Usefulness of End-tidal Carbon Dioxide as a Predictor of Emergency Intervention in Major Trauma Patients

중증 외상 환자에서의 응급중재술 시행 예측 인자로서의 호기말 이산화탄소 분압의 유용성

  • Kim, Sung Ho (Department of Emergency Medicine, Yonsei University College of Medicine) ;
  • Kim, Seunghwan (Center for Disaster Relief Training and Research, Yonsei University Severance Hospital) ;
  • Lee, Jae Gil (Department of Surgery, Yonsei University College of Medicine) ;
  • Chung, Sung Phil (Department of Emergency Medicine, Yonsei University College of Medicine) ;
  • Kim, Seung Ho (Department of Emergency Medicine, Yonsei University College of Medicine)
  • 김성호 (연세대학교 의과대학 응급의학교실) ;
  • 김승환 (연세대학교 세브란스병원 재난의료교육센터) ;
  • 이재길 (연세대학교 의과대학 외과학교실) ;
  • 정성필 (연세대학교 의과대학 응급의학교실) ;
  • 김승호 (연세대학교 의과대학 응급의학교실)
  • Received : 2014.08.05
  • Accepted : 2014.10.14
  • Published : 2014.12.31

Abstract

Purpose: If the survival of patients suffering from severe blunt trauma is to be improved, appropriate interventions should be taken immediately. The purpose of this study is to evaluate the clinical utility of end-tidal carbon dioxide ($ETCO_2$) as a surrogate marker for predicting both the need for intervention and the prognosis. Methods: This is a prospective observational study. Nasal cannula was applied to measure $ETCO_2$, and the following parameters, which are known to be related to the prognosis for a patient, were recorded: injury severity score (ISS), revised trauma score (RTS), arterial blood gas (ABG), lactate, and hemoglobin (Hb). To evaluate the outcome, we investigated the details of emergent interventions and expired patients. Results: A total of 93 patients were enrolled in this study. Emergent intervention was significantly associated with systolic blood pressure (sBP, p-value=0.001), $ETCO_2$ (p-value<0.001), serum lactate level (p-value<0.001), pH (p-value< 0.003), $HCO_3$ (p-value=0.004), base excess (p-value<0.002), ISS (p-value<0.001) and RTS (p-value=0.005). In the multivariate logistic regression, only $ETCO_2$ (odds ratio (OR): 0.897, 95% confidence interval (CI): 0.792-0.975, p-value= 0.048) and ISS (OR: 1.132, 95% CI: 1.053-1.233, p-value=0.002) were associated with emergent intervention whereas $ETCO_2$ (p-value=0.973) and ISS (p-value=0.511) were not statistically significant in predicting the survival of patients in the univariate analysis. An optimal ETCO cut-off of 29 mmHg on the ROC curve was determined, with the area under the ROC curve (AUC) being 0.824 (0.732-0.917)]. Conclusion: This study has revealed that $ETCO_2$, which can be rapid and easily measured through a nasal cannula, and the ISS may be prognostic indicators of emergent interventions in Emergency Departments.

