Shock index as a mortality predictor in patients with acute polytrauma

Evaluation and treatment of gastrointestinal bleeding in patients taking anticoagulants presenting to the emergency department

This manuscript is a consensus document of an expert panel on the Evaluation and Treatment of Gastrointestinal Bleeding in Patients Taking Anticoagulants Presenting to the Emergency Department, sponsored by the American College of Emergency Physicians.

Shock index to predict outcomes in patients with trauma following traffic collisions: a retrospective cohort study

PURPOSE

Taiwan, which has a rate of high vehicle ownership, faces significant challenges in managing trauma caused by traffic collisions. In Taiwan, traffic collisions contribute significantly to morbidity and mortality, with a high incidence of severe bleeding trauma. The shock index (SI) and the modified shock index (MSI) have been proposed as early indicators of hemodynamic instability. In this study, we aimed to assess the efficacy of SI and MSI in predicting adverse outcomes in patients with trauma following traffic collisions.

METHODS

This retrospective cohort study was conducted at Chi Mei Hospital from January 2015 to December 2020. The comprehensive analysis included 662 patients, with data collected on vital signs and outcomes such as mortality, blood transfusion, emergent surgical intervention (ESI), transarterial embolization (TAE), and intensive care unit (ICU) admission. Optimal cutoff points for SI and MSI were identified by calculating the Youden index. Logistic regression analysis was used to assess outcomes, adjusting for demographic and injury severity variables.

RESULTS

An SI threshold of 1.11 was associated with an increased risk of mortality, while an SI of 0.84 predicted the need for blood transfusion in the context of traffic collisions. Both SI and MSI demonstrated high predictive power for mortality and blood transfusion, with acceptable accuracy for TAE, ESI, and ICU admission. Logistic regression analyses confirmed the independence of SI and MSI as risk factors for adverse outcomes, thus, providing valuable insights into their clinical utility.

CONCLUSIONS

SI and MSI are valuable tools for predicting mortality and blood transfusion needs in patients with trauma due to traffic collisions. These findings advance the quality of care for patients with trauma during their transition from the emergency room to the ICU, facilitating prompt and reliable decision-making processes and improving the care of patients with trauma.

Early Abnormal Vital Signs Predict Poor Outcomes in Normotensive Patients Following Penetrating Trauma

INTRODUCTION

Because trauma patients in class II shock (blood loss of 15%-30% of total blood volume) arrive normotensive, this makes the identification of shock and subsequent prognostication of outcomes challenging. Our aim was to identify early predictive factors associated with worse outcomes in normotensive patients following penetrating trauma. We hypothesize that abnormalities in initial vital signs portend worse outcomes in normotensive patients following penetrating trauma.

METHODS

A retrospective review was performed from 2006 to 2021 using our trauma database and included trauma patients presenting with penetrating trauma with initial normotensive blood pressures (systolic blood pressure ≥90 mmHg). We compared those with a narrow pulse pressure (NPP ≤25% of systolic blood pressure), tachycardia (heart rate ≥100 beats per minute), and elevated shock index (SI ≥ 0.8) to those without. Outcomes included mortality, intensive care unit admission, and ventilator use. Chi-squared, Mann-Whitney tests, and regression analyses were performed as appropriate.

RESULTS

We identified 7618 patients with penetrating injuries and normotension on initial trauma bay assessment. On univariate analysis, NPP, tachycardia, and elevated SI were associated with increases in mortality compared to those without. On multivariable logistic regression, only NPP and tachycardia were independently associated with mortality. Tachycardia and an elevated SI were both independently associated with intensive care unit admission. Only an elevated SI had an independent association with ventilator requirements, while an NPP and tachycardia did not.

CONCLUSIONS

Immediate trauma bay NPP and tachycardia are independently associated with mortality and adverse outcomes and may provide an opportunity for improved prognostication in normotensive patients following penetrating trauma.

Shock index as a predictor of postpartum haemorrhage after vaginal delivery: Secondary analysis of a multicentre randomised controlled trial

OBJECTIVE

To describe the shock index (SI) distribution during the first 2 hours after delivery and to evaluate its performance when measured 15 and 30 minutes after delivery for predicting postpartum haemorrhage (PPH) occurrence in the general population of parturients after vaginal delivery.

DESIGN

Secondary analysis of a multicentre randomised controlled trial testing prophylactic administration of tranexamic acid versus placebo in addition to prophylactic oxytocin to prevent PPH.

SETTING

15 French maternity units in 2015-2016.

SAMPLE

3891 women with a singleton live fetus ≥35 weeks, born vaginally.

METHODS

For each PPH-related predicted outcome, we calculated the area under the receiver operating characteristic curve (AUROC) values of the SI at 15 and 30 minutes after delivery and its predictive performance for SI cut-off values of 0.7, 0.9 and 1.1.

MAIN OUTCOME MEASURES

Quantitative blood loss ≥1000 ml (QBL ≥1000 ml) measured in a graduated collector bag and provider-assessed clinically significant PPH (cPPH).

RESULTS

Prevalence of QBL ≥1000 ml and cPPH was respectively 2.7% (104/3839) and 9.1% (354/3891). The distributions of the SI at 15 and 30 minutes after delivery were similar with a median value of 0.73 and 97th percentile of 1.11 for both. The AUROC values of the 15-minute SI for discriminating QBL ≥1000 ml and cPPH were respectively 0.66 (lower limit of the 95% confidence interval [LCI] 0.60) and 0.56 (LCI 0.52); and for the 30-minute SI 0.68 (LCI 0.61) and 0.49 (LCI 0.43).

CONCLUSIONS

The shock index at 15 and 30 minutes after delivery did not satisfactorily predict either QBL ≥1000 ml or clinical PPH.

Shock index as predictor of massive transfusion and mortality in patients with trauma: a systematic review and meta-analysis

BACKGROUND

Management of bleeding trauma patients is still a difficult challenge. Massive transfusion (MT) requires resources to ensure the safety and timely delivery of blood products. Early prediction of MT need may be useful to shorten the time process of blood product preparation. The primary aim of this study was to assess the accuracy of shock index to predict the need for MT in adult patients with trauma. For the same population, we also assessed the accuracy of SI to predict mortality.

