Skip to main content

Advertisement

SpringerLink
Log in

The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account

  • Original Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Background

Two-tier trauma team activation (TTA)—protocols often fail to safely identify severely injured patients. A possible amendment to existing triage scores could be the measurement of serum lactate. The aim of this study was to determine the ability of the combination of serum lactate and age to predict severe injuries (ISS > 15).

Methods

We conducted a retrospective cohort study in a single level one trauma center in a 20 months study-period and analyzed every trauma team activation (TTA) due to the mechanism of injury (MOI). Primary endpoint was the correlation between serum lactate (and age) and ISS and mortality. The validity of lactate (LAC) and lactate contingent on age (LAC + AGE) were assessed using the area under the curve (AUC) of the receiver operating characteristics (ROC) curve. We used a logistic regression model to predict the probability of an ISS > 15.

Results

During the study period we included 325 patients, 75 met exclusion criteria. Mean age was 43 years (Min.: 11, Max.: 90, SD: 18.7) with a mean ISS of 8.4 (SD: 8.99). LAC showed a sensitivity of 0.82 with a specificity of 0.62 with an optimal cutoff at 1.72 mmol/l to predict an ISS > 15. The AUC of the ROC for LAC was 0.764 (95% CI: 0.67–0.85). The LAC + AGE model provided a significantly improved predictive value compared to LAC (0.765 vs. 0.828, p < 0.001).

Conclusions

The serum lactate concentration is able to predict injury severity. The prognostic value improves significantly taking the patients age into consideration. The combination of serum lactate and age could be a suitable Ad-on to existing two-tier triage protocols to minimize undertriage.

Level of evidence: Level IV, retrospective cohort study.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Availability of data and materials

The data set generated and analyzed during the current study is not publicly accessible but is available from the corresponding author on reasonable request.

Code availability

Not applicable.

References

  1. Newgard CD, Staudenmayer K, Hsia RY, Mann NC, Bulger EM, Holmes JF, et al. The cost of overtriage: more than one-third of low-risk injured patients were taken to major trauma centers. Health Aff (Millwood). 2013;32:1591–9. https://doi.org/10.1377/hlthaff.2012.1142.

    Article  Google Scholar 

  2. Newgard CD, Yang Z, Nishijima D, McConnell KJ, Trent SA, Holmes JF, et al. Cost-effectiveness of field trauma triage among injured adults served by emergency medical services. J Am Coll Surg. 2016;222:1125–37. https://doi.org/10.1016/j.jamcollsurg.2016.02.014.

    Article  PubMed  PubMed Central  Google Scholar 

  3. Linder F, Holmberg L, Eklöf H, Björck M, Juhlin C, Mani K. Better compliance with triage criteria in trauma would reduce costs with maintained patient safety. Eur J Emerg Med. 2019;26:283–8. https://doi.org/10.1097/MEJ.0000000000000544.

    Article  PubMed  Google Scholar 

  4. Jenkins P, Rogers J, Kehoe A, Smith JE. An evaluation of the use of a two-tiered trauma team activation system in a UK major trauma centre. Emerg Med J. 2015;32:364–7. https://doi.org/10.1136/emermed-2013-203402.

    Article  CAS  PubMed  Google Scholar 

  5. MacKenzie E, Weir S, Rivara F, et al. The value of trauma center care. J Trauma. 2010;69:1–10. https://doi.org/10.1097/TA.0B013E3181E03A21.

    Article  PubMed  Google Scholar 

  6. Scott M, Abouelela W, Blitzer D, Murphy W. Trauma service utilization increases cost but does not add value for minimally injured patients. Value Health. 2020;23:705–9. https://doi.org/10.1016/J.JVAL.2020.02.009.

    Article  PubMed  Google Scholar 

  7. van der Sluijs R, Fiddelers A, Waalwijk J, Reitsma J. The impact of the trauma triage app on pre-hospital trauma triage: design and protocol of the stepped-wedge, cluster-randomized TESLA trial. Diagnostic Progn Res. 2020. https://doi.org/10.1186/S41512-020-00076-1.

