Epidemiology of hypothermia in trauma patients
Epidemiologisk beskrivning av hypotermi hos traumapatienter
Författare: Erika Martell
Termin 4, 2017
Examensarbete: Magister, 15 hp Huvudområde: Omvårdnadsvetenskap
Specialistsjuksköterskeprogrammet, akutsjukvård
Institutionen för hälsovetenskaper, Örebro Universitet. Handledare: Annsofie Adolfsson, lektor, Örebro Universitet Examinator: Ulrica Nilsson, lektor, Örebro Universitet
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Innehållsförteckning
ABSTRACT ... 2 SAMMANFATTNING ... 3 ARTICLE ... 4 INTRODUCTION ... 4 Figure 1. ... 5 METHOD ... 6The Study Group ... 6
Data collection ... 6 Statistical analysis ... 8 Recived care ... 8 Ethical considerations ... 8 RESULTS ... 9 DISCUSSION ... 13 Limitations ... 15 CLINICAL IMPLICATIONS ... 16 CONCLUSION ... 16 REFERENCES ... 17
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Abstract
IntroductionAccidental hypothermia is a common problem in trauma patients. Previous studies have shown that hypothermic trauma patients have higher mortality and suffer from more posttraumatic complications. The purpose of this study is to describe the epidemiology of hypothermia in trauma patients admitted to the Intesive Care Unit, Observation Ward or Surgical Theatre at the University Hospital of Örebro by comparing incidence, sex, age, trauma mechanism, injuries, time to admission and mortality in hypothermic trauma patients to normothermic trauma patients.
Method
This study is a retrospective single center cohort study. The data were collected primarily from the first hours after the accident. All patients generating a trauma call, who were admitted to the Intensive Care Unit, Observation Ward or Surgical Theatre after treatment in the emergency room in the University Hospital of Örebro from January 2015 to December 2016 were assessed as potential cases. Hypothermia was considered temperature below 36oC. The hypo- and normothermic group was compared to different variables through statistical analyses.
Result
The study included 120 patients. Hypothermia was present in 35,8% (n =43) of the patients. Temperature in the prehospital setting and at the emergency department was rarely
documented. The majority of injuries was sustained from car, traffic or fall accident. Face, head and c-spine injuries was common among the hypothermic patients. The incidence of hypothermia was mainly during spring. The mortality in the hypothermic group was 20% (n =8).
Conclusion
The results indicates that hypothermia is a common complication in trauma patients and that there is an increased risk for mortality, but it could not be significantly established.
Keywords: Accidental Hypothermia, Emergency Department, Intensive Care Unit, Prehospital, Trauma
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Sammanfattning
Introduktion
Accidentell hypotermi är vanligt förekommande hos traumapatienter. Tidigare studier har visat att hypoterma traumapatienter har högre mortalitet och oftare lider av posttraumatiska komplikationer. Syftet med den här studien var att göra en epidemiologisk beskrivning av hypotermi hos traumapatienter inlagda på intensivvårdsavdelning, observationsavdelning eller operation genom att jämföra incidens, kön, ålder, traumamechanism, skador, tid till
inläggning och mortalitet mellan hypo- och normoterma traumapatienter på Universitetssjukhuset Örebro.
Metod
Studien är en single center cohort-studie. Data har hämtats primärt från de första timmarna efter olyckan. Alla patienter som genererade ett traumalarm och lades in på
intensivvårdsavdelning, observationsavdelning eller operation från akutmottagningen Universitetssjukhuset Örebro under januari 2015 till december 2016 bedömdes som möjliga studiedeltagare. Hypotermi ansågs vara temperatur under 36oC. Variabler i den hypo- och normoterma gruppen jämfördes genom statistiska analyser.
Resultat
Totalt inkluderades 120 patienter i studien. Hypotermi förekom hos 35,8% (n = 43) av traumapatienterna. Temperatur var sällan dokumenterad prehospitalt eller på
akutmottagningen. Majoriteten av skadorna uppkom till följd av bil-, trafik- eller fallolyckor. Ansikts-, huvud- och nackskador var vanligt förekommande hos hypoterma patienter.