METHODS

This systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. We performed a systematic search on MEDLINE, Scopus, and Web of Science from inception to March 2022. Studies were included if they reported MT or mortality with SI recorded at arrival in the field or the emergency department. The risk of bias was assessed using the QUADAS-2.

RESULTS

Thirty-five studies were included in the systematic review and meta-analysis, for a total of 670,728 patients. For MT the overall sensibility was 0.68 [0.57; 0.76], the overall specificity was 0.84 [0.79; 0.88] and the AUC was 0.85 [0.81; 0.88]. Positive and Negative Likelihood Ratio (LR+; LR-) were 4.24 [3.18-5.65] and 0.39 [0.29-0.52], respectively. For mortality the overall sensibility was 0.358 [0.238; 0.498] the overall specificity 0.742 [0.656; 0.813] and the AUC 0.553 (confidence region for sensitivity given specificity: [0.4014; 0.6759]; confidence region for specificity given sensitivity: [0.4799; 0.6332]). LR+ and LR- were 1.39 [1.36-1.42] and 0.87 [0.85-0.89], respectively.

CONCLUSIONS

Our study demonstrated that SI may have a limited role as the sole tool to predict the need for MT in adult trauma patients. SI is not accurate to predict mortality but may have a role to identify patients with a low risk of mortality.

Shock Index for the Prediction of Interventions and Mortality in Patients With Blunt Thoracic Trauma

INTRODUCTION

Shock index (SI) is a bedside simple scoring tool; however, it has not yet been tested in blunt thorax trauma (BTT). We sought to evaluate the prognostic value of SI for chest interventions (thoracostomy tube or thoracotomy), blood transfusion, and mortality in patients with BTT. We hypothesized that high SI is associated with worse outcomes in patients with BTT.

METHODS

We conducted a retrospective analysis of all BTT patients (chest Abbreviated Injury Score [AIS] > 1) hospitalized in a level 1 trauma center between 2011 and 2020. Patients with AIS >1 for head or abdominal injuries and patients undergoing open reduction and internal fixation surgery or penetrating injuries were excluded. Patients were categorized into two groups (low SI <0.80 versus high SI ≥0.80) based on the receiver operating characteristic curve analysis. Multivariable regression analysis was performed to identify the predictors of mortality.

RESULTS

A total of 1645 patients were admitted with BTT; of them, 24.5% had high SI. The mean age was 39.2 ± 15.2 y, and most were males (91%). Patients with high SI were younger, had sustained severer injuries, and required more chest interventions (P = 0.001), blood transfusion (P = 0.001), and massive transfusion protocol activation (P = 0.001) compared with low SI group. The overall in-hospital mortality rate was 2.6%, which was more in the high SI group (8.2% versus 0.8%; P = 0.001). SI significantly correlated with age (r = -0.281), injury severity score (r = 0.418), Glasgow Come Score on arrival (r = -0.377), Trauma and Injury Severity Score (r = -0.144), Revised Trauma Score (r = -0.219), serum lactate (r = 0.434), blood transfusion units (r = 0.418), and chest AIS (r = 0.066). SI was an independent predictor of mortality (odds ratio 3.506; 95% confidence interval 1.389-8.848; P = 0.008), and this effect persisted after adjustment for chest intervention (odds ratio 2.923; 95% confidence interval 1.146-7.455; P = 0.02).

CONCLUSIONS

The present study highlights the prognostic value of SI as a rapid bedside tool to predict the use of interventions and the risk of mortality in patients with BTT. The study findings help the emergency physicians for early and appropriate risk stratification and triaging of patients with BTT.

Comparison of different scoring systems in predicting mortality and postoperative complications in acute care surgery patients at a Saudi Academic Centre

PURPOSE

Emergency surgery carries an increased risk of death and complications. Scoring systems can help identify patients at higher risk of mortality and complications. Scoring systems can also help benchmark acute care services. This study aims to compare different scoring systems in predicting outcomes among acute care surgery patients.

METHODS

Our study is a retrospective cohort study that included all adult emergency surgery admissions between 2017 and 2019. Data were obtained from patients' electronic health records. Same admission mortality and postoperative complications were collected. Data were recorded to calculate the American Society of Anesthesiologists Physical Status classification system (ASA-PS), Shock Index Score (SI), Age Shock Index Score (AgeSI), and the Emergency Surgery Score (ESS). The probability of death and complications was correlated with each scoring system and was assessed by calculating the c-statistic.

RESULTS

During the study period, 1606 patients fulfilled inclusion criteria. The mortality rate was 2.2%, complication rate was 18.7%. ESS predicted mortality with a c-statistic of 0.87 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.81, 0.74, and 0.57, respectively. ESS also predicted the occurrence of complications with a c-statistic of 0.83 better than ASA-PS, AgeSI, and SI with a calculated c-statistic of 0.72, 0.71, and 0.63, respectively.

CONCLUSION

ESS demonstrated a better prognostic accuracy for hospital mortality and postoperative complications than other prognostic scoring systems. Our findings suggest that a scoring system designed for the acute care surgical population may provide enhanced prognostic performance over other surgical prognostic scoring systems.

Reasons for in-hospital delays to emergency surgical care in a resource-limited setting: Surgery versus anesthesiology perspective

Patients experience delays in emergency surgical care. Our 3-month mixed-methods observational prospective study examined the duration of in-hospital delays (IHDs) to emergency surgery at a tertiary hospital in Malawi and perceived reasons for such delay, assessing the correlation between surgery and anesthesia. Delays over two hours occurred in the majority, and almost 20% waited over twelve hours. However, we found no correlation between surgeons and anaesthetists in the perceived reasons for In-hospital delays to emergency surgical care.

Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale

BACKGROUND

Paediatric age-adjusted shock index (SIPA) has emerged as a predictor of morbidity and mortality in trauma. Poor sensitivity and low generalisability demonstrated in previous studies have limited its use. We evaluate the use of SIPA in the general Australian paediatric trauma population and the combination of SIPA with GCS.

