In-Field Lactate Testing Could Improve Trauma Patient Triage
In-field lactate testing by emergency responders can significantly improve the triage of trauma patients en route to the hospital, according to a study published in the March issue of the Journal of Trauma and Acute Care Surgery. Point-of-care lactate (P-LAC) better predicts which trauma patients will need resuscitative care (RC), compared to traditionally used field […]
In-field lactate testing by emergency responders can significantly improve the triage of trauma patients en route to the hospital, according to a study published in the March issue of the Journal of Trauma and Acute Care Surgery. Point-of-care lactate (P-LAC) better predicts which trauma patients will need resuscitative care (RC), compared to traditionally used field measures based on vital signs. The authors say that more than 1.8 million trauma patients annually may be inappropriately undertriaged, increasing morbidity and mortality, as a result of imperfect prehospital trauma triage g! uidelines. Lactate, a circulating biomarker of organ perfusion failure, has been shown inhospital to be associated with mortality in patients with sepsis, myocardial infarction, and trauma. P-LAC devices, which can be used prehospital, operate similarly to glucometers, and cost only a few dollars per patient, may improve identification of underlying severe traumatic injury prior to arrival at the hospital. Data from nine sites (Level I or II trauma center) participating in the Resuscitation Outcomes Consortium from March 2011 to August 2012 were used to compare prehospital P-LAC measurements with systolic blood pressure (SBP) for predicting the need for RC in trauma patients (SBP between 70 mm Hg and 100 mm Hg) transported by ground emergency medical services. A drop of blood obtained during IV line insertion was placed on a measurement strip for lactate testing using a hand-held device (Lactate Pro; Arkray, Japan). Both the emergency medical services and emergency department receiving care team were blinded to the lactate results. RC was defined as needed if any of the following occurred within six hours of emergency department arrival: blood transfusion of five U or greater; intervention for hemorrhage including thoracotomy, laparotomy, pelvic fixation, or interventional radiology embolization; or death. The researchers found that 18 percent of the 387 patients required RC. A P-LAC cutoff point of 2.5 mmol/L was used to yield approximately the same estimated specificity as that of SBP of 90 mm Hg or less (≈ 48 percent). There were significant differences in the sensitivities of P-LAC of 2.5 mmol/L or greater (93 percent) versus SBP of 90 mm Hg or less (67 percent). Regardless of timing of P-LAC (either less than 15 minutes from 911 call to lactate measurement or greater than 15 minutes) P-LAC sensitivity was better than SBP. While higher P-LAC was tied to higher need for RC, P-LAC less than 2.5 mmol/L had a negative predictive value of 97 percent, compared with 87 percent for SBP greater than 90 mm Hg. P-LAC was also statistically superior to shock index (heart rate / SBP) for predicting RC. “Given the association between elevated P-LAC and the need for RC, informing the trauma team may result in an appropriate response and a reduced time to definitive care,” write the authors led by Francis Guyette, M.D., from University of Pittsburgh in Pennsylvania. Takeaway: Use of P-LAC testing may improve the triage of trauma patients during transport to the hospital.