    Article  Google Scholar 

  8. Linder F, Holmberg L, Bjorck M, Juhlin C, Thorbjornsen K, Wisinger J, et al. A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden—the TRAUMALERT study. Scand J Trauma Resusc Emerg Med. 2019;27:1–10. https://doi.org/10.1186/s13049-019-0619-1.

    Article  Google Scholar 

  9. Davis T, Dinh M, Roncal S, Byrne C, Petchell J, Leonard E, et al. Prospective evaluation of a two-tiered trauma activation protocol in an Australian major trauma referral hospital. Injury. 2010;41:470–4. https://doi.org/10.1016/j.injury.2010.01.003.

    Article  PubMed  Google Scholar 

  10. Voskens FJ, Van Rein EAJ, Van Der Sluijs R, Houwert RM, Lichtveld RA, Verleisdonk EJ, et al. Accuracy of prehospital triage in selecting severely injured trauma patients. JAMA Surg. 2018;153:322–7. https://doi.org/10.1001/jamasurg.2017.4472.

    Article  PubMed  Google Scholar 

  11. Schweigkofler U, Sauter M, Wincheringer D, Barzen S, Hoffmann R. Emergency room activation due to trauma mechanism TT - Schockraumindikation nach Unfallhergang. Unfallchirurg. 2019. https://doi.org/10.1007/s00113-019-00733-1.

    Article  PubMed  Google Scholar 

  12. Van Rein EAJ, Houwert RM, Gunning AC, Lichtveld RA, Leenen LPH, Van Heijl M. Accuracy of prehospital triage protocols in selecting severely injured patients: a systematic review. J Trauma Acute Care Surg. 2017;83:328–39. https://doi.org/10.1097/TA.0000000000001516.

    Article  PubMed  Google Scholar 

  13. Martín-Rodríguez F, López-Izquierdo R, Medina-Lozano E, Ortega Rabbione G, del Pozo VC, Carbajosa Rodríguez V, et al. Accuracy of prehospital point-of-care lactate in early in-hospital mortality. Eur J Clin Invest. 2020. https://doi.org/10.1111/eci.13341.

    Article  PubMed  Google Scholar 

  14. Brown JB, Lerner EB, Sperry JL, Billiar TR, Peitzman AB, Guyette FX. Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level. J Trauma Acute Care Surg. 2016;81:445–52. https://doi.org/10.1097/TA.0000000000001085.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  15. Baxter J, Cranfield KR, Clark G, Harris T, Bloom B, Gray AJ. Do lactate levels in the emergency department predict outcome in adult trauma patients? A systematic review. J Trauma Acute Care Surg. 2016;81:555–66. https://doi.org/10.1097/TA.0000000000001156.

    Article  CAS  PubMed  Google Scholar 

  16. Guyette FX, Meier EN, Newgard C, McKnight B, Daya M, Bulger EM, 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. 2015;78:600–6. https://doi.org/10.1097/TA.0000000000000549.

    Article  CAS  PubMed  Google Scholar 

  17. Hagebusch P, Faul P, Klug A, Gramlich Y, Hoffmann R, Schweigkofler U. Elevated serum lactate levels and age are associated with an increased risk for severe injury in trauma team activation due to trauma mechanism. Eur J Trauma Emerg Surg. 2021. https://doi.org/10.1007/S00068-021-01811-Z.

    Article  PubMed  Google Scholar 

  18. Raa A, Sunde GA, Bolann B, Kvåle R, Bjerkvig C, Eliassen HS, et al. Validation of a point-of-care capillary lactate measuring device (Lactate Pro 2). Scand J Trauma Resusc Emerg Med. 2020. https://doi.org/10.1186/s13049-020-00776-z.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Galvagno SM, Sikorski RA, Floccare DJ, Rock P, Mazzeffi MA, DuBose JJ, et al. Prehospital point of care testing for the early detection of shock and prediction of lifesaving interventions. Shock. 2020;54:710–6. https://doi.org/10.1097/SHK.0000000000001567.