METHODS

All patients from January 2015 to August 2020 at a major Australian paediatric trauma centre were reviewed. Pre-arrival SIPA (pSIPA) and arrival SIPA (aSIPA) were calculated. If SIPA was elevated or the Glasgow Coma Scale ≤ 13, SIPA with mental state (SIPAms) was marked positive for pre-arrival (pSIPAms) and arrival (aSIPAms) respectively.

RESULTS/DISCUSSION

Data from 480 patients were analysed. pSIPA and aSIPA poorly predicted outcomes of morbidity. Only aSIPA predicted mortality. However, both pre-arrival and arrival SIPAms variables predict mortality, major trauma (ISS≥12), hospital LOS, need for ICU admission, and major surgery. Furthermore, median ISS and lactate were significantly higher in positive pSIPA, aSIPA, pSIPAms, and aSIPAms groups than negative. aSIPAms has a sensitivity of 76% and specificity of 70% for major trauma.

CONCLUSION

Broad inclusion criteria reduce SIPA's ability to predict morbidity. Combining it with GCS improves this and is most valuable when calculated at arrival. In addition, the score is more reliable for major trauma (ISS≥12). Future studies should evaluate the use of SIPAms in activation criteria.

Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital

Introduction

Over 90% of trauma-related deaths worldwide, ensue in low- and middle-income countries. Multiple useful trauma scoring systems have been devised. Although validated in high-income countries, they cannot always be replicated in resource-limited countries. This study compares six trauma scores to identify the best-suited system to use for polytrauma patients in a hospital in Pretoria, South Africa.

Methods

This is an observational retrospective analysis of polytrauma admissions from 1 July 2016 to 31 December 2016. Data collected from patients' records from the EC of Steve Biko Academic Hospital, was analysed using Stata Release 14. Outcomes were recorded as 30-day survival, ICU– and overall hospital LOS. Scores pertaining to patient mortality, were compared in terms of sensitivity, specificity, and cut-off points based on ROC curve. Finally, for LOS Pearson correlation analysis was used.

Results

At the best calculated mortality prediction cut-points for the scores, the sensitivities and specificities were respectively 87% and 68% for TRISS, 81% and 61% for ISS, RTS yielded 81% and 60%, while for REMS it was 61% and 69%. The SI and RSI (cut-points used in agreement with the literature) produced sensitivities 58% and only 48%, and specificities of 73% and 83%, respectively.

45(41,7%) patients required ICU admission. Though the ICU LOS best correlated with ISS(r = 0.2710), the ICU LOS correlation coefficient was weak for all trauma scores. None of the scores had a significant p value for hospital LOS.

Discussion

Among the scores compared, TRISS had the highest sensitivity and NPV for mortality prediction in this South African polytrauma population. ISS correlated best with ICU LOS. However, compared to developed countries, ROC analyses & predictability of these scores fare relatively worse, and no correlation was found with hospital LOS. Therefore, we conclude that further studies are needed to ascertain a more suitable system for resource-limited settings.

Enhanced recovery after surgery (ERAS) in patients undergoing emergency laparotomy after trauma: a prospective, randomized controlled trial

Background

The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma.

Methods

In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate.

Results

Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p<0.01). Time to remove nasogastric tube (1.1±0.1 vs. 2.2±0.9; p<0.01), urinary catheter (1.1±0.1 vs. 3.5±1.6; p<0.01), and drain (1.0±0.2 vs. 3.7±1.6; p<0.01) was shorter in the ERAS group. In ERAS group, there was earlier initiation of liquid diet (1.1±0.1 vs. 2.3±1.0; p<0.01) and solid diet (2.1±0.1 vs. 3.6±1.3; p<0.01). The usage of epidural analgesia (63% vs. 30%; p=0.01), non-steroidal anti-inflammatory drugs (93% vs. 67%; p-0.02) and deep vein thrombosis prophylaxis (100% vs. 70%; p<0.01) was higher in the ERAS group. There was no difference in the recovery of bowel function (2.4±1.0 vs. 2.1±0.9; p=0.15), pain scores (3.2±1.0 vs. 3.1±1.1; p=0.87), complications (27% vs. 23%; p=0.99) and readmission rates (07% vs. 10%; p=0.99) between the two groups.

Conclusion

ERAS protocol, when implemented in patients undergoing laparotomy for trauma, has decreased duration of hospital stay with no additional complications.

Level of evidence

Level 1, randomized controlled trial, care management.

Trial registration number

Clinical Trials Registry of India (CTRI/2019/06/019533).

Shock index as a prognosticator for emergent surgical intervention and mortality in trauma patients in Johannesburg: A retrospective cohort study

Introduction

Trauma is the leading cause of morbidity and mortality worldwide with exsanguination being the primary preventable cause through early surgical intervention. We assessed two popular trauma scoring systems, injury severity scores (ISS) and shock index (SI) to determine the optimal cut off values that may predict the need for emergent surgical intervention (ESI) and in-hospital mortality.

Methods

A retrospective analysis of patient records from a tertiary hospital's trauma unit for the year 2019 was done. Descriptive statistics, univariate and multivariate logistic regression analyses were performed. Receiver operator characteristic (ROC) curve analysis was conducted and area under the curve (AUC) reported for predicting the need for ESI in all study participants, as well as in patients with penetrating injuries alone, based on continuous variables of ISS, SI or a combination of ISS and SI. The Youdin Index was applied to determine the optimal ISS and SI cut off values.

Results

A total of 1964 patients’ records were included, 89.0% were male and the median age (IQR) was 30 (26–37) years. Penetrating injuries accounted for 65.9% of all injuries. ISS and SI were higher in the ESI group with median (IQR) 11 (10–17) and 0.74 (0.60–0.95), respectively. The overall mortality rate was 4.5%. The optimal cut-off values for ESI and mortality by ISS (AUC) were 9 (0.74) and 12 (0.86) (p = 0.0001), with optimal values for SI (AUC) being 0.72 (0.60), and 0.91 (0.68) (p = 0.0001), respectively.

