Editors' ChoiceCRITICAL CARE

Lactate trumps blood pressure for trauma triage

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Science Translational Medicine  11 Mar 2015:
Vol. 7, Issue 278, pp. 278ec43
DOI: 10.1126/scitranslmed.aaa9866

When dealing with trauma patients, paramedics must make rapid life-altering decisions on the fly, often with limited information. How severely injured is this patient? Does this patient require resuscitation? Should we transport to the closest hospital or to the local trauma center? These and other questions must be answered with little guidance other than individual experience and vague triage guidelines. However, there is new evidence that a simple point-of-care measurement of blood lactate concentration might clarify the decision-making process during these oftentimes murky situations.

Guyette and colleagues from the Resuscitation Outcomes Consortium tested the ability of a single measurement of blood lactate performed by paramedics in the field to predict the need for “resuscitative care” (RC), defined as the need for a major blood transfusion, urgent surgery to stop bleeding, or death within 6 hours of arrival to the emergency department. After injury, blood lactate concentrations can climb as a result of anaerobic metabolism when blood loss is severe enough to induce shock. The investigators compared the performance of the lactate test with a systolic blood pressure measurement <90 mmHg, which is a cornerstone of current trauma triage guidelines also used to identify blood loss and shock. Of 387 subjects studied, the sensitivity to predict RC patients was increased to 93% when the lactate concentration was >2.5mmol/L, compared with a sensitivity of only 67% when systolic blood pressure was <90 mmHg, a significant improvement. More knowledge of the relationships between shock and blood-lactate concentrations after trauma is required to fully integrate this test across the spectrum of clinical care. However, prehospital lactate testing demonstrates that point-of-care technology is now capable of providing clarity in the often challenging prehospital environment.

F. X. Guyette et al., A comparison of prehospital lactate and systolic blood pressure for predicting the need for resuscitative care in trauma transported by ground. J. Trauma Acute Care Surg. 78, 600–606 (2015). [Abstract]

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