    Article  CAS  PubMed  Google Scholar 

  20. Martín-Rodríguez F, López-Izquierdo R, Delgado Benito JF, Sanz-García A, del Pozo VC, Castro Villamor MÁ, et al. Prehospital point-of-care lactate increases the prognostic accuracy of national early warning score 2 for early risk stratification of mortality: results of a multicenter. Observ Study J Clin Med. 2020;9:1156. https://doi.org/10.3390/jcm9041156.

    Article  Google Scholar 

  21. Wilson MS, Konda SR, Seymour RB, Karunakar MA. Early predictors of mortality in geriatric patients with trauma. J Orthop Trauma. 2016;30:e299-304. https://doi.org/10.1097/BOT.0000000000000615.

    Article  PubMed  Google Scholar 

  22. Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, et al. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;76:894–901. https://doi.org/10.1097/TA.0b013e3182ab0763.

    Article  PubMed  Google Scholar 

  23. Kodadek LM, Selvarajah S, Velopulos CG, Haut ER, Haider AH. Undertriage of older trauma patients: Is this a national phenomenon? J Surg Res. 2015;199:220–9. https://doi.org/10.1016/j.jss.2015.05.017.

    Article  PubMed  Google Scholar 

  24. Uribe-Leitz T, Jarman MP, Sturgeon DJ, Harlow AF, Lipsitz SR, Cooper Z, et al. National study of triage and access to trauma centers for older adults. Ann Emerg Med. 2020;75:125–35. https://doi.org/10.1016/j.annemergmed.2019.06.018.

    Article  PubMed  Google Scholar 

  25. Wentling J, Krall SP, McNierney A, Dewey K, Richman PB, Blow O. Predictive value of point-of-care lactate measurement in patients meeting level II and III trauma team activation criteria that present to the emergency department: a prospective study. J Emerg Trauma Shock. 2019;12:203–8. https://doi.org/10.4103/JETS.JETS_120_18.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Martín-Rodríguez F, López-Izquierdo R, Castro Villamor MA, Mangas IM, Del Brío IP, Delgado Benito JF, et al. Prognostic value of lactate in prehospital care as a predictor of early mortality. Am J Emerg Med. 2019;37:1627–32. https://doi.org/10.1016/j.ajem.2018.11.028.

    Article  PubMed  Google Scholar 

  27. Magnusson C, Herlitz J, Höglind R, Wennberg P. Prehospital lactate levels in blood as a seizure biomarker: a multi-center observational study. Epilepsia. 2021;62:408–15. https://doi.org/10.1111/EPI.16806.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Baron BJ, Nguyen A, Stefanov D, Shetty A, Zehtabchi S. Clinical value of triage lactate in risk stratifying trauma patients using interval likelihood ratios. Am J Emerg Med. 2018;36:784–8. https://doi.org/10.1016/j.ajem.2017.10.015.

    Article  PubMed  Google Scholar 

  29. Bertil Bouillon, Pieper D. S3-Leitlinie Polytrauma / Schwerverletzten-Behandlung. AWMF Regist 2016.

  30. Bolorunduro OB, Villegas C, Oyetunji TA, Haut ER, Stevens KA, Chang DC, et al. Validating the injury severity score (ISS) in different populations: ISS predicts mortality better among hispanics and females. J Surg Res. 2011;166:40–4. https://doi.org/10.1016/j.jss.2010.04.012.

    Article  CAS  PubMed  Google Scholar 

  31. Braken P, Amsler F, Gross T. Simple modification of trauma mechanism alarm criteria published for the TraumaNetwork DGU® may significantly improve overtriage—a cross sectional study. Scand J Trauma Resusc Emerg Med. 2018;26:1–10. https://doi.org/10.1186/s13049-018-0498-x.

    Article  Google Scholar 

  32. Maliziola C, Frigerio S, Lanzarone S, Barale A. Sensitivity and specificity of trauma team activation protocol criteria in an Italian trauma center: a retrospective observational study. Int Emerg Nurs. 2019;44:20–4. https://doi.org/10.1016/J.IENJ.2019.02.002.

    Article  PubMed  Google Scholar 

  33. Stuke L, Duchesne J, Hunt J, Marr A, et al. Mechanism of injury is not a predictor of trauma center admission. Am Surg. 2013;79:1149–53.

