Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis

Shock index reference ranges in the first 48 h postpartum following elective cesarean delivery: A prospective cohort study

PURPOSE

To determine the reference values for the shock index (SI) in postpartum patients undergoing elective cesarean delivery with regional anesthesia.

METHODS

This prospective study was conducted at our tertiary center between August 1, 2023, and March 1, 2024. We calculated the reference values for the SI within the first 48 h postpartum for patients who underwent elective cesarean delivery after the 34th week of gestation. We excluded cases of vaginal delivery, post-term delivery (≥42 weeks of gestation), multiple pregnancies, stillbirths, fetal abnormalities, maternal cardiac disease, anemia, untreated hypo- or hyperthyroidism, and any hypertensive disorders diagnosed before or during pregnancy. Data collection, measurement of vital signs, and the administration of fluids pre-, intra-, and post-operatively, as well as the use and dosing of uterotonic agents for the prevention of postpartum hemorrhage (PPH), were standardized for all patients.

RESULTS

Our final analysis included 311 patients, with a mean SI value of approximately 0.7 (0.67-0.77) for all measurement performed within the first 48 h of the postpartum period. Further analyses revealed that the 90th and 95th percentiles of SI were around 0.9 throughout the study period. Additionally, SI reference values analyzed at different time points were consistent. Our analysis demonstrated that SI values were not influenced by the presence of a previous caesarean section, the administration of oxytocin or carbetocin, or parity in this particular cohort. Our analyses of vital signs also indicated that the 95th percentile of heart rate (HR) ranged from 96 to 100 bpm.

DISCUSSION

An SI value of 0.9 represents the 95th percentile of SI values throughout the first 48 h of the postpartum period. Any greater value should be evaluated carefully for potential adverse outcomes.

[Typical causes and clinical presentations of traumatic and nontraumatic soft tissue and organ haemorrhage in emergency departments]

Acute bleeding often occurs in a wide variety of forms in clinical emergency medicine. In traumatic bleeding, soft tissue injuries to the head or extremities are common, while severe bleeding is less common in chest injuries or pelvic trauma. In nontraumatic emergencies, gastrointestinal bleeding is the leading cause, but many other bleeding entities are possible. Structured management helps to detect the critically ill patient, identify the possible source of bleeding and provide appropriate radiological diagnostics and therapy. Clinical examination, blood gas analyses and emergency ultrasound are crucial in the initial phase of diagnosis. Initially, symptomatic therapy is usually indicated to stabilize the patient, and then interventional or surgical care is indicated in the course of the disease, depending on the location of the bleeding. Volume and catecholamine therapy, coagulation management and emergency transfusion are important components of interdisciplinary emergency care, in addition to primary bleeding control, especially in the case of open injuries.

Improving the early diagnosis and clinical outcomes of shock patients via laser speckle contrast imaging assessment of peripheral hemodynamics

Shock is defined as a critical circulatory failure that requires prompt diagnosis to optimize patient outcomes. Traditional diagnostic methods have limitations, including contact-based measurements, high costs, and lengthy procedures. The study evaluated the efficacy of laser speckle contrast imaging (LSCI), a noncontact technique, for assessing peripheral hemodynamics in shock patients. Results showed that LSCI accurately captured dynamic changes in blood flow, revealing early indicators of shock. ROI diff and ROI diff/ROI2 values significantly differed between shock patients and healthy controls. Spearman's correlation analysis revealed associations between ROI diff and key physiological parameters, such as blood pressure and heart rate. ROC analysis revealed that ROI diff and ROI diff/ROI2 had strong accuracy (72.5% and 82.5%, respectively) for detecting shock. Additionally, LSCI reduced testing time by over 50%, offering faster assessments. These findings demonstrate the potential of LSCI to improve diagnosis and management of shock, especially in complex clinical environments.

The clinical utility of shock index in hospitalised patients requiring activation of the rapid response team

BACKGROUND

The systolic shock index (SSI) is used to direct management and predict outcomes, but its utility in patients requiring rapid response team (RRT) activation is unclear.

OBJECTIVES

We explored whether SSI can predict the outcomes of ward patients experiencing clinical deterioration and compared its performance with other parameters.

METHODS

This retrospective study included adult patients in medical/surgical wards who required RRT activation. We calculated SSI (heart rate/systolic blood pressure [BP]), diastolic shock index (DSI, heart rate/diastolic BP), modified shock index (heart rate/mean BP), and quick Sequential Organ Failure Assessment (qSOFA) score at activation. We categorised patients into two groups (SSI: ≥1.0 and <1.0). We performed univariate and multivariable logistic regression analyses to evaluate the association of SSI with intensive care unit (ICU) admission, vasopressor therapy, and in-hospital mortality. The covariates included demographics, comorbidities, and reasons for RRT activation.

