SCORE:
FF SCORE | HS | HI |
0 | 0 (0%) | 16 (17%) |
I | 2 (3%) | 34 (35%) |
II | 19 (30%) | 36 (37%) |
III | 42 (67%) | 11 (11%) |
66% Patients who had free fluid score III were hemodynamically unstable and 89% of patients who had free fluid score < III were stable.
FF SCORE | HEMO UNSTABLE | HEMO STABLE |
III | 42 (66%) | 11 (11%) |
<III | 21 (33%) | 86 (89%) |
Direct correlation was seen between the patient’s free fluid score and hemodynamic status. As the score increase more chances of patient being hemodynamically unstable.
| SENSITIVITY% | SPECIFICITY% | PPV% | NPC% |
FLAT IVC VS HEMODYMANIC STATUS | 73 | 80 | 70 | 82 |
FREE FLUID GRADE VS HEMODYNAMICSTATUS | 66 | 88 | 79 | 80 |
COMBINED FREE FLUID SCORE AND FLAT IVC VS HEMODYNAMIC STATUS | 84 | 79 | 72 | 88 |
Flat IVC was more sensitive in detecting the hemodynamic instability however free fluid score showed high specificity for the same. However flat IVC and free fluid score together showed high sensitivity and specificity in predicting hemodynamic stability.
CORRELATION OF FACTORS GAURDING HEMODYNAMIC STATUS AND NEED FOR SURGERY:
RX | NO OF CASES | PERCENTAGE (%) |
CONSERVATIVE | 74 | 46% |
SURGERY | 86 | 54% |
HEMODYNAMIC STABILITY VS RX:
HEMODYNAMICSTABILITY | RX | |
| CONSEVATIVE | SURGICAL | Total |
STABLE (SI < 0.9) | 66 (68%) | 31 (32%) | 97 |
UNSTABLE (SI > 0.9) | 8 (13%) | 55 (87%) | 63 |
68 % of the patients labeled hemodynamically stable under went conservative management however 32 % of them required surgical intervention. On the other hand 87 % of the patients who were hemodynamically unstable needed surgical management and only 13 % were managed conservatively.
•75 % of the patients with normal IVC under went conservative management however 25 % of them required surgical intervention. On the other hand 97 % of the patients who had flat IVC needed surgical management and only 3 % were managed conservatively.
•66 % of the patients with free fluid score < III under went conservative management however 34 % of them required surgical intervention. On the other hand 94 % of the patients who had free fluid score III needed surgical management and only 6 % were managed conservatively.
•Combined flat IVC and free fluid score showed that 81 % of the patients with both under normal limits under went conservative management however 16 % of them required surgical intervention. On the other hand 94 % of the patients who had either of them positive needed surgical management and only 6 % were managed conservatively.
•Of the 164 patients :
•Group 1: 68% patients labeled hemodynamically stable (based on SI) under went NOM, however 32% of them required surgical intervention. 87% of the patients who were hemodynamically unstable required OM and only 13% were managed NOM.
•Group 2: 75% of the patients with normal IVC under went NOM however 25 % of them required OM. 97 % of the patients who had flat IVC required OM and only 3% had NOM.
•Group 3: 66% of the patients with FFS < III under went NOM, however 34% of them required OM. On the other hand 94% of the patients who had FFS III needed OM and only 6% had NOM.
•Combined flat IVC and FFS showed that 81% of the patients having normal values for both had NOM however 16% of them required OM. 94% of the patients who had either of them positive needed surgical management and only 6% had NOM. OM was required in 86 patients and was best predicted by the presence of either flat IVC and or FFS III [odds ratio (OR) 76.5]. 67 fold increased relative odds for OM was observed if flat IVC alone was considered.
CONSERVATIVE | NO OF CASES | PERCENTAGE (%) |
HS | 66 | 68% |
NORMAL IVC | 72 | 75% |
FREE FLUID SCORE < III | 71 | 66% |
FFSCORE < III + NORMAL IVC | 70 | 81% |
SURGERY | NO OF CASES | PERCENTAGE (%) |
HI | 55 | 87% |
FLAT IVC | 63 | 97% |
FREE FLUID SCORE III | 50 | 94% |
FFSCORE III + FLAT IVC | 70 | 94% |
From the above table we conclude that the flat IVC is the best predictor of need for surgery and combined free fluid score < III and normal IVC are the best predictor for conservative management.
| ODDS RATIO | CONFIDENCE LIMITS (95%) Lower Bound Upper Bound | KAPPA | P VALUE |
HEMODYNAMICS | 14.6 | 6.2 | 34.4 | 0.520 | < 0.0001 |
FLAT IVC | 67.1 | 15.4 | 219.9 | 0.605 | <0.0001 |
FREE FLUID SCORE III | 32.8 | 9.5 | 112.6 | 0.525 | < 0.0001 |
FLAT IVC / SCORE III | 76.5 | 24.4 | 240.5 | 0.751 | < 0.0001 |
Surgery was required in 86 patients and was best predicted by the presence of either flat IVC and or free fluid score III [odds ratio (OR) 76.5, 95% CI 24.4 – 240.5].
67 fold increased relative odds for need for surgery was observed if flat IVC alone was considered (OR 67.1, 95% CI 15.4 – 219.9).
To conclude the prevalence of flat IVC and free fluid score among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT.