    Article  Google Scholar 

  34. Rotondo M, Cribari C, Smith R. Resources for optimal care of the traumatised patient. 6th ed. Chicago: American College of Surgeons; 2014.

    Google Scholar 

  35. Davis JW, Dirks RC, Kaups KL, Tran P. Base deficit is superior to lactate in trauma. Am J Surg. 2018;215:682–5. https://doi.org/10.1016/j.amjsurg.2018.01.025.

    Article  PubMed  Google Scholar 

  36. Gale SC, Kocik JF, Creath R, Crystal JS, Dombrovskiy VY. A comparison of initial lactate and initial base deficit as predictors of mortality after severe blunt trauma. J Surg Res. 2016;205:446–55. https://doi.org/10.1016/j.jss.2016.06.103.

    Article  CAS  PubMed  Google Scholar 

  37. Raux M, Le Manach Y, Gauss T, Baumgarten R, Hamada S, Harrois A, et al. Comparison of the prognostic significance of initial blood lactate and base deficit in trauma patients. Anesthesiology. 2017;126:522–33. https://doi.org/10.1097/ALN.0000000000001490.

    Article  CAS  PubMed  Google Scholar 

  38. Javali R, Ravindra P, Patil A, Srinivasarangan M. A clinical study on the initial assessment of arterial lactate and base deficit as predictors of outcome in trauma patients. Indian J Crit Care Med. 2017;21:719–25. https://doi.org/10.4103/IJCCM.IJCCM_218_17.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Swan KL, Keene T, Avard BJ. A 12-month clinical audit comparing point-of-care lactate measurements tested by paramedics with in-hospital serum lactate measurements. Prehosp Disaster Med. 2018;33:36–42. https://doi.org/10.1017/S1049023X17007130.

    Article  PubMed  Google Scholar 

  40. Ter Avest E, Griggs J, Wijesuriya J, Russell MQ, Lyon RM. Determinants of prehospital lactate in trauma patients: a retrospective cohort study. BMC Emerg Med. 2020. https://doi.org/10.1186/s12873-020-00314-1.

    Article  PubMed  PubMed Central  Google Scholar 

  41. Dezman Z, Comer A, Smith G. Failure to clear elevated lactate predicts 24-hour mortality in trauma patients. J Trauma Acute Care Surg. 2015;79:580–5. https://doi.org/10.1097/TA.0000000000000810.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  42. Klein K, Lefering R, Jungbluth P, Lendemans S, Hussmann B. Is prehospital time important for the treatment of severely injured patients? A matched-triplet analysis of 13,851 patients from the TraumaRegister DGU®. Biomed Res Int. 2019. https://doi.org/10.1155/2019/5936345.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Jagan N, Morrow LE, Walters RW, Plambeck RW, Patel TM, Moore DR, et al. Sympathetic stimulation increases serum lactate concentrations in patients admitted with sepsis: implications for resuscitation strategies. Ann Intensive Care. 2021. https://doi.org/10.1186/s13613-021-00805-9.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Kushimoto S, Akaishi S, Sato T, Nomura R, Fujita M, Kudo D, et al. Lactate, a useful marker for disease mortality and severity but an unreliable marker of tissue hypoxia/hypoperfusion in critically ill patients. Acute Med Surg. 2016;3:293–7. https://doi.org/10.1002/ams2.207.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Cannon CM, Miller RT, Grow KL, Purcell S, Nazir N. Age-adjusted and expanded lactate thresholds as predictors of all-cause mortality in the emergency department. West J Emerg Med. 2020;21:1249. https://doi.org/10.5811/WESTJEM.2020.5.46811.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Salottolo KM, Mains CW, Offner PJ, Bourg PW, Bar-Or D. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scand J Trauma Resusc Emerg Med. 2013. https://doi.org/10.1186/1757-7241-21-7.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Van Rein EAJ, Van Der Sluijs R, Voskens FJ, Lansink KWW, Houwert RM, Lichtveld RA, et al. Development and validation of a prediction model for prehospital triage of trauma patients. JAMA Surg. 2019. https://doi.org/10.1001/jamasurg.2018.4752.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Funding

Not applicable.