RESULTS

Among the 837 study patients, 297 (35.5%) had an SSI ≥1.0. On univariate analysis, SSI was associated with vasopressor therapy (odds ratio [OR]: 2.04, 95% confidence interval [CI]: 1.40-2.99) but not ICU admission or in-hospital mortality. On multivariable logistic regression analysis, an SSI ≥1.0 was associated with ICU admission (adjusted OR: 1.55, 95% CI: 1.05-2.28), vasopressor therapy (adjusted OR: 3.05, 95% CI: 1.86-5.00), and in-hospital mortality (adjusted OR: 2.18, 95% CI: 1.42-3.33). A systolic BP <90 mmHg, mean BP < 65 mmHg, and qSOFA score ≥2 were associated with these outcomes in univariate and multivariable regression analyses (adjusted ORs close to those of SSI). Separate receiver operating characteristic curve analysis found that SSI, diastolic shock index, and modified shock index poorly discriminated between survivors and nonsurvivors (area under the curve: <0.60 for all).

CONCLUSIONS

In ward patients experiencing clinical deterioration, an SSI ≥1.0 was associated with adverse outcomes but did not perform better than systolic and mean BP and qSOFA. This limits its standalone clinical utility in these patients.

Assessment of the shock index in septic shock: A systematic review

OBJECTIVE

To identify published research on the Shock Index (SI) in patients with septic shock or severe sepsis and to describe its main findings and conclusions.

DESIGN

Systematic review of the literature following the recommendations of the PRISMA protocol (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

SETTINGS

The following databases were consulted: Pubmed, Embase, Library Cochrane and Lilacs.

PATIENTS

Patients older than 14 years with septic shock. Pregnant women and population with COVID-19 were excluded.

INTERVENTIONS

Studies reporting measurement of the shock index or its modified variants.

MAIN VARIABLES OF INTEREST

Absolute frequencies and relative frequencies were assessed with measures of central tendency and dispersion. Effect estimators (OR, RR and HR) were extracted according to the context of each study.

RESULTS

Seventeen articles were included, of which 11 investigated the SI as a predictor of mortality. Seven of them found significant differences in the SI when comparing survivors to non-survivors and observed a relationship between the SI evolution and clinical outcomes. Additional research evidenced a relation between the Modified Shock Index and myocardial depression, as well as mortality. Furthermore, they identified a relationship between the Diastolic Shock Index, the dose of administered dobutamine, and mortality.

CONCLUSIONS

The results suggest that both the SI and its modified versions, particularly in serial assessments, can be considered for evaluating patient prognosis. The SI can also aid in determining fluid management for patients.

Shock Index is a Stronger Predictor of Outcomes in Older Compared to Younger Patients

INTRODUCTION

The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults.

METHODS

We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy).

RESULTS

A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both).

CONCLUSIONS

These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.

Shock index and shock index, pediatric age-adjusted as predictors of mortality in pediatric patients with trauma: A systematic review and meta-analysis

This study aimed to assess the predictive ability of the shock index (SI) and the shock index, pediatric age-adjusted (SIPA) for mortality among pediatric patients with trauma (aged ≤ 18 years). A systematic search used PubMed, Embase, and Cochrane Library databases to identify pertinent articles published from their inception to 13 February 2023. For each SI and SIPA, the pooled sensitivity, specificity, diagnostic odds ratio (DOR), and area under the summary receiver operating characteristic curve (AUC) with the corresponding 95% confidence intervals were calculated. We planned a priori meta-regression analyses to explore heterogeneity using the following covariates: country, clinical setting, type of center, data source, and cutoff value. Twelve studies were included based on the inclusion criteria. Among them, nine studies with 195,469 patients were included for the SIPA at the hospital, four studies with 4,970 patients were included for the pre-hospital SIPA, and seven studies with 606,445 patients were included to assess the ability of the SI in predicting mortality. The pooled sensitivity and specificity with 95% confidence interval for predicting mortality were as follows: 0.58 (0.44-0.70) and 0.72 (0.60-0.82), respectively, for the SIPA at the hospital; 0.61 (0.47-0.74) and 0.67 (0.61-0.73), respectively, for the pre-hospital SIPA; and 0.71 (0.59-0.81) and 0.45 (0.31-0.59), respectively for the SI. The DOR were 3.80, 3.28, and 2.06 for the SIPA at the hospital, pre-hospital SIPA, and SI, respectively. The AUC were 0.693, 0.689, and 0.618 for the SIPA at the hospital, pre-hospital SIPA, and SI, respectively. The SI and SIPA are simple predictive tools with sufficient accuracy that can be readily applied to pediatric patients with trauma, but SIPA and SI should be utilized cautiously due to their limited sensitivity and specificity, respectively.