Hypotermi förekom framför allt under våren. Mortaliteten bland hyoterma patienter var 20% (n =8).
Konklusion
Resultaten tyder på att hypotermi är en vanligt förekommande komplikation hos
traumapatienter och att det finns en ökad risk för mortalitet men det kunde inte statistiskt fastställas.
Nyckelord: Accidentell hypotermi, Akutmottagning, Intensivvårdsavdelning, Prehospital, Trauma
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Article
IntroductionTrauma is the leading cause of mortality in Europe in people younger than 40 years and causes 10% of all the deaths worldwide1,13. In Scandinavia, the incidence of major trauma range between 30 to 52 per 100 000 inhabitants per year2. Hypothermia is very common in multiply injured patients, it has been reported to be present in over 40% of trauma patients14, 15. Hypothermia is an independent risk factor for mortality15, 16 and multiple organ dysfunction syndrome14. The core temperature is related to mortality regardless of the incidence of shock, resuscitation fluid or the severity of the injury17. Severely injured patients are especially exposed to hypothermia because of hypovolemia, exposure to cold environment, sedative drugs and cold fluid administration12.
An investigation requested by the Swedish government recommend that the trauma care should be centralized3. The demographic and geographical conditions in Sweden entails longer transportations of severely injured patients and the risk of hypothermia might therefore be increased.
There are two types of hypothermia, induced and accidental hypothermia. Induced hypothermia is mainly used as a therapy after cardiac arrest where it involves controlled cooling of the body to prevent ischemic injury to the tissue15. Accidental hypothermia is an effect of outer components without medical intervention18. In this article, the term
hypothermia will be used referring to accidental hypothermia.
Hypothermia is commonly described as body temperature lower than 35°C19. However, according to the Advanced Trauma Life Support (ATLS), the limit of hypothermia in trauma patients should be increased to 36°C because of the negative effects on coagulation and perfusion10. Hypothermia constitutes one of the fundamentals of the so called Lethal Triad, where the patient suffers from metabolic acidosis, coagulopathy and hypothermia because of shock (Figure 120). This has a negative effect on myocardial performance, the metabolism and the coagulation cascade12. The result is decreased perfusion and reduced ability to stop
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Figure 1. Lethal triad20
In an epidemiological study, from Weuster et al, 15 230 trauma patients were included and 5078 of them were hypothermic. They found that blunt trauma, as car accidents or fall, and longer prehospital rescue time were more common in the hypothermic group. They also found that female gender, nighttime, winter, shock on site, preclinical volume therapy and time until hospital admission were significant factors to develop hypothermia below 33°C8.
Treating hypothermia depends on the level of hypothermia. It ranges from warm blankets and intravenous fluids to cardiopulmonary bypass10. Despite all the options, there is no evidence-based approach to managing hypothermia. This may be due to that hypothermia may be overlooked in the initial assessment because more life-threatening injuries requires intervention. A study conducted in Norway by Karlsen et al found that only 12% of the ambulance service had a thermometer and 14 % had an active warming equipment21. In the University hospital of Örebro the temperature prehospital is registered by ear thermometer. At the Intensive Care Unit registration through urinary catheter with temperature registration is the most common way to ensure core temperature. Method of temperature measurement differ in the emergency department between ear and urinary catheter with temperature registration. Temperature registration through urinary temperature catheter is a reliable and validated instrument23.
The World Health Organization (WHO, 2017b) identifies the need to emphasize the
importance of patient safety. Harm to patients due to medical errors is described as a global problem. It is of outmost importance for health care personnel to avoid preventable harm. The results of medical errors might lead to longer hospital stay, permanent injuries or even death. The complications might lead to devastating results for the patients and increased expenses
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for the health care system25. Hypothermia is a complication of which can be prevented and treated in the acute phase.