Author information

Authors and Affiliations

  1. Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt Am Main gGmbH, Friedberger Landstr. 430, 60389, Frankfurt am Main, Germany

    Paul Hagebusch, Philipp Faul, Reinhard Hoffmann, Uwe Schweigkofler & Yves Gramlich

  2. Interdisciplinary Center Clinical Trials (IZKS), University Medical Center Mainz, Langenbeckstraße 1, 55131, Mainz, Germany

    Christian Ruckes

  3. Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University Frankfurt Am Main, Theodor-Stern-Kai 7, 60590, Frankfurt, Germany

    Philipp Störmann & Ingo Marzi

Authors
  1. Paul Hagebusch
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Philipp Faul
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Christian Ruckes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Philipp Störmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Ingo Marzi
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Reinhard Hoffmann
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Uwe Schweigkofler
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Yves Gramlich
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

PH (BG Unfallklinik Frankfurt am Main—Department of Trauma and Orthopedic Surgery) is the corresponding author. PF (BG Unfallklinik Frankfurt am Main—Department of Trauma and Orthopedic Surgery) made substantial contributions to the conception, the design of the work, the acquisition, the analysis and interpretation of data and was a major contributor in writing the manuscript. CR (University Medical Center Mainz—Interdisciplinary Center Clinical Trials (IZKS)) made substantial contributions to the conception and the analysis and interpretation of data. PS (Hospital of the Goethe University Frankfurt /Main, Department of Trauma, Hand and Reconstructive Surgery) made substantial contributions to the conception and design of the work and substantively revised it. IM (Hospital of the Goethe University Frankfurt/Main, Department of Trauma, Hand and Reconstructive Surgery) made substantial contributions to the conception and design of the work and substantively revised it. RH (BG Unfallklinik Frankfurt am Main—Department of Trauma and Orthopedic Surgery) made substantial contributions to the conception and design of the work and substantively revised it. US (BG Unfallklinik Frankfurt am Main—Department of Trauma and Orthopedic Surgery) made substantial contributions to the conception, the design of the work, the acquisition, the analysis and interpretation of data and substantively revised it. YG (BG Unfallklinik Frankfurt am Main—Department of Trauma and Orthopedic Surgery) made substantial contributions to the conception, the design of the work, the acquisition, the analysis and interpretation of data and substantively revised it. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Paul Hagebusch.

Ethics declarations

Conflict of interest

The authors listed below declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Corresponding author Dr. Paul Hagebusch, MD. BG Unfallklinik Frankfurt am Main, Department of Trauma and Orthopedic Surgery. Dr. Philipp Faul, MD, BG Unfallklinik Frankfurt am Main, Department of Trauma and Orthopedic Surgery. Dr. Christian Ruckes, University Medical Center Mainz, Interdisciplinary Center Clinical Trials (IZKS). PD Dr. Philipp Störmann, MD, Hospital of the Goethe University Frankfurt/Main, Department of Trauma, Hand and Reconstructive Surgery. Prof. Dr. Ingo Marzi, MD, PhD, Hospital of the Goethe University Frankfurt/Main, Department of Trauma, Hand and Reconstructive Surgery. Prof. Dr. Dr. Reinhard Hoffmann, MD, PhD, BG Unfallklinik Frankfurt am Main, Department of Trauma and Orthopedic Surgery. PD Dr. Uwe Schweigkofler, MD, PhD, BG Unfallklinik Frankfurt am Main, Department of Trauma and Orthopedic Surgery. PD Dr. Yves Gramlich, MD, PhD, BG Unfallklinik Frankfurt am Main, Department of Trauma and Orthopedic Surgery.

Ethical approval

The protocol of investigation was checked and approved by the Regional Ethics Committee (2020-1746-evBO).

Consent to participate

The requirement for informed consent was waived due to the retrospective study design.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hagebusch, P., Faul, P., Ruckes, C. et al. The predictive value of serum lactate to forecast injury severity in trauma-patients increases taking age into account. Eur J Trauma Emerg Surg (2022). https://doi.org/10.1007/s00068-022-02046-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1007/s00068-022-02046-2

Keywords

Search

Navigation