Retrospective evaluation of shock index and mortality in dogs with head trauma (2015-2020): 86 cases

OBJECTIVE

To assess the relationship between shock index (SI) and mortality in dogs with head trauma (HT). A secondary objective was to compare SI with the animal trauma triage (ATT) score and Modified Glasgow Coma Scale (MCGS) score in HT cases. A tertiary aim was to assess if SI is predictive of survival to discharge or improvement in presenting neurologic signs.

DESIGN

Retrospective study from January 2015 to December 2020.

SETTING

Tertiary referral level II veterinary trauma center.

ANIMALS

Eighty-six dogs with evidence of HT presenting through emergency for various traumas compared to 60 healthy control dogs.

MEASUREMENTS AND MAIN RESULTS

SI was calculated using the quotient of heart rate over systolic blood pressure measured on presentation. SI was significantly higher in HT patients than healthy controls (P = 0.0019). SI was not significantly different between traumatic brain injury dogs that died or were euthanized and HT dogs that lived until the time of discharge (P = 0.98). SI was not significantly different between HT dogs that were neurologically normal at the time of discharge and HT dogs that were static or improved but not normal neurologically at the time of discharge (P = 0.84). In HT dogs, SI did not correlate with ATT score (P = 0.16) or MGCS score (P = 0.75). There was no significant difference in SI and length of hospitalization until death or discharge (P = 0.78).

CONCLUSIONS

SI was significantly higher in HT patients compared to control patients. Interestingly, SI was not correlated with ATT score or MGCS score. The use of SI in HT patients warrants further investigation to assess the efficacy in predicting mortality.

Shock Index and Physiological Stress Index for reestratifying patients with intermediate-high risk pulmonary embolism

OBJECTIVE

Study and Evaluation of Two Scores: Shock Index (SI) and Physiological Stress Index (PSI) as discriminators for proactive treatment (reperfusion before decompensated shock) in a population of intermediate-high risk pulmonary embolism (PE).

DESIGN

Using a database from a retrospective cohort with clinical variables and the outcome variable of "proactive treatment", a comparison of the populations was conducted. Optimal cut-off for "proactive treatment" points were obtained according to the SI and PSI. Comparisons were carried out based on the cut-off points of both indices.

SETTING

Patients admitted to a mixed ICU for PE.

PARTICIPANTS

Patients >18 years old admitted to the ICU with intermediate-high risk PE recruited from January 2015 to October 2022.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Population comparison and metrics regarding predictive capacity when determining proactive treatment.

RESULTS

SI and PSI independently have a substandard predictive capacity for discriminating patients who may benefit from an early reperfusion therapy. However, their combined use improves detection of sicker intermediate-high risk PE patients (Sensitivity = 0.66) in whom an early reperfusion therapy may improve outcomes (Specificity = 0.9).

CONCLUSIONS

The use of the SI and PSI in patients with intermediate-high risk PE could be useful for selecting patients who would benefit from proactive treatment.

Predictors of Clinical Outcomes and the Need for Massive Transfusion Protocols in Geriatric Trauma Patients With Hemorrhagic Shock: A Systematic Review

INTRODUCTION

The current literature lacks a clear consensus on the predictors of mortality and outcomes of geriatric trauma patients in hemorrhagic shock. This systematic review aims to investigate predictors of clinical outcomes and the need for massive transfusion protocol in the geriatric trauma population with hemorrhagic shock.

METHODS

PubMed, EMBASE, Cochrane, ProQuest, and Google Scholar were searched for studies evaluating geriatric trauma patients in hemorrhagic shock or receiving MTP. Outcomes of interest included the effect of advanced age on clinical outcomes, the accuracy of SI and other variables in predicting mortality and need for MTP, and associations between blood product ratio and clinical outcomes.

RESULTS

Fifteen studies were included in this systematic review. In most studies, advanced age was an accurate predictor of mortality and complication rates in geriatric patients undergoing management of shock with MTP. SI along with other variables such as systolic blood pressure (SBP) were sensitive predictors of mortality and the need for MTP. Studies evaluating blood product ratio found an increased incidence of complications with higher plasma: red blood cell ratios.

CONCLUSION

Advanced age among geriatric patients is associated with increased mortality and complications when undergoing MTP. Shock Index and age x Shock Index are accurate and reliable predictors of mortality and need for MTP in the geriatric trauma population with hemorrhagic shock suffering blunt and/or penetrating injuries. An increased plasma: RBC ratio was associated with more complications in geriatric patients.

