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McKimmie A, Keeves J, Gadowski A, Bagg MK, Antonic-Baker A, Hicks AJ, Hill R, Clarke N, Holland A, Veitch B, Fatovich D, Reeder S, Romero L, Ponsford JL, Lannin NA, O’Brien TJ, Cooper DJ, Rushworth N, Fitzgerald M, Gabbe BJ, Cameron PA. The Australian Traumatic Brain Injury Initiative: Systematic Review of Clinical Factors Associated with Outcomes in People with Moderate-Severe Traumatic Brain Injury. Neurotrauma Rep 2024; 5:0. [PMID: 39081663 PMCID: PMC11286001 DOI: 10.1089/neur.2023.0111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/02/2024] Open
Abstract
The aim of the Australian Traumatic Brain Injury Initiative (AUS-TBI) is to design a data dictionary to inform data collection and facilitate prediction of outcomes for moderate-severe traumatic brain injury (TBI) across Australia. The process has engaged diverse stakeholders across six areas: social, health, clinical, biological, acute interventions, and long-term outcomes. Here, we report the results of the clinical review. Standardized searches were implemented across databases to April 2022. English-language reports of studies evaluating an association between a clinical factor and any clinical outcome in at least 100 patients with moderate-severe TBI were included. Abstracts, and full-text records, were independently screened by at least two reviewers in Covidence. The findings were assessed through a consensus process to determine inclusion in the AUS-TBI data resource. The searches retrieved 22,441 records, of which 1137 were screened at full text and 313 papers were included. The clinical outcomes identified were predominantly measures of survival and disability. The clinical predictors most frequently associated with these outcomes were the Glasgow Coma Scale, pupil reactivity, and blood pressure measures. Following discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous studies evaluating associations between clinical factors and outcomes in patients with moderate-severe TBI. A small number of factors were reported consistently, however, how and when these factors were assessed varied. The findings of this review and the subsequent consensus process have informed the development of an evidence-informed data dictionary for moderate-severe TBI in Australia.
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Affiliation(s)
- Ancelin McKimmie
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jemma Keeves
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Faculty of Health Sciences, Curtin Health Innovation Research Institute, Curtin University, Bentley, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Australia
| | - Adelle Gadowski
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew K. Bagg
- Faculty of Health Sciences, Curtin Health Innovation Research Institute, Curtin University, Bentley, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Australia
- Centre for Pain IMPACT, Neuroscience Research Australia, Sydney, Australia
- School of Health Sciences, University of Notre Dame Australia, Fremantle, Australia
| | - Ana Antonic-Baker
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - Amelia J. Hicks
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Regina Hill
- Regina Hill Effective Consulting Pty Ltd, Melbourne, Australia
| | - Nyssa Clarke
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew Holland
- Faculty of Medicine and Health, The Children’s Hospital at Westmead Clinical School, University of Sydney School of Medicine, Westmead, Australia
| | - Bill Veitch
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Daniel Fatovich
- Emergency Medicine, Royal Perth Hospital, University of Western Australia, Perth, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Nedlands, Australia
| | - Sandy Reeder
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | | | - Jennie L. Ponsford
- Monash-Epworth Rehabilitation Research Centre, Epworth Healthcare, Melbourne, Australia
- School of Psychological Sciences, Monash University, Melbourne, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
- Alfred Health, Melbourne, Australia
| | - Terence J. O’Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Australia
| | - D. Jamie Cooper
- School of Public Health and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Department of Intensive Care and Hyperbaric Medicine, Melbourne, Australia
| | | | - Melinda Fitzgerald
- Faculty of Health Sciences, Curtin Health Innovation Research Institute, Curtin University, Bentley, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Australia
