• Samuel A Tisherman, Robert H Schmicker, Karen J Brasel, Eileen M Bulger, Jeffrey D Kerby, Joseph P Minei, Judy L Powell, Donald A Reiff, Sandro B Rizoli, and Martin A Schreiber.
• *University of Maryland, Baltimore, MD †University of Washington, Seattle, WA ‡Medical College of Wisconsin, Milwaukee, WI §University of Alabama at Birmingham, Birmingham, AL ¶University of Texas Southwestern Medical Center, Dallas, TX ‖St Michael's Hospital, Toronto, ON, Canada; and **Oregon Health and Science University, Portland, OR.
• Ann. Surg. 2015 Mar 1; 261 (3): 586-90.

ObjectiveTo identify causes and timing of mortality in trauma patients to determine targets for future studies.BackgroundIn trials conducted by the Resuscitation Outcomes Consortium in patients with traumatic hypovolemic shock (shock) or traumatic brain injury (TBI), hypertonic saline failed to improve survival. Selecting appropriate candidates is challenging.MethodsRetrospective review of patients enrolled in multicenter, randomized trials performed from 2006 to 2009. Inclusion criteria were as follows: injured patients, age 15 years or more with hypovolemic shock [systolic blood pressure (SBP) ≤ 70 mm Hg or SBP 71-90 mm Hg with heart rate ≥ 108) or severe TBI [Glasgow Coma Score (GCS) ≤ 8]. Initial fluid administered was 250 mL of either 7.5% saline with 6% dextran 70, 7.5% saline or 0.9% saline.ResultsA total of 2061 subjects were enrolled (809 shock, 1252 TBI) and 571 (27.7%) died. Survivors were younger than nonsurvivors [30 (interquartile range 23) vs 42 (34)] and had a higher GCS, though similar hemodynamics. Most deaths occurred despite ongoing resuscitation. Forty-six percent of deaths in the TBI cohort were within 24 hours, compared with 82% in the shock cohort and 72% in the cohort with both shock and TBI. Median time to death was 29 hours in the TBI cohort, 2 hours in the shock cohort, and 4 hours in patients with both. Sepsis and multiple organ dysfunction accounted for 2% of deaths.ConclusionsMost deaths from trauma with shock or TBI occur within 24 hours from hypovolemic shock or TBI. Novel resuscitation strategies should focus on early deaths, though prevention may have a greater impact.

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