Cutoff of the reverse shock index multiplied by the Glasgow coma scale for predicting in-hospital mortality in adult patients with trauma: a retrospective cohort study

BACKGROUND

Early identification of patients at risk of potential death and timely transfer to appropriate healthcare facilities are critical for reducing the number of preventable trauma deaths. This study aimed to establish a cutoff value to predict in-hospital mortality using the reverse shock index multiplied by the Glasgow Coma Scale (rSIG).

METHODS

This multicenter retrospective cohort study used data from 23 emergency departments in South Korea between January 2011 and December 2020. The outcome variable was the in-hospital mortality. The relationship between rSIG and in-hospital mortality was plotted using the shape-restricted regression spline method. To set a cutoff for rSIG, we found the point on the curve where mortality started to increase and the point where the slope of the mortality curve changed the most. We also calculated the cutoff value for rSIG using Youden's index.

RESULTS

A total of 318,506 adult patients with trauma were included. The shape-restricted regression spline curve showed that in-hospital mortality began to increase when the rSIG value was less than 18.86, and the slope of the graph increased the most at 12.57. The cutoff of 16.5, calculated using Youden's index, was closest to the target under-triage and over-triage rates, as suggested by the American College of Surgeons, when applied to patients with an rSIG of 20 or less. In addition, in patients with traumatic brain injury, when the rSIG value was over 25, in-hospital mortality tended to increase as the rSIG value increased.

CONCLUSIONS

We propose an rSIG cutoff value of 16.5 as a predictor of in-hospital mortality in adult patients with trauma. However, in patients with traumatic brain injury, a high rSIG is also associated with in-hospital mortality. Appropriate cutoffs should be established for this group in the future.

Shock indices are associated with in-hospital mortality among patients with septic shock and normal left ventricular ejection fraction

BACKGROUND

The understanding of shock indices in patients with septic shock is limited, and their values may vary depending on cardiac function.

METHODS

This prospective cohort study was conducted across 20 university-affiliated hospitals (21 intensive care units [ICUs]). Adult patients (≥19 years) with septic shock admitted to the ICUs during a 29-month period were included. The shock index (SI), diastolic shock index (DSI), modified shock index (MSI), and age shock index (Age-SI) were calculated at sepsis recognition (time zero) and ICU admission. Left ventricular (LV) function was categorized as either normal LV ejection fraction (LVEF ≥ 50%) or decreased LVEF (<50%).

RESULTS

Among the 1,194 patients with septic shock, 392 (32.8%) who underwent echocardiography within 24 h of time zero were included in the final analysis (normal LVEF: n = 246; decreased LVEF: n = 146). In patients with normal LVEF, only survivors demonstrated significant improvement in SI, DSI, MSI, and Age-SI values from time zero to ICU admission; however, no notable improvements were found in all patients with decreased LVEF. The completion of vasopressor or fluid bundle components was significantly associated with improved indices in patients with normal LVEF, but not in those with decreased LVEF. In multivariable analysis, each of the four indices at ICU admission was significantly associated with in-hospital mortality (P < 0.05) among patients with normal LVEF; however, discrimination power was better in the indices for patients with lower lactate levels (≤ 4.0 mmol/L), compared to those with higher lactate levels.

CONCLUSIONS

The SI, DSI, MSI, and Age-SI at ICU admission were significantly associated with in-hospital mortality in patients with septic shock and normal LVEF, which was not found in those with decreased LVEF. Our study emphasizes the importance of interpreting shock indices in the context of LV function in septic shock.

Clinical Outcomes After Traumatic Brain Injury and Exposure to Extracranial Surgery: A TRACK-TBI Study

Importance

Traumatic brain injury (TBI) is associated with persistent functional and cognitive deficits, which may be susceptible to secondary insults. The implications of exposure to surgery and anesthesia after TBI warrant investigation, given that surgery has been associated with neurocognitive disorders.

Objective

To examine whether exposure to extracranial (EC) surgery and anesthesia is related to worse functional and cognitive outcomes after TBI.

Design, Setting, and Participants

This study was a retrospective, secondary analysis of data from the Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study, a prospective cohort study that assessed longitudinal outcomes of participants enrolled at 18 level I US trauma centers between February 1, 2014, and August 31, 2018. Participants were 17 years or older, presented within 24 hours of trauma, were admitted to an inpatient unit from the emergency department, had known Glasgow Coma Scale (GCS) and head computed tomography (CT) status, and did not undergo cranial surgery. This analysis was conducted between January 2, 2020, and August 8, 2023.