| | - Belinda J. Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
| | - Peter A. Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- National Trauma Research Institute, Melbourne, Australia
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia
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Xu Y, Malik N, Chernbumroong S, Vassallo J, Keene D, Foster M, Lord J, Belli A, Hodgetts T, Bowley D, Gkoutos G. Triage in major incidents: development and external validation of novel machine learning-derived primary and secondary triage tools. Emerg Med J 2024; 41:176-183. [PMID: 37751994 PMCID: PMC10894820 DOI: 10.1136/emermed-2022-212440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/12/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Major incidents (MIs) are an important cause of death and disability. Triage tools are crucial to identifying priority 1 (P1) patients-those needing time-critical, life-saving interventions. Existing expert opinion-derived tools have limited evidence supporting their use. This study employs machine learning (ML) to develop and validate models for novel primary and secondary triage tools. METHODS Adults (16+ years) from the UK Trauma Audit and Research Network (TARN) registry (January 2008-December 2017) served as surrogates for MI victims, with P1 patients identified using predefined criteria. The TARN database was split chronologically into model training and testing (70:30) datasets. Input variables included physiological parameters, age, mechanism and anatomical location of injury. Random forest, extreme gradient boosted tree, logistic regression and decision tree models were trained to predict P1 status, and compared with existing tools (Battlefield Casualty Drills (BCD) Triage Sieve, CareFlight, Modified Physiological Triage Tool, MPTT-24, MSTART, National Ambulance Resilience Unit Triage Sieve and RAMP). Primary and secondary candidate models were selected; the latter was externally validated on patients from the UK military's Joint Theatre Trauma Registry (JTTR). RESULTS Models were internally tested in 57 979 TARN patients. The best existing tool was the BCD Triage Sieve (sensitivity 68.2%, area under the receiver operating curve (AUC) 0.688). Inability to breathe spontaneously, presence of chest injury and mental status were most predictive of P1 status. A decision tree model including these three variables exhibited the best test characteristics (sensitivity 73.0%, AUC 0.782), forming the candidate primary tool. The proposed secondary tool (sensitivity 77.9%, AUC 0.817), applicable via a portable device, includes a fourth variable (injury mechanism). This performed favourably on external validation (sensitivity of 97.6%, AUC 0.778) in 5956 JTTR patients. CONCLUSION Novel triage tools developed using ML outperform existing tools in a nationally representative trauma population. The proposed primary tool requires external validation prior to consideration for practical use. The secondary tool demonstrates good external validity and may be used to support decision-making by healthcare workers responding to MIs.
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Affiliation(s)
- Yuanwei Xu
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Science Centre, University of Birmingham, Birmingham B15 2TT, UK
| | - Nabeela Malik
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Saisakul Chernbumroong
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
| | - James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Damian Keene
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Mark Foster
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Janet Lord
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Douglas Bowley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - George Gkoutos
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Science Centre, University of Birmingham, Birmingham B15 2TT, UK
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- MRC Health Data Research UK (HDR UK), Birmingham, UK
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Madar H, Deneux-Tharaux C, Sentilhes L. Shock index as a predictor of postpartum haemorrhage after vaginal delivery: Secondary analysis of a multicentre randomised controlled trial. BJOG 2024; 131:343-352. [PMID: 37555480 DOI: 10.1111/1471-0528.17634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 06/09/2023] [Accepted: 07/22/2023] [Indexed: 08/10/2023]
Abstract
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.
