Year of Publication

2016

Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation

College

Nursing

Department

Nursing

First Advisor

Dr. Debra Moser

Abstract

Injury is a global health problem and in the United States is the leading cause of death for persons aged 1 – 44 years. The primary causes of trauma related death are head injury and hemorrhage; hemorrhagic shock is difficult to recognize in the first hours after trauma. Identification of specific and optimal criteria upon which to base effective triage decisions for trauma patients has been an elusive goal for decades.

The purpose of this dissertation was to identify measures available in the prehospital phase of care and in the Emergency Department that should be included for a more comprehensive definition of the trauma patient who will require trauma center care to better allocate trauma care and resources available.

The first paper is a critical review of early physiologic markers of occult tissue hypoperfuson in which we examine markers of cardiovascular function and markers of tissue perfusion. In this review, we found surrogate measures of tissue perfusion include shock index as a measure of hemodynamic stability and acid-base indicators as measures of tissue oxygenation. This review guides the variable selection for the research study.

The second paper is a report of a study conducted to examine shock index calculated from the first available prehospital vital signs and first available emergency department vital signs as a predictor of mortality within 48-hours in trauma compared to the Injury Severity Score. Shock index can be calculated in real-time during the course of treatment and provides continuous input into the ever changing condition of the patient. Injury severity score is calculated once, at the time of hospital discharge and is used primarily as a marker for comparison of injury severity in research and quality measures of trauma care. The study consisted of 516,156 trauma patient data reported to the National Trauma Data Bank (NTDB) in 2009. The results revealed SI as calculated in both the pre-hospital phase of care by Emergency Medical Services and in the Emergency Department to be significant independent predictors of mortality within forty-eight hours from trauma injuries.

The third paper is a report of a study conducted to examine potential markers of occult tissue hypoperfusion within forty-eight hours of injury. The variables included four major variable categories, physiologic measures, anatomic measures, injury severity and presence of reported comorbid illness. The variable most predictive of death from trauma related injuries within forty-eight hours was the need for intubation.

The findings from this dissertation provide further evidence of the value of multiple physiologic markers in early recognition of occult tissue hypoperfusion. Data from neither the review of the literature nor the two data-based studies are sufficient to identify a brief, accurate, easily used clinical instrument. Further work is needed to develop a clinically useful instrument to identify the occult tissue hypoperfusion in the trauma patient.

Digital Object Identifier (DOI)

http://dx.doi.org/10.13023/ETD.2016.329

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