Exposure

Participants who underwent EC surgery during the index admission were compared with participants with no surgery in groups with a peripheral orthopedic injury or a TBI and were classified as having uncomplicated mild TBI (GCS score of 13-15 and negative CT results [CT- mTBI]), complicated mild TBI (GCS score of 13-15 and positive CT results [CT+ mTBI]), or moderate to severe TBI (GCS score of 3-12 [m/sTBI]).

Main Outcomes and Measures

The primary outcomes were functional limitations quantified by the Glasgow Outcome Scale-Extended for all injuries (GOSE-ALL) and brain injury (GOSE-TBI) and neurocognitive outcomes at 2 weeks and 6 months after injury.

Results

A total of 1835 participants (mean [SD] age, 42.2 [17.8] years; 1279 [70%] male; 299 Black, 1412 White, and 96 other) were analyzed, including 1349 nonsurgical participants and 486 participants undergoing EC surgery. The participants undergoing EC surgery across all TBI severities had significantly worse GOSE-ALL scores at 2 weeks and 6 months compared with their nonsurgical counterparts. At 6 months after injury, m/sTBI and CT+ mTBI participants who underwent EC surgery had significantly worse GOSE-TBI scores (B = -1.11 [95% CI, -1.53 to -0.68] in participants with m/sTBI and -0.39 [95% CI, -0.77 to -0.01] in participants with CT+ mTBI) and performed worse on the Trail Making Test Part B (B = 30.1 [95% CI, 11.9-48.2] in participants with m/sTBI and 26.3 [95% CI, 11.3-41.2] in participants with CT+ mTBI).

Conclusions and Relevance

This study found that exposure to EC surgery and anesthesia was associated with adverse functional outcomes and impaired executive function after TBI. This unfavorable association warrants further investigation of the potential mechanisms and clinical implications that could inform decisions regarding the timing of surgical interventions in patients after TBI.

Is the shock index correlated with blood loss? An experimental study on a controlled hemorrhagic shock model in piglets

INTRODUCTION

The quantification of blood loss in a severe trauma patient allows prognostic quantification and the engagement of adapted therapeutic means. The Advanced Trauma Life Support classification of hemorrhagic shock, based in part on hemodynamic parameters, could be improved. The search for reproducible and non-invasive parameters closely correlated with blood depletion is a necessity. An experimental model of controlled hemorrhagic shock allowed us to obtain hemodynamic and echocardiographic measurements during controlled blood spoliation. The primary aim was to demonstrate the correlation between the Shock Index (SI) and blood depletion volume (BDV) during the hemorrhagic phase of an experimental model of controlled hemorrhagic shock in piglets. The secondary aim was to study the correlations between blood pressure (BP) values and BDV, SI and cardiac output (CO), and pulse pressure (PP) and stroke volume during the same phase.

METHODS

We analyzed data from 66 anesthetized and ventilated piglets that underwent blood spoliation at 2 mL.kg-1.min-1 until a mean arterial pressure (MAP) of 40 mmHg was achieved. During this bleeding phase, hemodynamic and echocardiographic measurements were performed regularly.

RESULTS

The correlation coefficient between the SI and BDV was 0.70 (CI 95%, [0.64; 0.75]; p < 0.01), whereas between MAP and BDV, the correlation coefficient was -0.47 (CI 95%, [-0.55; -0.38]; p < 0.01). Correlation coefficient between SI and CO and between PP and stroke volume were - 0.45 (CI 95%, [-0.53; -0.37], p < 0.01) and 0.62 (CI 95%, [0.56; 0.67]; p < 0.01), respectively.

CONCLUSIONS

In a controlled hemorrhagic shock model in piglets, the correlation between SI and BDV seemed strong.

Emergency Department Shock Index Outperforms Prehospital and Delta Shock Indices in Predicting Outcomes of Trauma Patients

INTRODUCTION

Multiple shock indices (SIs), including prehospital, emergency department (ED), and delta (ED SI - Prehospital SI) have been developed to predict outcomes among trauma patients. This study aims to compare the predictive abilities of these SIs for outcomes of polytrauma patients on a national level.

METHODS

This was a retrospective analysis of the American College of Surgeons Trauma Quality Improvement Program (2017-2018). We included adult (≥18 y) trauma patients and excluded patients who were transferred, had missing vital signs, and those with severe head injuries (Head-Abbreviated Injury Scale>3). Outcome measures were 24-h and in-hospital mortality, 24-h packed red blood cells transfusions, and intensive care unit and hospital length of stay. Predictive performances of these SIs were evaluated by the Area Under the Receiver Operating Characteristics for the entire study cohort and across all injury severities.