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Affiliation(s)
- Hugo Madar
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
| | - Catherine Deneux-Tharaux
- Université Paris Cité, Women's Health IHM, U1153, Centre of Research In Epidemiology and Statistics, Obstetrical, Perinatal and Paediatric Epidemiology EPOPé Research Team, INSERM, INRAE, Paris, France
| | - Loïc Sentilhes
- Department of Obstetrics and Gynaecology, Bordeaux University Hospital, Bordeaux, France
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Salman S, Laeeque O, Jawaid B, Khalid OB, Shahab H, Faheem K. Pulse Pressure: A Predictor of Intervention in Blunt Abdominal Trauma. Cureus 2023; 15:e41305. [PMID: 37539430 PMCID: PMC10394963 DOI: 10.7759/cureus.41305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/02/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Patients with life-threatening hemorrhages due to blunt torso trauma are at a particularly high risk of being underdiagnosed. The pulse pressure (PP) starts narrowing down before the traditional parameters start changing, making it a useful tool for assessing and planning early intervention. OBJECTIVE To assess the utility of low PP in predicting massive transfusion (MT) or operative intervention in patients with isolated blunt abdominal trauma. MATERIAL AND METHODS A total of 186 patients were included. The PP and mean arterial pressure (MAP) were calculated. Vitals, PP, and MAP were monitored every 15 min during the first 6 h, then every 30 min during the next 6 h, and afterward, every 4 h until discharge. A Chi-square test and an independent t-test (as appropriate) were applied to compare variables with PP at the time of presentation. Differences were considered statistically significant at p-value ≤ 0.05. RESULTS A total of 55.9% of these patients had injuries due to road traffic accidents (RTA). Emergency operative intervention was provided to 26.3% of the patients. Death was 4.3%. MT was required by 26.3% of the patients. There was a statistically significant association between low PP and sex, length of stay, repeat extended focused assessment with sonography in trauma (eFAST), emergency operational intervention, outcome, MT, number of crystalloids consumed within the first four hours after presentation, injury severity score, systolic blood pressure (SBP), and pulse rate. CONCLUSION The PP <30 mmHg was observed as a useful predictor for increased blood loss requiring blood transfusion or operative intervention.
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Affiliation(s)
- Sumbla Salman
- General Surgery, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Osama Laeeque
- Orthopaedics and Traumatology, Liaquat National Hospital, Karachi, PAK
| | - Bushra Jawaid
- Surgery, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Omer B Khalid
- Surgery, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Hassan Shahab
- Surgery, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
| | - Komal Faheem
- Surgery, Dow University of Health Sciences, Civil Hospital Karachi, Karachi, PAK
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Prediction of pre-hospital blood transfusion in trauma patients based on scoring systems. BMC Emerg Med 2023; 23:2. [PMID: 36635632 PMCID: PMC9835327 DOI: 10.1186/s12873-022-00770-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 12/27/2022] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Pre-hospital blood transfusion (PHBT) is a safe and gradually expanding procedure applied to trauma patients. A proper decision to activate PHBT with the presently limited diagnostic options at the site of an incident poses a challenge for pre-hospital crews. The purpose of this study was to compare the selected scoring systems and to determine whether they can be used as valid tools in identifying patients with PHBT requirements. METHODS A retrospective single-center study was conducted between June 2018 and December 2020. Overall, 385 patients (aged [median; IQR]: 44; 24-60; 73% males) were included in this study. The values of five selected scoring systems were calculated in all patients. To determine the accuracy of each score for the prediction of PHBT, the Receiver Operating Characteristic (ROC) analysis was used and to measure the association, the odds ratio with 95% confidence intervals was counted (Fig. 1). RESULTS Regarding the proper indication of PHBT, shock index (SI) and pulse pressure (PP) revealed the highest value of AUC and sensitivity/specificity ratio (SI: AUC 0.88; 95% CI 0.82-0.93; PP: AUC 0.85 with 95% CI 0.79-0.91). CONCLUSION Shock index and pulse pressure are suitable tools for predicting PHBT in trauma patients.
