Keywords :
Burns, Critical care, Lethal triad, Mortality
Citation Information :
Muthukumar V, Karki D, Jatin B. Concept of Lethal Triad in Critical Care of Severe Burn Injury. Indian J Crit Care Med 2019; 23 (5):206-209.
Background: The trinity of hypothermia, acidosis and coagulopathy, the lethal triad in trauma setting is a well-known risk factor associated with high risk of death. Burn is also a pathological situation where inflammatory response, endothelial injury, hypovolemia, reduced end-organ perfusion, cellular hypoxia, and myocardial depression are frequently encountered. This study aimed to study the occurrence and outcome of patients presenting with the ‘triad of death’ in burn population.
Methods: The study population included patients between 18 years and 60 years presenting to the department with thermal and scald burns with total body surface area involving 50–70%. The study was conducted for a period of 180 days and patients were followed up for 30 days. A p value <0.05 was considered statistically significant.
Results: One hundred and ninety-six patients were admitted during study period. Fifty patients out of them were eligible and were included in the study. The average abbreviated burns score index was 11 in lethal triad subgroup when compared to eight in the subgroup without the lethal triad. The mortality in the subgroup with lethal triad was higher (68.8% vs 17.6%, p = 0.0009). The “on admission” acidosis, hypothermia, and coagulopathy were independently associated with significantly increased mortality. The overall relative risk of mortality in the presence of lethal triad was 3.896.
Conclusion: This study reiterates the fact that the lethal triad is seen in burn patient. Burn associated with on admission lethal triad has significantly higher mortality rates. There are only countable studies addressing this issue in burn setting.
Mitra B, Tullio F, Cameron P, Fitzgerald M. Trauma patients with the ‘triad of death’. Emerg Med J. 2011; 29:622–625. doi: 10.1136/ emj.2011.113167
Harris T, Davenport R, Hurst T, Jones J. Improving outcome in severe trauma: trauma systems and initial management—intubation, ventilation and resuscitation. Postgrad Med J. 2012; 88:588–594. doi: 10.1136/postgradmedj-2010-74245
Ball C. Damage control resuscitation: history, theory and technique. Can J Surg. 2014; 57:55–60.
Sherren P, Hussey J, Martin R, Kundishora T, Parker M, Emerson B. Lethal triad in severe burns. Burns. 2014; 40:1492–1496. doi: 10.1016/j. burns.2014.04.011
McDermott F, Cordner S, Cooper D, Winship V. Management deficiencies and death preventability of road traffic fatalities before and after a new trauma care system in Victoria, Australia. J Trauma. 2007; 63:331–338. doi: 10.1097/TA.0b013e31806dc5c4
Langhelle A, Lockey D, Harris T, Davies G. Body temperature of trauma patients on admission to hospital: a comparison of anaesthetised and non-anaesthetised patients. Emerg Med J. 2010; 29:239–242. doi: 10.1136/emj.2009.086967
Martin R, Kilgo P, Miller P, Hoth J, Meredith J, Chang M. Injuryassociated hypothermia: an analysis of the 2004 national trauma data bank. Shock 2005; 24:114–118.
Brohi K, Singh J, Heron M, Coats T. Acute traumatic coagulopathy. J Trauma. 2003; 54:1127–1130. doi: 10.1097/01.TA.0000069184.82147.06
Falcone R, Santanello S, Schulz M, Monk J, Satiani B, Carey L. Correlation of metabolic acidosis with outcome following injury and its value as a scoring tool. World J Surg. 1993; 17:575–579.
Latenser BA. Critical care of the burn patient: The first 48 hours. Critical Care Medicine. 2009; 37:2819–2826. doi: 10.1097/ CCM.0b013e3181b3a08f
Kamolz LP, Andel H, Schramm W, Meissl G, Herndon D, Frey M. Lactate: early predictor of morbidity and mortality in patients with severe burns. Burns. 2005; 31:986–990. doi: 10.1016/j.burns.2005.06.019
Singer A, Taira B, Thode H Jr, McCormack J, Shapiro M, Aydin A, et al. The Association between hypothermia, prehospital cooling, and mortality in burn victims. Acad Emerg Med. 2010; 17:456–459. doi: 10.1111/j.1553-2712.2010.00702.x
Cartotto R, Choi J, Gomez M, Cooper A. A prospective study on the implications of a base deficit during fluid resuscitation. J Burn Care Rehabil. 2003; 24:75–84. doi: 10.1097/01.BCR.0000054177.24411.13
Martini WZ. Coagulopathy by hypothermia and acidosis: mechanisms of thrombin generation and fibrinogen availability. J Trauma. 2009; 67:202–209. doi: 10.1097/TA.0b013e3181a602a7