The purpose of this study is to describe the epidemiology of hypothermia in trauma patients admitted to the Intensive Care Unit, Observation Ward or Surgical Theatre at the University Hospital of Örebro. More specifically to evaluate if there are any differences between normothermic and hypothermic trauma patients regarding incidence, sex, age, trauma mechanism, injuries, time to admission and mortality.
Method
This study is a retrospective single center cohort study comparing two groups, a hypothermic group (the exposed) to a normothermic group (control). The data were collected primarily from the first hours after the accident.
The Study Group
All patients generating a trauma call and who were admitted to the Intensive Care Unit (ICU), Observation Ward (OW) or Surgical Theatre (ST) after treatment in the emergency room in the University Hospital of Örebro from January 2015 to December 2016 were assessed as potential cases. Exclusion criteria were temperature not registered within two hours from arrival at ICU, OW or ST and age < 18 years.
Data collection
Data were collected retrospectively from the trauma archive in the Emergency Department at the University Hospital of Örebro. The registry contained a total of 1336 trauma patients during the study period. Out of 1336 patients who were assessed for the study, 170 patients met the inclusion criteria. Majority of the documentations of temperature in the Prehospital setting (n = 96 of 120) and in the ED (n = 106 of 120) was not recorded. No further analysis was made from the Prehospital and ED temperature because of the small sample. Since documentation of Prehospital and ED temp were missing, eight patients who only had
documentation of Prehospital or ED temperature registered, not ICU, OW or ST temperature, was excluded. Documentation was missing in 23 patients. Four patients could not be found in Klinisk Portal. In 15 patients, the temperature was documented later than 2 hours from admission to ICU, OW or ST. In total, 120 patients were included in the study.
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Figure 2. Flowchart above. Selection process of cases included in the study. Each individual was found by social security number in Klinisk Portal, a Swedish
documentation system. The data were then collected from the medical documentation and scanned monitoring journals from ICU, OW and ST. Information about temperature in different time phases, trauma mechanism, type of injury, survival to hospital discharge and month of accident were gathered. Trauma mechanism and type of injury were based on a code documented by a doctor in the journal. The analyze of temperature was divided into three different time phases, the prehospital setting, at the ED and at the ICU, OW or ST. Time were documented in minutes from SOS call until the ambulance arrived at scene, time before departure, time until arrival at the Emergency Department and time from SOS call until the first documentation at the ICU, OW or ST.
The patients were subdivided into a hypothermic group (temperature £35,9°C) and a
normothermic group (temperature ³36,0°C). The variables trauma mechanism, type of injury and month of accident were stratified into smaller groups. Trauma mechanism were divided into car accidents, traffic accidents, fall accidents, shooting accidents, knife accidents, suicide, burn, crush accidents and varia. By using the same anatomical subdivision as the Injury Severity Score (ISS), the injuries were categorized to head and c-spine injuries, face injuries, chest injuries, abdominal injuries, extremity injuries and external injuries. Month of accident were divided into the four seasons, winter (December to February), spring (March to May), summer (June to August) and autumn (September to November).
n = 1336 n = 170 n = 1166 No documentation (n = 27) No ICU/ST temperature (n = 8) Temp > 2 h (n=15) n = 120
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Statistical analysis
The statistical calculations were made with SPSS IBM version 23. The relationship between hypothermia and age, sex, month of accident, trauma mechanism, type of injury and survival to discharge was studied. The hypo- and normothermic groups were analyzed and compared to the variables by Chi-Square test, Fisher’s Exact Test and Independent Sample T-test. Statistical significance was established at p <0,05. Each variable was presented with descriptive statistics (mean, median, SD, min-max or number and percent). To identify patterns of hypothermia a Linear Regression Analysis were made comparing temperature in the ICU/Surgical theatre to time to admission and time at accident site. Logarithm of the variable time to ICU, OW or ST were made because of skewness.