Conclusion

ISS and SI are significant, independent prognosticators for the need of ESI and in-hospital mortality.

•

The ISS cut-off of 15 for severe trauma may underestimate the severity of trauma within our local South African population.

•

Our study reports an optimal SI cut off value of ≥0.72 for emergency surgical intervention.

•

At an optimal SI cut off of ≥0.91 for in-hospital mortality, the odds of demise were 6.7 times higher.

•

ISS was a stronger predictor than SI of both ESI and in-hospital mortality in our study.

Hospital effects drive variation in access to inpatient rehabilitation after trauma

BACKGROUND

Postacute care rehabilitation is critically important to recover after trauma, but many patients do not have access. A better understanding of the drivers behind inpatient rehabilitation facility (IRF) use has the potential for major cost-savings as well as higher-quality and more equitable patient care. We sought to quantify the variation in hospital rates of trauma patient discharge to inpatient rehabilitation and understand which factors (patient vs. injury vs. hospital level) contribute the most.

METHODS

We performed a retrospective cohort study of 668,305 adult trauma patients admitted to 900 levels I to IV trauma centers between 2011 and 2015 using the National Trauma Data Bank. Participants were included if they met the following criteria: age >18 years, Injury Severity Score of ≥9, identifiable injury type, and who had one of the Centers for Medicare & Medicaid Services preferred diagnoses for inpatient rehabilitation under the "60% rule."

RESULTS

The overall risk- and reliability-adjusted hospital rates of discharge to IRF averaged 18.8% in the nonelderly adult cohort (18-64 years old) and 23.4% in the older adult cohort (65 years or older). Despite controlling for all patient-, injury-, and hospital-level factors, hospital discharge of patients to IRF varied substantially between hospital quintiles and ranged from 9% to 30% in the nonelderly adult cohort and from 7% to 46% in the older adult cohort. Proportions of total variance ranged from 2.4% (patient insurance) to 12.1% (injury-level factors) in the nonelderly adult cohort and from 0.3% (patient-level factors) to 26.0% (unmeasured hospital-level factors) in the older adult cohort.

CONCLUSION

Among a cohort of injured patients with diagnoses that are associated with significant rehabilitation needs, the hospital at which a patient receives their care may drive a patient's likelihood of recovering at an IRF just as much, if not more, than their clinical attributes.

LEVEL OF EVIDENCE

Care management, level IV.

The advanced machine learner XGBoost did not reduce prehospital trauma mistriage compared with logistic regression: a simulation study

Background

Accurate prehospital trauma triage is crucial for identifying critically injured patients and determining the level of care. In the prehospital setting, time and data are often scarce, limiting the complexity of triage models. The aim of this study was to assess whether, compared with logistic regression, the advanced machine learner XGBoost (eXtreme Gradient Boosting) is associated with reduced prehospital trauma mistriage.

Methods

We conducted a simulation study based on data from the US National Trauma Data Bank (NTDB) and the Swedish Trauma Registry (SweTrau). We used categorized systolic blood pressure, respiratory rate, Glasgow Coma Scale and age as our predictors. The outcome was the difference in under- and overtriage rates between the models for different training dataset sizes.

Results

We used data from 813,567 patients in the NTDB and 30,577 patients in SweTrau. In SweTrau, the smallest training set of 10 events per free parameter was sufficient for model development. XGBoost achieved undertriage rates in the range of 0.314–0.324 with corresponding overtriage rates of 0.319–0.322. Logistic regression achieved undertriage rates ranging from 0.312 to 0.321 with associated overtriage rates ranging from 0.321 to 0.323. In NTDB, XGBoost required the largest training set size of 1000 events per free parameter to achieve robust results, whereas logistic regression achieved stable performance from a training set size of 25 events per free parameter. For the training set size of 1000 events per free parameter, XGBoost obtained an undertriage rate of 0.406 with an overtriage of 0.463. For logistic regression, the corresponding undertriage was 0.395 with an overtriage of 0.468.

Conclusion

The under- and overtriage rates associated with the advanced machine learner XGBoost were similar to the rates associated with logistic regression regardless of sample size, but XGBoost required larger training sets to obtain robust results. We do not recommend using XGBoost over logistic regression in this context when predictors are few and categorical.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-021-01558-y.

Delta Shock Index During Emergency Department Stay Is Associated With in Hospital Mortality in Critically Ill Patients

Background: Delta shock index (SI; i.e., change in SI over time) has been shown to predict mortality and need for surgical intervention among trauma patients at the emergency department (ED). However, the usefulness of delta SI for prognosis assessment in non-traumatic critically ill patients at the ED remains unknown. The aim of this study was to analyze the association between delta SI during ED management and in-hospital outcomes in patients admitted to the intensive care unit (ICU).

Method: This was a retrospective study conducted in two tertiary medical centers in Taiwan from January 1, 2016, to December 31, 2017. All adult non-traumatic patients who visited the ED and who were subsequently admitted to the ICU were included. We calculated delta SI by subtracting SI at ICU admission from SI at ED triage, and we analyzed its association with in-hospital outcomes. SI was defined as the ratio of heart rate to systolic blood pressure (SBP). The primary outcome was in-hospital mortality, and the secondary outcomes were hospital length of stay (HLOS) and early mortality. Early mortality was defined as mortality within 48 h of ICU admission.

Result: During the study period, 11,268 patients met the criteria and were included. Their mean age was 64.5 ± 15.9 years old. Overall, 5,830 (51.6%) patients had positive delta SI. Factors associated with a positive delta SI were multiple comorbidities (51.2% vs. 46.3%, p < 0.001) and high Simplified Acute Physiology Score [39 (29–51) vs. 37 (28–47), p < 0.001). Patients with positive delta SI were more likely to have tachycardia, hypotension, and higher SI at ICU admission. In the regression analysis, high delta SI was associated with in-hospital mortality [aOR (95% CI): 1.21 (1.03–1.42)] and early mortality [aOR (95% CI): 1.26 (1.07–1.48)], but not for HLOS [difference (95% CI): 0.34 (−0.48 to 1.17)]. In the subgroup analysis, high delta SI had higher odds ratios for both mortality and early mortality in elderly [aOR (95% CI): 1.59 (1.11–2.29)] and septic patients [aOR (95% CI): 1.54 (1.13–2.11)]. It also showed a higher odds ratio for early mortality in patients with triage SBP <100 mmHg [aOR (95% CI): 2.14 (1.21–3.77)] and patients with triage SI ≥ 0.9 [aOR (95% CI): 1.62 (1.01–2.60)].