HEMODYNAMIC STATUS OF PATIENTS:
| Present study | McIntyre et al (2005) | Peitzman et al (2005) | Velmahos et al (2003) | Salvatore et al (1995) | Taylor et al (1991) | Knottenbelt et al (1991) |
SI > 0.9 | 38.4 % | - | - | - | - | - | - |
PCV <30 | 36.6% | - | - | 32.4% | - | 24.3% | - |
<10 | 53.7% | - | - | - | - | - | 48% |
SYSTOLIC BP < 100 | 49.4% | - | 31% | 36.1% | 45.3% | - | 48% |
TACHYCARDIA | 42.1% | 52.3% | 31% | - | 47% | - | - |
In our study of 164 patients of blunt abdominal trauma 42% had tachycardia. In 49% patient the blood pressure was <100mmHg.
Shock index more than 0.9 was seen in 38.4% of the patients. 53.7 % of the patients had hemoglobin less than 10 gm%. PCV less than 30% was seen in 36.6% of the patients.
CORRELATION OF THE FACTORS USED FOR ASSESSING HEMODYNAMIC STATUS
| Present study | Yanar et al (2008) | Liangyou et al (2007) | Grimme et al (2005) | Wong of et al (2003) | Jay et al (2002) | Rady et al (1994) | Knottenbelt et al (1991) | Taylor et al (1991) |
SI > 0.9 | P < 0.05 | - | P < 0.05 | P < 0.05 | - | - | P < 0.05 | - | - |
PCV <30 | P < 0.05 | P < 0.05 | - | - | - | - | - | - | - |
<10 | P < 0.05 | - | - | - | - | - | - | P < 0.05 | P < 0.05 |
SYSTOLIC BP < 100 | P < 0.05 | P < 0.05 | P < 0.05 | P < 0.05 | p = 0.0064 | P < 0.05 | - | - | - |
TACHYCARDIA | P < 0.05 | 52.3% | P < 0.05 | P < 0.05 | - | - | - | - | - |
In our study shock index was taken as the criterion for hemodynamic status assessment and it showed statistically significant association.
Hematocrit less < 30 showed statistically significant association with shock index for calculating hemodynamic instability.
However the BP < 100 and Hb < 10 overestimated the hemodynamic instability.
FACTORS GAURDING HEMODYNAMIC STATUS & ITS VALUE IN PREDICTING HEMODYNAMIC INSTABILITY.
| Present Study | Kandpal et al (2008) | Yanagawa et al (2005) | Wong et al (2003) | Mirvis et al (1994) | Jeffery et al (1988) |
Flat IVC incidence | 40% | - | 42.8% | - | - | 7% |
% hemodynamic unstable patients with flat IVC | 73% | - | 80% | - | 76.9% | 85% |
P value | < 0.0001 | < 0.05 | < 0.05 | < 0.0124 | - | - |
FLAT IVC VS HEMODYNAMIC STATUS
In our study, Flat IVC was seen in 40 % of the cases suggesting significant blood loss and hypovolemia. Out of 63 hemodynamic unstable patients 73% had flat IVC.
The incidence of flat IVC was discordant to the incidence reported in Jeffery et al study. The possible explanation could be that, Jeffery et al study did not mentioned about the grade of severity of injury in there study population.
However the correlation of hemodynamic instability and flat IVC was in agreement with those seen in Jeffery et al , Wong et al , Mirvis and Yanagawa et al.
In our study, direct correlation was seen between the patient’s free fluid score and presence of flat IVC. The results were in agreement with those seen in Kandpal, Jeffery, Mirvis and Yanagawa et al studies.
FREE FLUID SCORE VS HEMODYNAMIC STATUS:
| Present Study | Sivit et al (1991) | Federle et al (1989) | Federle et al (1983) |
% Hemodynamic unstable patients with free fluid score > III | 66% | - | - | - |
P value | < 0.0001 | < 0.05 | < 0.05 | < 0.05 |
In our study, 66% Patients who had free fluid score III were hemodynamically unstable and 89% of patients who had free fluid score < III were stable.
CORRELATION OF FACTORS PREDICTING HEMODYNAMIC STATUS WITH NEED FOR SURGERY:
•In our study, surgical management was done in 87% patients who were hemodynamically unstable , 97% with flat IVC and 94% patients with free fluid score > III. Conservative management was successful in 68% hemodynamically stable patients , 75% patients with normal IVC and 66% with free fluid score < III.
•Of all the retrospectively evaluated factors in our study, the best predictor for type of management was concluded to be IVC status and was mostly overlooked.
Surgical management | Present study (2008) | Lee et al (2007) | Peitzman et al (2005) | Wong et al (2003) | Levine et al (1995) |
%patients with IVC / p value | 97% (p < 0.05) | - | - | P < 0.05 | - |
% patients who were hemodynamically unstable / p value | 87% (p < 0.05) | 83% | 66% | - | - |
% patients with free fluid score > III / p value | 94% (p < 0.05) | 89% | - | P < 0.05 | p < 0.002 |
Surgical management | Present study (2008) | Michael et al (1995) | Salvatore et al (1995) | Lee at al (1994) | Mirvis et al (1994) | Jeffery et al (1988) |
% patients with IVC / p value | 97% (p < 0.05) | - | - | - | 84% | 100% |
% patients who were hemodynamically unstable / p value | 87% (p < 0.05) | p <0.05 | 64% | - | - | - |
% patients with free fluid score > III / p value | 94% (p < 0.05) | - | - | 100% | - | - |
Conservative management | Present study (2008) | Lee et al (2007) | Levine et al (1995) | Salvatore et al (1995) |
% patients with normal IVC / p value | 75% (p < 0.05) | - | - | 0 – 85 |
% patients who were hemodynamically stable / p value | 68% (p < 0.05) | 42% | - | 49.3% |
% patients with free fluid score > III / p value | 66% (p < 0.05) | 58% | 71% | - |