Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes

Jonathan P. Meizoso, Juliet J. Ray, Charles A. Karcutskie, Casey J. Allen, Tanya Zakrison, Gerd Pust, Tulay Sengul, Enrique Ginzburg, Louis R Pizano, Carl I Schulman, Alan Livingstone, Kenneth G Proctor, Nicholas Namias

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24 Citations (Scopus)

Abstract

INTRODUCTION: Timely hemorrhage control is paramount in trauma, however a critical time interval from emergency department (ED) arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Adults (n=309) with hypotension and GSW to the torso requiring immediate operation from 01/2004 – 09/2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring > 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. Statistical significance was considered at p≤0.05. RESULTS: The study population was age 32±12 years, 92% male, Injury Severity Score 24±15, SBP 81±29 mmHg, Glasgow Coma Scale 13±4. Overall mortality was 27%. Mean time to operation was 19±13 min. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared to those who arrived in 10 minutes or less (HR 1.89, 95% CI 1.10-3.26, p=0.02); this was also true in the severely hypotensive patients with SBP ≤70 mmHg (HR 2.67, 95% CI 0.97-7.34, p=0.05). The time associated with a 50% cumulative mortality (LT50) was 16 minutes. CONCLUSIONS: Delay to the operating room of >10 minutes increases the risk of mortality by almost three-fold in hypotensive patients with GSW. Protocols should be designed to shorten time in the ED. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Level III, outcomes

Original languageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Aug 3 2016

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Torso
Gunshot Wounds
Mortality
Confidence Intervals
Operating Rooms
Hospital Emergency Service
Glasgow Coma Scale
Injury Severity Score
Wounds and Injuries
Thoracotomy
Survival Analysis
Proportional Hazards Models
Hypotension
Observational Studies
Prospective Studies
Hemorrhage
Population

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine
  • Surgery

Cite this

@article{6c41a9d485f1495586e5dfb8f6bfaafd,
title = "Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso: The golden 10 minutes",
abstract = "INTRODUCTION: Timely hemorrhage control is paramount in trauma, however a critical time interval from emergency department (ED) arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Adults (n=309) with hypotension and GSW to the torso requiring immediate operation from 01/2004 – 09/2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring > 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HR) and 95{\%} confidence intervals (CI) are reported. Statistical significance was considered at p≤0.05. RESULTS: The study population was age 32±12 years, 92{\%} male, Injury Severity Score 24±15, SBP 81±29 mmHg, Glasgow Coma Scale 13±4. Overall mortality was 27{\%}. Mean time to operation was 19±13 min. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared to those who arrived in 10 minutes or less (HR 1.89, 95{\%} CI 1.10-3.26, p=0.02); this was also true in the severely hypotensive patients with SBP ≤70 mmHg (HR 2.67, 95{\%} CI 0.97-7.34, p=0.05). The time associated with a 50{\%} cumulative mortality (LT50) was 16 minutes. CONCLUSIONS: Delay to the operating room of >10 minutes increases the risk of mortality by almost three-fold in hypotensive patients with GSW. Protocols should be designed to shorten time in the ED. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Level III, outcomes",
author = "Meizoso, {Jonathan P.} and Ray, {Juliet J.} and Karcutskie, {Charles A.} and Allen, {Casey J.} and Tanya Zakrison and Gerd Pust and Tulay Sengul and Enrique Ginzburg and Pizano, {Louis R} and Schulman, {Carl I} and Alan Livingstone and Proctor, {Kenneth G} and Nicholas Namias",
year = "2016",
month = "8",
day = "3",
doi = "10.1097/TA.0000000000001198",
language = "English (US)",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",

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TY - JOUR

T1 - Effect of time to operation on mortality for hypotensive patients with gunshot wounds to the torso

T2 - The golden 10 minutes

AU - Meizoso, Jonathan P.

AU - Ray, Juliet J.

AU - Karcutskie, Charles A.

AU - Allen, Casey J.

AU - Zakrison, Tanya

AU - Pust, Gerd

AU - Sengul, Tulay

AU - Ginzburg, Enrique

AU - Pizano, Louis R

AU - Schulman, Carl I

AU - Livingstone, Alan

AU - Proctor, Kenneth G

AU - Namias, Nicholas

PY - 2016/8/3

Y1 - 2016/8/3

N2 - INTRODUCTION: Timely hemorrhage control is paramount in trauma, however a critical time interval from emergency department (ED) arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Adults (n=309) with hypotension and GSW to the torso requiring immediate operation from 01/2004 – 09/2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring > 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. Statistical significance was considered at p≤0.05. RESULTS: The study population was age 32±12 years, 92% male, Injury Severity Score 24±15, SBP 81±29 mmHg, Glasgow Coma Scale 13±4. Overall mortality was 27%. Mean time to operation was 19±13 min. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared to those who arrived in 10 minutes or less (HR 1.89, 95% CI 1.10-3.26, p=0.02); this was also true in the severely hypotensive patients with SBP ≤70 mmHg (HR 2.67, 95% CI 0.97-7.34, p=0.05). The time associated with a 50% cumulative mortality (LT50) was 16 minutes. CONCLUSIONS: Delay to the operating room of >10 minutes increases the risk of mortality by almost three-fold in hypotensive patients with GSW. Protocols should be designed to shorten time in the ED. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Level III, outcomes

AB - INTRODUCTION: Timely hemorrhage control is paramount in trauma, however a critical time interval from emergency department (ED) arrival to operation for hypotensive gunshot wound (GSW) victims is not established. We hypothesize that delaying surgery for more than 10 minutes from arrival increases all-cause mortality in hypotensive patients with GSW. METHODS: Adults (n=309) with hypotension and GSW to the torso requiring immediate operation from 01/2004 – 09/2013 were retrospectively reviewed. Patients with resuscitative thoracotomies, traumatic brain injury, transfer from outside institutions, and operations occurring > 1 hour after arrival were excluded. Survival analysis using multivariate Cox regression models was used for comparison. Hazard ratios (HR) and 95% confidence intervals (CI) are reported. Statistical significance was considered at p≤0.05. RESULTS: The study population was age 32±12 years, 92% male, Injury Severity Score 24±15, SBP 81±29 mmHg, Glasgow Coma Scale 13±4. Overall mortality was 27%. Mean time to operation was 19±13 min. After controlling for organ injury, patients who arrived to the operating room after 10 minutes had a higher likelihood of mortality compared to those who arrived in 10 minutes or less (HR 1.89, 95% CI 1.10-3.26, p=0.02); this was also true in the severely hypotensive patients with SBP ≤70 mmHg (HR 2.67, 95% CI 0.97-7.34, p=0.05). The time associated with a 50% cumulative mortality (LT50) was 16 minutes. CONCLUSIONS: Delay to the operating room of >10 minutes increases the risk of mortality by almost three-fold in hypotensive patients with GSW. Protocols should be designed to shorten time in the ED. Further prospective observational studies are required to validate these findings. LEVEL OF EVIDENCE: Level III, outcomes

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