Conclusion: High delta SI during ED stay is correlated with in-hospital mortality and early mortality in patients admitted to the ICU via ED. Prompt resuscitation should be performed, especially for those with old age, sepsis, triage SBP <100 mmHg, or triage SI ≥ 0.9.

Dynamic trend or static variable: Shock Index Pediatric-Adjusted (SIPA) in warzone trauma

BACKGROUND

Civilian studies suggest that trending Shock-Index Pediatric Adjusted(SIPA) values can prove useful in the prediction of trauma outcomes. The purpose of this study was to evaluate the relationship between trends in SIPA and outcomes in pediatric warzone trauma.

METHODS

Retrospective review of the Department of Defense Trauma Registry from 2008 to 2015, including all patients age ≤17years. SIPA was calculated both pre-hospital and upon arrival, then classified as "normal" or "abnormal" based upon previously validated thresholds. Patients were stratified into groups based on the trend of their SIPA (1-normal to normal, 2-normal to abnormal, 3-abnormal to normal, 4-abnormal to abnormal). Key outcomes including ICU admission, severe injury, mechanical ventilation, and mortality were then compared between groups.

RESULTS

669 patients were included, mean ISS 12 ± 10. The most common mechanism of injury was blast (46.5%). Overall, 43% were stratified into Group 1, 13.9% into Group 2, 14.8% into Group 3, and 28.0% into Group 4. Those patients with a persistently abnormal SIPA (Group 4) had significantly increased incidence of severe injury, ICU admission, need for mechanical ventilation, and mortality.

CONCLUSION

Trends in SIPA may be used to predict trauma outcomes for children injured in warzones, with persistently abnormal values associated with worse outcomes overall.

Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma

INTRODUCTION

Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries.

METHODS

Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality.

RESULTS

A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality.

CONCLUSION

Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population.

LEVEL OF EVIDENCE

Prognostic study, level IV.

Massive Gastrointestinal Hemorrhage

Massive gastrointestinal hemorrhage is a life-threatening condition that can result from numerous causes and requires skilled resuscitation to decrease patient morbidity and mortality. Successful resuscitation begins with placement of large-bore intravenous or intraosseous access; early blood product administration; and early consultation with a gastroenterologist, interventional radiologist, and/or surgeon. Activate a massive transfusion protocol when initial red blood cell transfusion does not restore effective perfusion or the patient's shock index is greater than 1.0. Promptly reverse coagulopathies secondary to oral anticoagulant or antiplatelet use. Use thromboelastography or rotational thromboelastometry to guide further transfusions. Secure a definitive airway and minimize aspiration.

Patients With Combined Thermal and Intraabdominal Injuries: More Salvageable Than Not

This study aims to better characterize the course and outcome of the uncommon subset of trauma patients with combined thermal and intraabdominal organ injuries. The National Trauma Data Bank was queried for burn patients with intraabdominal injury treated in all U.S. trauma centers from July 1, 2011 to June 30, 2015. General demographics, Glasgow coma scale (GCS), shock index (SI), Abbreviated Injury Scale (AIS) for burn, Injury Severity Score (ISS), blood transfusions, and abdominal surgery were evaluated. During the 5-year study period, there were 334 burn patients with intraabdominal injury, 39 (13.2%) of which received abdominal surgery. Burn patients who underwent operations had more severe injuries reflected by higher SI, AIS, ISS, blood transfusion, and worse outcomes including higher mortality, longer hospital and ICU length of stay, and more ventilator days compared to patients who did not undergo an operation. Nonsurvivors also exhibited more severe injuries, and a higher proportion received abdominal operation compared to survivors. Multivariate logistic regression analysis revealed that GCS on arrival, SI, AIS, ISS, blood transfusion, and abdominal operation to be independent risk factors for mortality. Propensity score matching to control covariables (mean age, systolic blood pressure on arrival, GCS on arrival, SI, ISS, time to operation, blood transfusion, and comorbidities) showed that of trauma patients who received abdominal operation, those with concomitant burn injury exhibited a higher rate of complications but no significant difference in mortality compared to those without burns, suggesting that patients with concomitant burns are not less salvageable than nonburned trauma patients.

Determinants of prehospital lactate in trauma patients: a retrospective cohort study

Background

Point of care serum lactate measurement is emerging as an adjunct to prehospital clinical assessment and has the potential to guide triage and advanced treatment decision-making. In this study we aimed to assess which factors potentially affect prehospital lactate levels.

Methods

We performed a retrospective cohort study of all trauma patients attended by the Air Ambulance, Kent, Surrey & Sussex (AAKSS) between July 2017 and April 2018 in whom a pre-hospital lactate was measured. Lactate was measured before AAKSS treatments were commenced, but generally after prehospital treatment by ground ambulance crews was initiated. Primary endpoint of interest was the association of various patient- and treatment characteristics with prehospital lactate levels.

Results

During the study period, lactate was measured in 156 trauma patients. Median lactate was 3.0 [2.0–4.1] mmol/l. Patients with an elevated lactate more often had deranged indices of end organ perfusion- and oxygenation (shock index 0.80 [0.58–1.03] vs 0.61 [0.40–0.82], p < 0.001, SpO₂ 96 [89–100%] vs 98 [96–100%], p = 0.025). They more often suffered from head injuries (62% vs 41%, p = 0.008), and received less analgesia prior to arrival of the AAKSS team (51.6% vs 67.2%, p = 0.03). In multivariate analysis, indices of end organ perfusion- and oxygenation only explained 15% of the variation in lactate levels.