Received care
Patients presenting with traumatic injury is taken care of according to the Prehospital Trauma Life Support in the prehospital setting and Advanced Trauma Life Support at the Emergency Department at the University Hospital of Örebro. There was no difference in the criteria for trauma call during 2015 - 2016. Patients were transported either by ambulance or by
ambulance helicopter.
Ethical considerations
Information about the study was sent to concerned departments. The present study has been approved by lecturers at Örebro University, the Chief of Anesthesiology and Intensive Care Unit and the Chief of Surgery at the University Hospital of Örebro. Written consent has been signed by the Chief of Emergency Department at the University Hospital of Örebro. A registration number of the study was established to be able to follow the access to the patient journals. All personal data was put in a secure document and decoded to assure patient confidentiality. Each patient was given an identification number which was used instead of social security number and name. No sensitive data is presented in the study. The included patients were never exposed to any harm. The current study was conducted with respect for the patients and with the patient’s best interest at heart. The WMA Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects has been followed24. According to present guidelines at the University of Örebro there is no need for further ethical application.
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Results
The occurrence of hypothermia in the ICU, OW or ST was 35,8% (n = 43) of the included population. Mean temperature in all patients was 36,3°C. Temperature ranged from 32,6°C- 38,5°C. Mean age was 48,6 (SD 19,2). Overall there were more men (n = 92) than women (n = 28) among the included patients. Difference between age (p = 0,241) or distribution of sex (p = 0,376) was not significant between the hypo- and normothermic groups. The largest part of the patients over all was admitted to the ICU (n = 108). There was a difference in mortality between the hypothermic and normothermic group but statistical significance was not
achieved (p = 0,062). The mortality in the hypothermic group was 20% (n = 8) and in the normothermic group 6,9% (n = 5). Eight patients went to other hospitals, therefore survival to discharge could not be documented. See Table 1.
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Table 1. Presentation of Age, Sex, Admission, Survival and Temperature (°C)at ICU, OW and ST
All (n = 120) Normothermia n = 77 (64,2%) Hypothermia n = 43 (35,8%) p-value Temperature at ICU n = 120 0,0003 Mean (SD) 36,3 (1,2) 37 (0,7) 35,1 (0,8) Median (min-max) 36,4 (32,6-38,5) 36,8 (36,0-38,5) 35,3 (32,6-35,9) Age n = 120 0,2413 Mean (SD) 48,6 (19,2) 47,1 (18,7) 51,4 (19,9) Median (min-max) 47 (19-97) 43 (19-92) 51 (19-97) Sex, n (%) n = 120 0,3762 Male 92 (76,7) 61 (66,3) 31 (33,7) Female 28 (23,3) 16 (57,1) 12 (42,9) Admission ICU/ST, n (%) 0,5711 ICU 108 (90) 71 (92,2) 37 (86) ST 10 (8,3) 5 (6,5) 5 (11,6) OW 2 (1,7) 1 (1,3) 1 (2,3) Survival, n (%) n = 112 0,0622 Dead 13 (11,6) 5 (6,9) 8 (20) Discharged 99 (88,4) 67 (93,1) 32 (80)
Statistical calculations made by Chi-square test1, Likelihood ratio2 and Independent Sample T-test3
Fall accidents were the most common mechanism of trauma (26,4%) followed by car accidents (18,9%) and traffic accidents (18,9%). All patients with crush mechanism were normothermic (n = 8). No significant difference between trauma mechanism and temperature was established (see Table 2.).
Chest injuries were registered in 46 patients (43,4%). Head and c-spine injuries was the second largest group with 45 patients (42,5%). Injury pattern is described in Table 2. Several
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patients had sustained more than one injury. Patients presenting with face and head and c-spine injuries were more likely to also suffer from hypothermia (p = 0,004 and p =0,007 respectively). The large quantity of patients with extremity injuries was normothermic (p = 0,004). No further significance between the hypothermic and normothermic group in injuries could be made.
Divided into seasons, spring was the month with highest incidence of hypothermia, 13 out of 25 patients were hypothermic.
