Unstable Without a Source: The Non-Diagnostic Triad in Hypotensive Blunt Trauma Victims
Keywords:REBOA, Blunt Trauma, A.T.L.S., Algorithms
Background: Current algorithms for resuscitation in blunt trauma patients rely on chest x-ray, FAST, and pelvic x-ray to quickly elicit a source of major bleeding in the trauma bay. There are currently no good recommendations for the patient in whom all three of these imaging studies are negative.
Methods: We identified blunt trauma victims who presented with a systolic blood pressure below 100mmHg. Chest x-ray, FAST, and pelvic x-ray obtained in the trauma bay were reviewed, and patients who had all three studies negative underwent thorough chart review and characterization of injuries.
Results: Of the total hypotensive blunt trauma victims (n=649), we found 47 who had a “non-diagnostic triad” (NDT). Of the NDT group, 31.9% (n=15) were found to have a major injury contributing to hypotension, while 61% (n=29) were not diagnosed with a severe injury that could have contributed to hypotension. Of the NDT group with severe injury, 40% (n=6) were found to have retroperitoneal bleeding, 40% (n=6) were found to have intraperitoneal bleeding despite negative fast, 13% (n=2) were thought to have spinal shock, and one patient had a blunt cardiac injury.
Conclusions: Most of the NDT group patients in this study were not diagnosed with a serious injury. However, a significant minority (31%) were found to have a major injury contributing to hypotension. Of these patients, retroperitoneal and/or intra-abdominal bleeding were found in 80%, with neurogenic and cardiogenic shock less common. We feel these sicker NDT patients may benefit from REBOA, although more study is warranted before formal algorithms and recommendations are made.