Conclusions

Prehospital lactate levels are not solely associated with indices of end organ perfusion- and oxygenation. Injury type, treatments given on scene and many other (unmeasured) factors likely play an important role as well. This should be taken into account when lactate is used in clinical algorithms to guide prehospital triage or treatment.

The use of the shock index to predict hemodynamic collapse in hypotensive sepsis patients: A cross-sectional analysis

Objectives:

Septic shock, defined as sepsis with hypotension not responding to fluid resuscitation or requiring vasopressor support, results in the worst outcomes in sepsis patients. This subtype of the patient is often difficult to detect. The shock index (SI) has demonstrated the potential for predicting hemodynamic compromise and collapse and predicting patient outcomes in multiple medical and surgical settings. In our study, we assessed the utility of the SI as a hemodynamic screening tool to identify patients likely to fail to respond to fluids and ultimately to be diagnosed with septic shock.

Methodology:

A single-center cross-sectional analysis of patients presenting with hypotension and septicemia over 1 year. The study was conducted using the electronic medical records of the emergency department patients presenting to King Saud University Medical City. The charts were reviewed from 2 May 2015 to 24 April 2016 using the local medical registry. The study was approved by the hospital institutional review board (IRB). Data extraction was performed using a standardized form.

Results:

The area under the curve was 0.77 (P < 0.001) for the prediction of hemodynamic collapse. An initial SI ≥0.875 had a sensitivity of 81% and a specificity of 72% for the identification of patients in whom fluid resuscitation would fail.

Conclusions:

Based on our findings, we found that the SI was a reliable screening tool for the identification of hypotensive patients with sepsis who would ultimately be diagnosed with septic shock.

Abnormal shock index exposure and clinical outcomes among critically ill patients: A retrospective cohort analysis

PURPOSE

To assess the predictive value of a single abnormal shock index reading (SI ≥0.9; heart rate/systolic blood pressure [SBP]) for mortality, and association between cumulative abnormal SI exposure and mortality/morbidity.

MATERIALS AND METHODS

Cohort comprised of adult patients with an intensive care unit (ICU) stay ≥24-h (years 2010-2018). SI ≥0.9 exposure was evaluated via cumulative minutes or time-weighted average; SBP ≤100-mmHg was analyzed. Outcomes were in-hospital mortality, acute kidney injury (AKI), and myocardial injury.

RESULTS

18,197 patients from 82 hospitals were analyzed. Any single SI ≥0.9 within the ICU predicted mortality with 90.8% sensitivity and 36.8% specificity. Every 0.1-unit increase in maximum-SI during the first 24-h increased the odds of mortality by 4.8% [95%CI; 2.6-7.0%; p < .001]. Every 4-h exposure to SI ≥0.9 increased the odds of death by 5.8% [95%CI; 4.6-7.0%; p < .001], AKI by 4.3% [95%CI; 3.7-4.9%; p < .001] and myocardial injury by 2.1% [95%CI; 1.2-3.1%; p < .001]. ≥2-h exposure to SBP ≤100-mmHg was significantly associated with mortality.

CONCLUSIONS

A single SI reading ≥0.9 is a poor predictor of mortality; cumulative SI exposure is associated with greater risk of mortality/morbidity. The associations with in-hospital mortality were comparable for SI ≥0.9 or SBP ≤100-mmHg exposure. Dynamic interactions between hemodynamic variables need further evaluation among critically ill patients.

Utility of admission lactate concentration, lactate variables, and shock index in outcome assessment in dogs diagnosed with shock

OBJECTIVE

To determine whether admission venous plasma lactate concentration, calculated lactate variables, or shock index (SI) could discriminate hospital survivors from nonsurvivors in dogs admitted with shock.

DESIGN

Prospective investigation performed over a 19-month period.

SETTING

Large urban private teaching hospital.

ANIMALS

Twenty-three dogs consecutively admitted to the ICU from January 2008 to July 2009 with initial peripheral venous plasma lactate concentration >2 mmol/L (18.0 mg/dL) and clinical and hemodynamic parameters consistent with shock.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Heart rate, systolic blood pressure, and venous plasma lactate concentrations were serially recorded at predefined time points and used to calculate SI (SI = heart rate/systolic blood pressure) and lactate variables, including lactime (time lactate > 2.0 mmol/L), lactate clearance ([lactate_initial - lactate_delayed ]/lactate_initial × 100), and LAC_AREA (area under the lactate concentration versus time curve). Primary outcome was survival to discharge. Overall survival rate was 61%. Admission venous plasma lactate concentration did not differ between groups (P = 0.2). Lactime was shorter in survivors versus nonsurvivors (P = 0.02). Lactate clearance at 1, 10, 16, 24, and 36 hours, and final lactate clearance were greater in survivors versus nonsurvivors (P < 0.05). LAC_AREA at time intervals 0-1, 1-4, 4-10, 10-16, 16-24, 24-30, and 30-36 hours was larger in nonsurvivors versus survivors (P < 0.05). Total LAC_AREA did not differ between groups (P = 0.09). Admission SI and time to normalize SI (SI < 0.9) were not different between survivors and nonsurvivors (P > 0.05).

CONCLUSIONS

While admission venous plasma lactate concentration could not discriminate between hospital survivors and nonsurvivors, lactate variables showed clinical utility to predict outcome in dogs with shock. Further studies are needed to determine SI reference ranges and optimal SI cut-off values to improve its prognostic ability in sick dogs.

Development and validation of a new simplified anatomic trauma mortality score

BACKGROUND

Most trauma mortality prediction scores are complex in nature. GAP (Glasgow Coma Scale, Age, Systolic blood pressure) and mGAP (mechanism, Glasgow Coma Scale, Age, Systolic blood pressure) scores are relatively simple scoring tools. However, these scores were not validated in low and middle income countries including Malaysia and its accuracies are influenced by the fluctuating physiologic parameters. This study aims to develop a relevant simplified anatomic trauma scoring system for the local trauma patients in Malaysia.