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Table 2. Presentation of Trauma mechanism, Injury and Month of accident
(n = 120) All Normothermia n = 77 (64,2%) Hypothermia n = 43 (35,8%) p-value Mechanism, n (%) n = 106 Car 20 (18,9) 14 (70,0) 6 (30,0) 0,6091 Traffic 20 (18,9) 15 (75,0) 5 (25,0) 0,3021 Fall 28 (26,4) 15 (53,6) 13 (46,4) 0,1361 Shot 3 (2,8) 2 (66,7) 1 (33,3) 0,7222 Knife 8 (7,5) 7 (87,5) 1 (12,5) 0,162 Suicide 5 (4,7) 2 (40,0) 3 (60,0) 0,2292 Burn 6 (5,7) 4 (66,7) 2 (33,3) 0,6522 Crush 8 (7,5) 8 (100) 0 (0) 0,0482 Varia 8 (7,5) 2 (25,0) 6 (75,0) 0,0632 Injury, n (%) n = 106
Head and c-spine 45 (42,5) 23 (32,9) 22 (61,1) 0,0071
Face 14 (13,2) 4 (5,7) 10 (27,8) 0,0042 Chest 46 (43,4) 31 (44,3) 15 (41,7) 0,7971 Abdomen 25 (23,6) 17 (24,3) 8 (22,2) 0,8131 Extremity 30 (28,3) 25 (35,7) 5 (13,9) 0,0181 External 8 (7,5) 6 (8,6) 2 (5,6) 0,7182 Season of accident n (%) n = 120 Winter 26 (21,7) 18 (23,4) 8 (18,6) 0,5431 Spring 25 (20,8) 12 (15,6) 13 (30,2) 0,0581 Summer 36 (30) 24 (31,2) 12 (27,9) 0,7081 Autumn 33 (27,5) 23 (29,9) 10 (23,3) 0,4371
Statistical calculations made by Fischer’s Exact test2 and Chi-square1
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The Linear Regression analysis did not prove any significant association between temperature at the ICU and time in the prehospital setting or time from SOS call to arrival at ICU (Table 3.).
Table 3. Comparing Temperature at ICU with time
Dependent Independent R-square B-coefficient p
TempICU TimePH 0,009 0,048 0,388
TempICU TimeICU 0,02 0,095 0,166
Linear Regression Analysis
Discussion
Hypothermia (£ 35,9°C) is a common problem in trauma patients admitted to ICU, OW or ST (35,8%). This result conforms with the previous research8, 14, 19. Hypothermia was in the present study considered to be temperatures below 36°C10. Other studies have used
temperature below 35°C as the limit of hypothermia15, 19. The decision to use 36 °C or below is related to the use and recommendations of Prehospital Trauma Life Support and Advanced Trauma Life Support as standard assessment and treatment method in the University Hospital of Örebro. To use a limit below 35°C would not be in line with the current guidelines of assessment.
Only 14 out of 120 patients had registered temperature at the Emergency Department, the same number in the prehospital setting was 34 out of 120. The large loss of data confined the possibility of comparison between temperature in the three time phases which would have been of interest. The loss of data is described in previous studies as well8, 21. Loss of
temperature registration might result in patients at risk of hypothermia not being discovered. This violates the responsibility of the health care personnel to prevent harm to the patient. The criteria to be admitted to ICU, OW or ST excluded many patients. The decision to not include patients that was not admitted to any observational unit was because the patients admitted to ICU, OW or ST (the patients demanding the highest level of care) are according to previous research more likely to suffer from severe complications of accidental
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Female gender seemed to be more susceptible to hypothermia although the result was not significantly established. The reason for this is unclear, but previous studies have shown that female gender is a significant risk factor to become hypothermic8.
In line with Weuster et al. this study indicates that hypothermic patients often also suffer from head and face injuries compared to the normothermic patients8. Patients suffering from head trauma is more at risk of unconsciousness. This can damage the thermoregulatory areas in the brain and effect ability to preserve heat. Unconscious patients have shown to have a
significant risk of developing hypothermia8.