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Campos-Serra A, Mesquida J, Montmany-Vioque S, Rebasa-Cladera P, Barquero-Lopez M, Cidoncha-Secilla A, Llorach-Perucho N, Morales-Codina M, Puyana JC, Navarro-Soto S. Alterations in tissue oxygen saturation measured by near-infrared spectroscopy in trauma patients after initial resuscitation are associated with occult shock. Eur J Trauma Emerg Surg 2023; 49:307-315. [PMID: 36053289 PMCID: PMC9925470 DOI: 10.1007/s00068-022-02068-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 07/16/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Persistent occult hypoperfusion after initial resuscitation is strongly associated with increased morbidity and mortality after severe trauma. The objective of this study was to analyze regional tissue oxygenation, along with other global markers, as potential detectors of occult shock in otherwise hemodynamically stable trauma patients. METHODS Trauma patients undergoing active resuscitation were evaluated 8 h after hospital admission with the measurement of several global and local hemodynamic/metabolic parameters. Apparently hemodynamically stable (AHD) patients, defined as having SBP ≥ 90 mmHg, HR < 100 bpm and no vasopressor support, were followed for 48 h, and finally classified according to the need for further treatment for persistent bleeding (defined as requiring additional red blood cell transfusion), initiation of vasopressors and/or bleeding control with surgery and/or angioembolization. Patients were labeled as "Occult shock" (OS) if they required any intervention or "Truly hemodynamically stable" (THD) if they did not. Regional tissue oxygenation (rSO2) was measured non-invasively by near-infrared spectroscopy (NIRS) on the forearm. A vascular occlusion test was performed, allowing a 3-min deoxygenation period and a reoxygenation period following occlusion release. Minimal rSO2 (rSO2min), Delta-down (rSO2-rSO2min), maximal rSO2 following cuff-release (rSO2max), and Delta-up (rSO2max-rSO2min) were computed. The NIRS response to the occlusion test was also measured in a control group of healthy volunteers. RESULTS Sixty-six consecutive trauma patients were included. After 8 h, 17 patients were classified as AHD, of whom five were finally considered to have OS and 12 THD. No hemodynamic, metabolic or coagulopathic differences were observed between the two groups, while NIRS-derived parameters showed statistically significant differences in Delta-down, rSO2min, and Delta-up. CONCLUSIONS After 8 h of care, NIRS evaluation with an occlusion test is helpful for identifying occult shock in apparently hemodynamically stable patients. LEVEL OF EVIDENCE IV, descriptive observational study. TRIAL REGISTRATION ClinicalTrials.gov Registration Number: NCT02772653.
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Affiliation(s)
- Andrea Campos-Serra
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208, Sabadell (Barcelona), Spain.
| | - Jaume Mesquida
- Critical Care Department, Parc Taulí Hospital Universitari, Sabadell, Spain
| | - Sandra Montmany-Vioque
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | - Pere Rebasa-Cladera
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | | | - Ariadna Cidoncha-Secilla
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | - Núria Llorach-Perucho
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
| | | | | | - Salvador Navarro-Soto
- Department of Surgery, Universitat Autònoma de Barcelona, Parc Taulí Hospital Universitari, Parc del Taulí 1, 08208 Sabadell (Barcelona), Spain
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Frieler S, Lefering R, Gerstmeyer J, Drotleff N, Schildhauer TA, Waydhas C, Hamsen U. Keeping it simple: the value of mortality prediction after trauma with basic indices like the Reverse Shock Index multiplied by Glasgow Coma Scale. Emerg Med J 2022; 39:912-917. [PMID: 35676070 DOI: 10.1136/emermed-2020-211091] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Identification of trauma patients at significant risk of death in the prehospital setting is challenging. The prediction probability of basic indices like vital signs, Shock Index (SI), SI multiplied by age (SIA) or the GCS is limited and more complex scores are not feasible on-scene. The Reverse SI multiplied by GCS score (rSIG) has been proposed as a triage tool to identify trauma patients with an increased risk of dying at EDs. Age adjustment (rSIG/A) displayed no advantage.We aim to (1) validate the accuracy of the rSIG in predicting death or early transfusion in a large trauma registry population, and (2) determine if the rSIG is valid for evaluation of trauma patients in the prehospital setting. METHODS 70 829 trauma patients were retrieved from the TraumaRegister DGU database (time period between 2008 and 2017). The area under the receiver operating characteristic curve (AUROC) was calculated to measure the ability of SI, SIA, rSIG and rSIG divided by age (rSIG/A) to predict in-hospital mortality from data at the time of hospital arrival and solely from prehospital data. RESULTS The rSIG at time of hospital admission was not sufficiently predictive for clinical decision-making. However, rSIG calculated solely from prehospital data accurately predicted risk of death. Using prehospital data, the AUROC for mortality of rSIG/A was the highest (0.85; CI: 0.85 to 0.86), followed by rSIG (0.76; CI: 0.75 to 0.77), SIA (0.71; CI: 0.70 to 0.71) and SI (0.48; CI: 0.47 to 0.49). CONCLUSION The prehospital rSIG/A can be a useful adjunct for the prehospital evaluation of trauma patients and their allocation to trauma centres or trauma team activation. However, we could not confirm that the rSIG at hospital admission is a reliable tool for risk stratification.