METHOD

A total of 3825 trauma patients from 2011 to 2016 were extracted from the Hospital Sultanah Aminah Trauma Surgery Registry. Patients were split into a development sample (n = 2683) and a validation sample (n = 1142). Univariate analysis is applied to identify significant anatomic predictors. These predictors were further analyzed using multivariable logistic regression to develop the new score and compared to existing score systems. The quality of prediction was determined regarding discrimination using sensitivity, specificity and receiver operating characteristic [ROC] curve.

RESULTS

Existing simplified score systems (GAP & mGAP) revealed areas under the ROC curve of 0.825 and 0.806. The newly developed HeCLLiP (Head, cervical spine, lung, liver, pelvic fracture) score combines only five anatomic components: injury involving head, cervical spine, lung, liver and pelvic bone. The probabilities of mortality can be estimated by charting the total score points onto a graph chart or using the cut-off value of (>2) with a sensitivity of 79.2 and specificity of 70.6% on the validation dataset. The HeCLLiP score achieved comparable values of 0.802 for the area under the ROC curve in validation samples.

CONCLUSION

HeCLLiP Score is a simplified anatomic score suited to the local Malaysian population with a good predictive ability for trauma mortality.

Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments

STUDY OBJECTIVES

The shock index (SI), defined as the ratio of the heart rate (HR) to the systolic blood pressure (BP), is used as a prognostic tool in trauma and in specific disease states. However, there is scarcity of data about the utility of the SI in the general emergency department (ED)population. Our goal was to use a large national database of EDs in the United States (US) to determine whether the likelihood of inpatient mortality and hospital admission was associated with initial SI at presentation.

METHODS

Data from the National Hospital Ambulatory Medical Care Survey were retrospectively reviewed to obtain a weighted sample of all US ED visits between 2005 and 2010. All adults >18 years old who survived the ED visit were included, regardless of their chief complaint. Likelihood ratios (LR) were calculated for a range of SI values, in order to determine SI thresholds most predictive of hospital admission and inpatient mortality. +LRs >5 were considered to be clinically significant.

RESULTS

A total of 526 455 251 adult patient encounters were included in the analysis. 56.9% were women, 73.9% were white and 53.2% were between the ages of 18 and 44 years. 88 326 638 (15.7%) unique ED visits resulted in hospital admission and 1 927 235 (2.6%) visits resulted in inpatient mortality. SI>1.3 was associated with a clinically significant increase in both the likelihood of hospital admission (+LR=6.64) and inpatient mortality (+LR=5.67). SI>0.7 and >0.9, the traditional cited cut-offs, were only associated with marginal increases (+LR= 1.13; 1.54 for SI>0.7 and +LR=1.95; 2.59 for SI>0.9 for hospital admission and inpatient mortality, respectively).

CONCLUSIONS

In this largest retrospective study to date on SI in the general ED population, we demonstrated that initial SI at presentation to the ED could potentially be useful in predicting the likelihood of hospital admission and inpatient mortality, which could help guide rapid and accurate acuity designation, resource allocation and disposition.

Shock Index-A Useful Noninvasive Marker Associated With Age-Specific Early Mortality in Children With Severe Sepsis and Septic Shock: Age-Specific Shock Index Cut-Offs

BACKGROUND

Aim of the study was to analyze the association of shock index (SI) from 0 to 6 hours with early mortality in severe sepsis/septic shock and to explore its age-specific cut-off values. To investigate association of change in SI over first 6 hours with early mortality.

METHODS

A prospective cohort study of children (<14 years) admitted in emergency department, tertiary care hospital with severe sepsis or septic shock, divided into 3 groups: group 1: 1 month to <1 year; group 2: 1 to <6 years; group 3: 6 to 12 years. Shock index (SI = heart rate/systolic blood pressure) measured at admission (X0) and hourly till 6 hours (X1-6). Primary outcome was death within 48 hours of admission. Area under receiver operating characteristic curves were constructed for SI (0-6). Optimal cut-offs of SI 0 and SI 6, maximizing both sensitivity and specificity were determined and positive and negative predictive values (PPV, NPV) were calculated.

RESULTS

From 2015 to 2016, 120 children were recruited. Septic shock was present at admission in 56.7% children. Early mortality was 50%. All hourly shock indices (SI 0-6) were higher among nonsurvivors in group 2 (P ≤ .03) and group 3 (P < .001). In group 1, SI after 2 hours was higher in nonsurvivors (P 2-6: ≤ .02). Area under receiver operating characteristic curves (95% CI) for SI at 0 hour was 0.72 (0.5-0.9), 0.66 (0.5-0.8), and 0.77 (0.6-0.9) and at 6 hours was 0.8 (0.6-1), 0.75 (0.6-0.9), and 0.8 (0.7-1) in 3 groups. The cut-off values of SI 0 (sensitivity; specificity; PPV; NPV) in 3 groups: 1.98 (77; 75; 67; 83), 1.50 (65; 65; 68; 63), and 1.25 (90; 67; 77; 83) and SI6: 1.66 (85; 80; 73; 89), 1.36 (73; 70; 73; 70), and 1.30 (74; 73; 78; 69). Improvement of SI over 6 hours was associated with better outcome. Children with higher SI at both time points had higher mortality than those with SI score below the cut-offs (P = .001).

CONCLUSIONS

Age-specific SI cut-off values may identify children at high risk of early mortality in severe sepsis/septic shock and allow for better targeted management.

En Route Critical Care Transfer From a Role 2 to a Role 3 Medical Treatment Facility in Afghanistan

BACKGROUND

En route care is the transfer of patients requiring combat casualty care within the US military evacuation system. No reports have been published about en route care of patients during transfer from a forward surgical facility (role 2) to a combat support hospital (role 3) for comprehensive care.

OBJECTIVE

To describe patients transferred from a role 2 to a role 3 US military treatment facility in Afghanistan.

METHODS

A retrospective review of data from the Joint Trauma System Role 2 Database was conducted. Patient characteristics were described by en route care medical attendants.