RESULTS

A total of 750,407 patients were identified. Meanstandard deviation age and lowest systolic blood pressure were 53 ± 21 y, and 81 ± 32 mmHg, respectively. Overall, 24-h and in-hospital mortality were 1.2% and 2.5%, respectively. On multivariable analysis, all three SIs were independently associated with higher rates of 24-h and in-hospital mortality, blood product requirements, intensive care unit and hospital length of stay (P < 0.001). ED SI was superior to prehospital and delta SIs (P < 0.001) for all outcomes. On subanalysis of patients with moderate injuries, severe injuries, and positive delta SI, the results remained the same.

CONCLUSIONS

ED SI outperformed both prehospital and delta SIs across all injury severities. Trauma triage guidelines should prioritize ED SI in the risk stratification of trauma patients who may benefit from earlier and more intense trauma activations.

The new combination of oxygen saturation with age shock index predicts the outcome of COVID-19 pneumonia

Introduction

Emergency departments around the world have been struggling to deal with patients with COVID-19 and presumed COVID-19. Triaging patients who need further medical support is the key matter to emergency physicians as the delay of proper treatment may worsen the results. The aim of this study was to validate the ability of age shock index and hypoxia-age-shock index at the time of presentation to the emergency department to predict case fatality in patients with COVID-19 pneumonia.

Methods

We only included patients who had COVID-19-associated pneumonia who needed in-hospital treatment. The vital signs and oxygen saturation used in the study were collected, especially from the triage sector, before patients were given supplemental oxygen.

Results

A total of 241 patients enrolled in the study. The case fatality rate was 27%. The median age of the study samples was 78 (66-86) years with 133 male and 108 female patients. Hypoxia-age-shock index showed the best performance in analysis (odds ratio 15.1, 95% confidence interval: 5.1-44.4; adjusted odds ratio 8.6, 95% confidence interval: 2.8-26.8).

Conclusion

The hypoxia-age-shock index was a strong predictor for in-hospital mortality of COVID-19 pneumonia. Furthermore, when it was compared with age shock index, hypoxia-age-shock index showed better performance in predicting fatality of the disease.

Pre-Hospital Blood Products for the Care of Bleeding Trauma Patients

BACKGROUND

Controversy surrounds the administration of blood products to severely traumatized patients before they arrive in the hospital in order to compensate for early blood loss and/or to correct coagulation disturbances that arise shortly after the traumatic event. A number of terrestrial and air rescue services have begun to provide this kind of treatment.

METHODS

This review is based on articles using the PICO framework, published from January 2001 to January 2021, that were retrieved by a selective search, with structured searching strategies and searching bundles in Medline (OVIDSP), the Cochrane Central Register of Controlled Trials (CENTRAL), and Epistemonikos. A demand analysis was carried out on the basis of data from the trauma registry of the German Society of Trauma Surgery (TR-DGU) and practical experience from program development and implementation was provided by the Bundeswehr Hospital Ulm.

RESULTS

The currently available evidence on the pre-hospital administration of blood products in the early treatment of severely injured patients is based largely on retrospective, single-center case series. Two randomized controlled trials (RCTs) concerning the early use of fresh frozen plasma concentrates have yielded partly conflicting results. Three further RCTs on the use of lyophilized plasma (lyplas), lyplas plus erythrocyte concentrate, or whole blood likewise revealed non-uniform effects on short-term and intermediate-term mortality. Our demand analysis based on data from the TR-DGU showed that 300 to 1800 patients per year in Germany could benefit from the pre-hospital administration of blood products. This might be indicated in patients who have systolic hypotension (<100 mmHg) in combination with a suspected or confirmed hemorrhage, as well as pathological shock parameters in the point-of-care diagnostic testing performed on the scene (serum base excess ≤ -2.5 mmol/L and/or serum lactate concentration >4 mmol/L).

CONCLUSION

The studies that have been published to date yield no clear evidence either for or against the early pre-hospital administration of blood products. Any treatment of this kind should be accompanied by scientific evaluation.

Shock index in the emergency department as a predictor for mortality in COVID-19 patients: A systematic review and meta-analysis

Background

The shock index (SI) ratio serves as a straightforward predictor to identify patients who are either at risk of or experiencing shock. COVID-19 patients with shock face increased mortality risk and reduced chances of recovery. This review aims to determine the role of SI in the emergency department (ED) to predict COVID-19 patient outcomes.

Methods

The systematic search was conducted in PubMed, ProQuest, Scopus, and ScienceDirect on June 16, 2023. We included observational studies evaluating SI in ED and COVID-19 patient outcomes. Random-effect meta-analysis was done to generate odds ratios of SI as the predictor of intensive care unit (ICU) admission and mortality. The sensitivity and specificity of SI in predicting these outcomes were also pooled, and a summary receiver operating characteristics (sROC) curve was generated.