The results suggest that the risk of developing hypothermia is highest in spring. This can be due to underestimation of weather conditions in the medical personnel. This contradicts Weuster et al (2026) who saw an increase of hypothermia in wintertime.
The relationship between time and temperature in the ICU, OW or ST could not be
determined as has been in other studies8,19. Preclinical circumstances effecting time, such as extraction from car can worsen the hypothermia8, 19. There are many factors that can
contribute to effects on the temperature, factors that is not possible to account for, such as weather or injury severity. Those factors might influence the result, thus the correlation between temperature and time cannot be ruled out. A multivariate analysis might have answered the question in a better manner.
There is also some variance within the groups. Some patients are secondary transports from other hospitals. If a traumatic accident occurs in near distance of a small hospital the current guideline is for the ambulance to make a brief stop for damage control at the local hospital, if the patient is severely injured and in need of immediate advanced care, before proceeding to a larger hospital with more advanced specialists. There were also some patients transported by ambulance helicopter from traumatic accident sites in other regions to the University Hospital of Örebro. The time before admission was in those cases prolonged. Those patients compose a small part of the studied population but might get more common with centralization of the trauma care suggested by SBU3.
A small proportion of the patients were at the emergency department for a long time before admission at the ICU, OW or ST. Those patients were often initially assessed as minor or moderate injured and therefore probably had easier to maintain body core temperature. They
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contribute to the long time before admission which might influence the correlation between time and temperature.
The current data shows that hypothermia is an independent risk factor for posttraumatic mortality but there are studies that show the opposite12, 21, 22. This study indicates a higher mortality in the hypothermic trauma patient (20%) than the normothermic trauma patient (6,9%), which is in line with other studies8, 15-17. The small sample in this study may be the reason for not achieving statistical significance. The fragmentation into hypothermic and normothermic patients made the groups small and therefore few deceased patients in each group.
Limitations
Because of the narrow inclusion criteria and loss of data the individual groups became small when subdivided into categories. This might have influenced the ability to reach significance in the analyses made.
The age differed from 19 to 97 years of age. The elder population might have affected the result since no consideration has been taken for comorbidity.
The temperature registered at the ICU, OW or ST might vary in measurement method. Standard is urinary catheter with temperature registration which is a validated and reliable method of measurement of core body temperature. In some cases, the documentation of how the temperature was measured was missing.
The subdivision of injury and mechanism was based on documented codes in the patient journals. The documentation was made by doctors in charge of the patient. In some cases, the documentation of codes was insufficient. Other studies have used Injury Severity Score (ISS)8, 15. That kind of standardized documentation system would be an advantage, but no such documentation existed in the processed material. The documentation of time and temperature was also depending on documentation by health care personnel. Since this is a retrospective study there was no guidelines in how, what or when to document the variables of interest, therefore some of the data might have been compromised by the human factor. The statistical method used was primarily Chi-square in nominal variables. The subcategories could probably be distributed differently, for example mechanism divided into blunt and penetrating trauma to gain larger groups to compare.
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Clinical implications
As the results suggests, hypothermia is still a common problem in trauma patients even though the risk of hypothermia has been emphasized for a long time. This contradicts the responsibility of heath care personnel to prevent harm. Hypothermia is a potential cause of mortality and post traumatic complications. The documentation of temperature in the Prehospital settings and Emergency Department is low. The awareness should be raised to emphasize the importance of early hypothermia recognition to improve patient outcome. Conclusion
The present study indicates that hypothermia is a common complication in trauma patients at the University Hospital of Örebro. Patients with face, head and c-spine injuries seems to be more exposed. No statistical significance could be established in difference between the hypothermic and normothermic group regarding sex, age, trauma mechanism, time or survival. The lack of data in the Prehospital setting and at the Emergency Department is a problem since patients at risk of hypothermia might not be discovered. There is a need for further prospective studies to be able to dictate what data to be collected and standardize care and measurements.
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