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Affiliation(s)
- Sven Frieler
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Julius Gerstmeyer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Niklas Drotleff
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Christian Waydhas
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
- Medical Faculty University Duisburg-Essen, Essen, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Chiang CY, Lin CF, Liu PH, Chen FC, Chiu IM, Cheng FJ. Clinical Validation of the Shock Index, Modified Shock Index, Delta Shock Index, and Shock Index-C for Emergency Department ST-Segment Elevation Myocardial Infarction. J Clin Med 2022; 11:jcm11195839. [PMID: 36233705 PMCID: PMC9573755 DOI: 10.3390/jcm11195839] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 09/23/2022] [Accepted: 09/29/2022] [Indexed: 11/06/2022] Open
Abstract
Background: ST-segment elevation myocardial infarction (STEMI) is a leading cause of death worldwide. A shock index (SI), modified SI (MSI), delta-SI, and shock index-C (SIC) are known predictors of STEMI. This retrospective cohort study was designed to compare the predictive value of the SI, MSI, delta-SI, and SIC with thrombolysis in myocardial infarction (TIMI) risk scales. Method: Patients > 20 years old with STEMI who underwent percutaneous coronary intervention (PCI) were included. Receiver operating characteristic (ROC) curve analysis with the Youden index was performed to calculate the optimal cutoff values for these predictors. Results: Overall, 1552 adult STEMI cases were analyzed. The thresholds for the emergency department (ED) SI, MSI, SIC, and TIMI risk scales for in-hospital mortality were 0.75, 0.97, 21.00, and 5.5, respectively. Accordingly, ED SIC had better predictive power than the ED SI and ED MSI. The predictive power was relatively higher than TIMI risk scales, but the difference did not achieve statistical significance. After adjusting for confounding factors, the ED SI > 0.75, MSI > 0.97, SIC > 21.0, and TIMI risk scales > 5.5 were statistically and significantly associated with in-hospital mortality of STEMI. Compared with the ED SI and MSI, SIC (>21.0) had better sensitivity (67.2%, 95% CI, 58.6−75.9%), specificity (83.5%, 95% CI, 81.6−85.4%), PPV (24.8%, 95% CI, 20.2−29.6%), and NPV (96.9%, 95% CI, 96.0−97.9%) for in-hospital mortality of STEMI. Conclusions: SIC had better discrimination ability than the SI, MSI, and delta-SI. Compared with the TIMI risk scales, the ACU value of SIC was still higher. Therefore, SIC might be a convenient and rapid tool for predicting the outcome of STEMI.