Keywords

References

  1. MacKenzie EJ, Rivara FP, Jurkovich GJ, Nathens AB, Frey KP, Egleston BL, et al. A national evaluation of the effect of trauma-center care on mortality. N Engl J Med 2006; 354: 366-78. https://doi.org/10.1056/NEJMsa052049
  2. Kaplan LJ, Kellum JA. Initial pH, base deficit, lactate, anion gap, strong ion difference, and strong ion gap predict outcome from major vascular injury. Crit Care Med 2004; 32: 1120-4. https://doi.org/10.1097/01.CCM.0000125517.28517.74
  3. Kroezen F, Bijlsma TS, Liem MS, Meeuwis JD, Leenen LP. Base deficit-based predictive modeling of outcome in trauma patients admitted to intensive care units in Dutch trauma centers. J Trauma 2007; 63: 908-13. https://doi.org/10.1097/TA.0b013e318151ff22
  4. Tyburski JG, Carlin AM, Harvey EH, Steffes C, Wilson RF. End-tidal CO2-arterial CO2 differences: a useful intraoperative mortality marker in trauma surgery. J Trauma 2003; 55: 892-6; discussion 6-7. https://doi.org/10.1097/01.TA.0000097827.51916.7E
  5. Tyburski JG, Collinge JD, Wilson RF, Carlin AM, Albaran RG, Steffes CP. End-tidal CO2-derived values during emergency trauma surgery correlated with outcome: a prospective study. J Trauma 2002; 53: 738-43. https://doi.org/10.1097/00005373-200210000-00020
  6. Wilson RF, Tyburski JG, Kubinec SM, Warsow KM, Larky HC, Wilson SR, et al. Intraoperative end-tidal carbon dioxide levels and derived calculations correlated with outcome in trauma patients. J Trauma 1996; 41: 606-11. https://doi.org/10.1097/00005373-199610000-00003
  7. Caputo ND, Fraser RM, Paliga A, Matarlo J, Kanter M, Hosford K, et al. Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients: a prospective cohort study. J Trauma Acute Care Surg 2012; 73: 1202-7. https://doi.org/10.1097/TA.0b013e318270198c
  8. Shim H, Jang JY, Lee JG, Kim S, Kim MJ, Park YS, et al. Application of Critical Pathway in Trauma Patients. J Trauma Inj 2012; 25: 159-65.
  9. Hanley JA, McNeil BJ. A method of comparing the areas under receiver operating characteristic curves derived from the same cases. Radiology 1983; 148: 839-43. https://doi.org/10.1148/radiology.148.3.6878708
  10. Obuchowski NA, McClish DK. Sample size determination for diagnostic accuracy studies involving binormal ROC curve indices. Stat Med 1997; 16: 1529-42. https://doi.org/10.1002/(SICI)1097-0258(19970715)16:13<1529::AID-SIM565>3.0.CO;2-H
  11. Dubin A, Murias G, Estenssoro E, Canales H, Sottile P, Badie J, et al. End-tidal CO2 pressure determinants during hemorrhagic shock. Intensive Care Med 2000; 26: 1619-23. https://doi.org/10.1007/s001340000669
  12. Madati PJ, Bachur R. Development of an emergency department triage tool to predict acidosis among children with gastroenteritis. Pediatr Emerg Care 2008; 24: 822-30. https://doi.org/10.1097/PEC.0b013e31818ea004
  13. Fearon DM, Steele DW. End-tidal carbon dioxide predicts the presence and severity of acidosis in children with diabetes. Academic Emergency Medicine 2002; 9: 1373-8. https://doi.org/10.1111/j.1553-2712.2002.tb01605.x
  14. Christopher LH, Salvatore S, Matthew D, Jay LF, Linda P. End-tidal carbon dioxide is associated with mortality and lactate in patients with suspected sepsis. The American Journal of Emergency Medicine 2013; 31: 6471.
  15. Deakin CD, Sado DM, Coats TJ, Davies G. Prehospital End- Tidal Carbon Dioxide Concentration and Outcome in Major Trauma. The Journal of Trauma: Injury, Infection, and Critical Care 2004; 57: 65-8. https://doi.org/10.1097/01.TA.0000103984.70306.22
  16. Baker SP, O'Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. The Journal of trauma 1974; 14: 187-96. https://doi.org/10.1097/00005373-197403000-00001
  17. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. The Journal of trauma 1989; 29: 623-9. https://doi.org/10.1097/00005373-198905000-00017
  18. Hasler RM, Nuesch E, Juni P, Bouamra O, Exadaktylos AK, Lecky F. Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: Multicentre cohort study. Resuscitation 2012; 83: 476-81. https://doi.org/10.1016/j.resuscitation.2011.10.018
  19. Frank K, Taco SB, Mike SLL, Meeuwis JD, Luke PHL. Base Deficit-Based Predictive Modeling of Outcome in Trauma Patients Admitted to Intensive Care Units in Dutch Trauma Centers. The Journal of Trauma: Injury, Infection, and Critical Care 2007; 63: 908-13. https://doi.org/10.1097/TA.0b013e318151ff22