Results

A total of eight studies involving 4557 participants were included in the pooled analysis. High SI was found to be associated with an increased risk of ICU admission (OR 5.81 [95%CI: 1.18-28.58], p = 0.03). Regarding mortality, high SI was linked to higher rates of in-hospital (OR 7.45 [95%CI: 2.44-22.74], p = 0.0004), within 30-day (OR 7.34 [95%CI: 5.27-10.21], p < 0.00001), and overall (OR 7.52 [95%CI: 3.72-15.19], p < 0.00001) mortality. The sensitivity and specificity of SI for predicting ICU admission were 76.2% [95%CI: 54.6%-89.5%] and 64.3% [95%CI: 19.6%-93.0%], respectively. In terms of overall mortality, the sensitivity and specificity were 54.0% (95%CI: 34.3%-72.6%) and 85.9% (95%CI: 75.8%-92.3%), respectively, with only subtle changes for in-hospital and within 30-day mortality. Adjustment of SI cut-off to >0.7 yielded improved sensitivity (95%CI: 78.0% [59.7%-89.4%]) and specificity (95%CI: 76.8% [41.7%-93.9%]) in predicting overall mortality.

Conclusion

SI in emergency room may be a simple and useful triage instrument for predicting ICU admission and mortality in COVID-19 patients. Future well-conducted studies are still needed to corroborate the findings of this study.

Shock Index for Early Detection of Low Plasma Fibrinogen in Trauma: A Prospective Observational Cohort Pilot Study

Shock index (a ratio between heart rate and systolic blood pressure) predicts transfusion requirements and the need for haemostatic resuscitation in severe trauma patients. In the present study, we aimed to determine whether prehospital and on-admission shock index values can be used to predict low plasma fibrinogen in trauma patients. Between January 2016 and February 2017, trauma patients admitted from the helicopter emergency medical service into two large trauma centres in the Czech Republic were prospectively assessed for demographic, laboratory and trauma-associated variables and shock index at scene, during transport and at admission to the emergency department. Hypofibrinogenemia defined as fibrinogen plasma level of 1.5 g·L^-l was deemed as a cut-off for further analysis. Three hundred and twenty-two patients were screened for eligibility. Of these, 264 (83%) were included for further analysis. The hypofibrinogenemia was predicted by the worst prehospital shock index with the area under the receiver operating characteristics curve (AUROC) of 0.79 (95% CI 0.64-0.91) and by the admission shock index with AUROC of 0.79 (95% CI 0.66-0.91). For predicting hypofibrinogenemia, the prehospital shock index ≥ 1 has 0.5 sensitivity (95% CI 0.19-0.81), 0.88 specificity (95% CI 0.83-0.92) and a negative predictive value of 0.98 (0.96-0.99). The shock index may help to identify trauma patients at risk of hypofibrinogenemia early in the prehospital course.

The Association of Blood Banks per City with Mortality Due to Traumatic Hemorrhagic Shock in Colombia: A Population-Based Analysis

Background

Hemorrhagic shock is the second leading cause of death for injured people and disproportionately affects low resource economies. The potential role of spatial allocation of blood banks and the unmet transfusion needs of patients are yet to be characterized. We aimed to estimate the effect of the number of blood banks in mortality due to traumatic hemorrhagic shock (THS) in Colombia.

Methods

We performed a population-based cross-sectional study using secondary data from the Colombian Government: including annual reports from the Blood Bank Network, mortality, and population estimates for 2015-2016. International Classification of Disease 10th code T79.4 identified THS as the primary cause of death. A city-clustered multivariate negative binomial regression, weighted by violent deaths rate, was used to obtain incidence rate ratios (IRR) of death due to THS with 95% confidence intervals (95%CI).

Results

Of the 59,030 violent deaths in Colombia in 2015-2016, 36.76% were due to THS. Only 3.13% of Colombian municipalities had a blood bank. THS incidence decreased as the number of blood banks in a city increased, and the lowest incidence was observed at ten banks (IRR:0.18, 95%CI:0.15-0.22). Receiving medical care in a city with blood banks had a more substantial impact on THS (IRR:0.85; 95%CI:0.76-0.96).

Conclusion

The number of blood banks per city was associated with lower incidence of THS deaths. These findings may highlight the inequitable distribution of blood systems and their association with preventable deaths. Further studies with more focused clinical and geographical data might clarify the geographic determinants of blood products' availability.

