Prehospital Lactate Predicts Need for Resuscitative Care in Non-hypotensive Trauma Patients

• Published in: The western journal of emergency medicine Vol. 19; no. 2; pp. 224 - 231
• Main Authors: St John, Alexander E, McCoy, Andrew M, Moyes, Allison G, Guyette, Francis X, Bulger, Eileen M, Sayre, Michael R
• Format: Journal Article
• Language: English
• Published: United States Department of Emergency Medicine, University of California, Irvine School of Medicine 01-03-2018; eScholarship Publishing, University of California
• Subjects: Adult; Blood Pressure - physiology; Emergency Medical Services; Female; Humans; Lactic Acid - blood; Male; Prospective Studies; Resuscitation - methods; Resuscitation - mortality; Shock - diagnosis; Shock - mortality; Trauma; Triage; Wounds and Injuries
• ISSN: 1936-9018; 1936-900X; 1936-9018
• DOI: 10.5811/westjem.2017.10.34674

The prehospital decision of whether to triage a patient to a trauma center can be difficult. Traditional decision rules are based heavily on vital sign abnormalities, which are insensitive in predicting severe injury. Prehospital lactate (PLac) measurement could better inform the triage decision. PLac's predictive value has previously been demonstrated in hypotensive trauma patients but not in a broader population of normotensive trauma patients transported by an advanced life support (ALS) unit.
This was a secondary analysis from a prospective cohort study of all trauma patients transported by ALS units over a 14-month period. We included patients who received intravenous access and were transported to a Level I trauma center. Patients with a prehospital systolic blood pressure ≤ 100 mmHg were excluded. We measured PLac's ability to predict the need for resuscitative care (RC) and compared it to that of the shock index (SI). The need for RC was defined as either death in the emergency department (ED), disposition to surgical intervention within six hours of ED arrival, or receipt of five units of blood within six hours. We calculated the risk associated with categories of PLac.
Among 314 normotensive trauma patients, the area under the receiver operator characteristic curve for PLac predicting need for RC was 0.716, which did not differ from that for SI (0.631) (p=0.125). PLac ≥ 2.5 mmol/L had a sensitivity of 74.6% and a specificity of 53.4%. The odds ratio for need for RC associated with a 1-mmol/L increase in PLac was 1.29 (95% confidence interval [CI] [0.40 - 4.12]) for PLac < 2.5 mmol/L; 2.27 (1.10 - 4.68) for PLac from 2.5 to 4.0 mmol/L; and 1.26 (1.05 - 1.50) for PLac ≥ 4 mmol/L.
PLac was predictive of need for RC among normotensive trauma patients. It was no more predictive than SI, but it has certain advantages and disadvantages compared to SI and could still be useful. Prospective validation of existing triage decision rules augmented by PLac should be investigated.