RESULTS

More than one-fourth of patients were intubated at transfer (26.9%), although at transfer fewer than 10% of patients had a base deficit of more than 5 (3.5%), a pH of less than 7.3 (5.2%), an international normalized ratio of more than 2 (0.8%), or temporary abdominal or chest closure (7.4%). The en route care medical attendant was most often a nurse (35.5%), followed by technicians (14.1%) and physicians (10.0%). Most patients (75.3%) were transported by medical evacuation (on rotary-wing aircraft).

CONCLUSION

This is the first comprehensive review of patients transported from a forward surgical facility to a more robust combat support hospital in Afghanistan. Understanding the epidemiology of these patients will inform provider training and the appropriate skill mix for the transfer of postsurgical patients within a combat setting.

Derivation of a screen to identify severe sepsis and septic shock in the ED-BOMBARD vs. SIRS and qSOFA

STUDY OBJECTIVE

To predict severe sepsis/septic shock in ED patients.

METHODS

We conducted a retrospective case-control study of patients ≥18 admitted to two urban hospitals with a combined ED census of 162,000. Study cases included patients with severe sepsis/septic shock admitted via the ED. Controls comprised admissions without severe sepsis/septic shock. Using multivariate logistic regression, a prediction rule was constructed. The model's AUROC was internally validated using 1000 bootstrap samples.

RESULTS

143 study and 286 control patients were evaluated. Features predictive of severe sepsis/septic shock included: SBP ≤ 110 mm Hg, shock index/SI ≥ 0.86, abnormal mental status or GCS < 15, respirations ≥ 22, temperature ≥ 38C, assisted living facility residency, disabled immunity. Two points were assigned to SI and temperature with other features assigned one point (mnemonic: BOMBARD). BOMBARD was superior to SIRS criteria (AUROC 0.860 vs. 0.798, 0.062 difference, 95% CI 0.022-0.102) and qSOFA scores (0.860 vs. 0.742, 0.118 difference, 95% CI 0.081-0.155) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was more sensitive than SIRS ≥ 2 (74.8% vs. 49%, 25.9% difference, 95% CI 18.7-33.1) and qSOFA ≥ 2 (74.8% vs. 33.6%, 41.2% difference, 95% CI 33.2-49.3) at predicting severe sepsis/septic shock. A BOMBARD score ≥ 3 was superior to SIRS ≥ 2 (76% vs. 45%, 32% difference, 95% CI 10-50) and qSOFA ≥ 2 (76% vs. 29%, 47% difference, 95% CI 25-63) at predicting sepsis mortality.

CONCLUSION

BOMBARD was more accurate than SIRS and qSOFA at predicting severe sepsis/septic shock and sepsis mortality.

Can we safely decrease intensive care unit admissions for children with high grade isolated solid organ injuries? Using the shock index, pediatric age-adjusted and hematocrit to modify APSA admission guidelines

BACKGROUND

In 2000, the American Pediatric Surgical Association (APSA) disseminated consensus practice guidelines for the management of blunt liver and splenic injury which included intensive care unit (ICU) admission for children with grade IV injuries. We sought to determine if we could better predict which children with isolated solid organ injuries (SOI) underwent an ICU-level intervention, thus necessitating ICU admission.

METHODS

Children with isolated liver, spleen, or kidney injuries admitted to the ICU from November 2003 to August 2015 were identified in our trauma registry, and data were extracted from the medical record. ICU-level interventions were defined as transfusion, vasopressor use, intubation, and operative/procedural intervention. Shock index and pediatric age-adjusted (SIPA) was calculated for all patients. The sensitivity and negative predictive values (NPV) were determined.

RESULTS

133 children met inclusion criteria. 19 (14.3%) required ICU-level intervention, and 114 (85.1%) did not. 95% (n=18) of the intervention group had either an elevated SIPA or a hematocrit <30% on admission compared to 22% (n=25) of patients in the no intervention group. Sensitivity was 95%, and NPV was 99%.

CONCLUSIONS

Limiting ICU admission in children with isolated SOI to those with an elevated SIPA or hematocrit <30% would reduce the ICU admission rate by two-thirds while maintaining patient safety.

TYPE OF STUDY

Diagnostic study.

LEVEL OF EVIDENCE

III.

Elevated Modified Shock Index Within 24 Hours of ICU Admission Is an Early Indicator of Mortality in the Critically Ill

PURPOSE

To assess whether exposure to modified shock index (MSI) in the first 24 hours of intensive care unit (ICU) admission is associated with increased in-hospital mortality.

METHODS

Adult critically ill patients were included in a case-control design with 1:2 matching. Cases (death) and controls (alive) were abstracted by a reviewer blinded to exposure status (MSI). Cases were matched to controls on 3 factors-age, end-stage renal disease, and ICU admission diagnosis.

RESULTS

Eighty-three cases and 159 controls were included. On univariate analysis, lorazepam administration (odds ratio [OR]: 5.75, confidence interval [CI] = 2.28-14.47; P ≤ .01), shock requiring vasopressors (OR: 3.62, CI = 1.77-7.40; P ≤ .01), maximum MSI (OR: 2.77 per unit, CI = 1.63-4.71; P ≤ .001), and elevated acute physiologic and chronic health evaluation (APACHE) III score at 1 hour (OR: 1.41 per 10 units, CI = 1.19-1.66; P ≤ .001) were associated with mortality. Maximum MSI (OR: 1.93 per unit, CI = 1.07-3.48, P = .03) and APACHE III score at 1 hour (OR: 1.29 per 10 units, CI = 1.09-1.53; P = .003) remained significant with mortality in the multivariate analysis. The optimal cutoff point for high MSI and mortality was 1.8.

CONCLUSION

Critically ill patients who demonstrate an elevated MSI within the first 24 hours of ICU admission have a significant mortality risk. Given that MSI is easily calculated at the bedside, clinicians may institute interventions earlier which could improve survival.

Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients

BACKGROUND

Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia.

METHODS

During a 2-year period (2012-2013), blunt and penetrating trauma patients (≥ 15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥ 4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality.

RESULTS

We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers.

CONCLUSION

There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT.

LEVEL OF EVIDENCE

Therapy/care management study, level IV.