Circulatory shock in adults in emergency department

Circulatory shock is a common condition that carries high morbidity and mortality. This review aims to update the critical steps in managing common types of shock in adult patients admitted to medical emergency and intensive care units. A literature review was performed by searching PubMed, EMBASE Ovid, and Cochrane Library, using the following search items: ("shock" OR "circulatory shock" OR "septic shock" OR "cardiogenic shock") AND ("management" OR "treatment" OR "resuscitation"). The review emphasizes prompt shock identification with tissue hypoperfusion, knowledge of the underlying pathophysiological mechanism, initial fluid resuscitation with balanced crystalloids, norepinephrine as the preferred vasopressor in septic and profound cardiogenic shock, and tailored intervention addressing specific etiologies. Point-of-care ultrasound may help evaluate an undifferentiated shock and determine fluid responsiveness. The approach to septic shock is improving; however, confirmatory studies are required for many existing (e.g., amount of initial fluids and steroids) and emerging (e.g., angiotensin II) therapies. Knowledge gaps and wide variations persist in managing cardiogenic shock that needs urgent addressing to improve outcomes.

Early Mortality Risk in Acute Trauma Patients: Predictive Value of Injury Severity Score, Trauma Index, and Different Types of Shock Indices

Objective: This study aimed to explore the predictive value of the Injury Severity Score (ISS), Trauma Index (TI) and different types of shock indices (SI) on the early mortality risk of acute trauma patients. Methods: Clinical data of acute trauma patients who met the inclusion and exclusion criteria of this study and were treated in the hospital from January 2020 to December 2020 were retrospectively collected, including gender, age, trauma mechanism, severe injury site, ISS, TI, admission vital signs, different types of shock indices (SI), death within 7 days, length of hospital stay, and Glasgow Outcome Score (GOS). The predictive value of the Injury Severity Score, Trauma Index, and different types of shock indices on the risk of early mortality in patients with acute trauma were compared using relevant statistical methods. Results: A total of 283 acute trauma patients (mean age 54.0 ± 17.9 years, 30.74% female) were included, and 43 (15.19%) of the patients died during 7 days of hospitalization. The admission ISS, TI, SI, MSI, and ASI in the survival group were significantly lower than those in the death group, and the difference was statistically significant (p < 0.05). Meanwhile, different trauma assessment tools included in the study have certain predictive value for early mortality risk of trauma patients. Conclusions: The TI indicates a better capability to predict the risk of early death in patients with acute trauma. As the most sensitive predictor, the SI has the greatest reference value in predicting the risk of early death in patients with traumatic shock.

Early identification of bleeding in trauma patients: external validation of traumatic bleeding scores in the Swiss Trauma Registry

BACKGROUND

Early identification of bleeding at the scene of an injury is important for triage and timely treatment of injured patients and transport to an appropriate facility. The aim of the study is to compare the performance of different bleeding scores.

METHODS

We examined data from the Swiss Trauma Registry for the years 2015-2019. The Swiss Trauma Registry includes patients with major trauma (injury severity score (ISS) ≥ 16 and/or abbreviated injury scale (AIS) head ≥ 3) admitted to any level-one trauma centre in Switzerland. We evaluated ABC, TASH and Shock index (SI) scores, used to predict massive transfusion (MT) and the BATT score and used to predict death from bleeding. We evaluated the scores when used prehospital and in-hospital in terms of discrimination (C-Statistic) and calibration (calibration slope). The outcomes were early death within 24 h and the receipt of massive transfusion (≥ 10 Red Blood cells (RBC) units in the first 24 h or ≥ 3 RBC units in the first hour).

RESULTS

We examined data from 13,222 major trauma patients. There were 1,533 (12%) deaths from any cause, 530 (4%) early deaths within 24 h, and 523 (4%) patients who received a MT (≥ 3 RBC within the first hour). In the prehospital setting, the BATT score had the highest discrimination for early death (C-statistic: 0.86, 95% CI 0.84-0.87) compared to the ABC score (0.63, 95% CI 0.60-0.65) and SI (0.53, 95% CI 0.50-0.56), P < 0.001. At hospital admission, the TASH score had the highest discrimination for MT (0.80, 95% CI 0.78-0.82). The positive likelihood ratio for early death were superior to 5 for BATT, ABC and TASH. The negative likelihood ratio for early death was below 0.1 only for the BATT score.

CONCLUSIONS

The BATT score accurately estimates the risk of early death with excellent performance, low undertriage, and can be used for prehospital treatment decision-making. Scores predicting MT presented a high undertriage rate. The outcome MT seems not appropriate to stratify the risk of life-threatening bleeding.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT04561050 . Registered 15 September 2020.