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Affiliation(s)
- Charng-Yen Chiang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Chien-Fu Lin
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Peng-Huei Liu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Taoyuan 33302, Taiwan
| | - Fu-Cheng Chen
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
| | - Fu-Jen Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, College of Medicine, Chang Gung University, Kaohsiung 833, Taiwan
- Correspondence: ; Tel.: +886-975-056-646
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Lee GH, Choi JW. Initial assessment of hemorrhagic shock by trauma computed tomography measurement of the inferior vena cava in blunt trauma patients. JOURNAL OF TRAUMA AND INJURY 2022. [DOI: 10.20408/jti.2021.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Purpose: Inferior vena cava (IVC) collapse is related to hypovolemia. Sonography has been used to measure the IVC diameter, but there is variation depending on the skill of the operator and it is difficult to obtain accurate measurements in patients who have a large amount of intestinal gas or are obese. As a modality to obtain accurate measurements, we measured the diameters of the IVC and aorta on trauma computed tomography scans and investigated the correlation between the IVC to aorta ratio and the shock index in blunt trauma patients.Methods: We retrospectively analyzed the medical records of 588 trauma patients who were transferred to the regional trauma center (level 1) of Wonkang University hospital from March 2020 to February 2021. We included trauma patients 18 years or older who met the trauma activation criteria and underwent trauma computed tomography scans with intravenous contrast within 40 minutes of admission. The shock index was calculated from vital signs before trauma computed tomography scan, and measurements of the anteroposterior diameter of the IVC (AP), the transverse diameter of the IVC (T), and aorta were made 10 mm above the right renal vein in the venous phase.Results: Overall, 271 patients were included in this study, of whom 150 had a shock index ≤0.7 and 121 had a shock index >0.7. The T to AP ratio and AP to aorta ratio were significantly different between groups. Cutoffs were identified for the T to AP ratio and AP to aorta ratio (2.37 and 0.62, respectively) that produced clinically useful sensitivity and specificity for predicting a shock index >0.7, demonstrating moderate accuracy (T to AP ratio: area under the curve, 0.71; sensitivity, 59%; specificity, 87% and AP to aorta ratio: area under the curve, 0.70; sensitivity, 55%; specificity, 91%).Conclusions: The T to AP ratio and AP to aorta ratio are useful for predicting hemorrhagic shock in trauma patients.
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10
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Xu F, Zhang L, Huang T, Han D, Yang R, Zheng S, Feng A, Huang L, Yin H, Lyu J. Effects of growth trajectory of shock index within 24 h on the prognosis of patients with sepsis. Front Med (Lausanne) 2022; 9:898424. [PMID: 36072946 PMCID: PMC9441919 DOI: 10.3389/fmed.2022.898424] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/02/2022] [Indexed: 01/09/2023] Open
Abstract
BackgroundSepsis is a serious disease with high clinical morbidity and mortality. Despite the tremendous advances in medicine and nursing, treatment of sepsis remains a huge challenge. Our purpose was to explore the effects of shock index (SI) trajectory changes on the prognosis of patients within 24 h after the diagnosis of sepsis.MethodsThis study was based on Medical Information Mart for Intensive Care IV (MIMIC- IV). The effects of SI on the prognosis of patients with sepsis were investigated using C-index and restricted cubic spline (RCS). The trajectory of SI in 24 h after sepsis diagnosis was classified by latent growth mixture modeling (LGMM). Cox proportional hazard model, double robust analysis, and subgroup analysis were conducted to investigate the influence of SI trajectory on in-hospital death and secondary outcomes.ResultsA total of 19,869 patients were eventually enrolled in this study. C-index showed that SI had a prognostic value independent of Sequential Organ Failure Assessment for patients with sepsis. Moreover, the results of RCS showed that SI was a prognostic risk factor. LGMM divided SI trajectory into seven classes, and patients with sepsis in different classes had notable differences in prognosis. Compared with the SI continuously at a low level of 0.6, the SI continued to be at a level higher than 1.0, and the patients in the class whose initial SI was at a high level of 1.2 and then declined had a worse prognosis. Furthermore, the trajectory of SI had a higher prognostic value than the initial SI.ConclusionBoth initial SI and trajectory of SI were found to be independent factors that affect the prognosis of patients with sepsis. Therefore, in clinical treatment, we should closely monitor the basic vital signs of patients and arrive at appropriate clinical decisions on basis of their change trajectory.
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Affiliation(s)
- Fengshuo Xu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Nosocomial Infection Management, Luoyang Orthopedic-Traumatological Hospital, Orthopedics Hospital of Henan Province, Zhengzhou, China
- School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Luming Zhang
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Didi Han
- School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Rui Yang
- School of Public Health, Xi’an Jiaotong University Health Science Center, Xi’an, China
| | - Shuai Zheng
- School of Public Health, Shaanxi University of Chinese Medicine, Xianyang, China
| | - Aozi Feng
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Liying Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Haiyan Yin
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Haiyan Yin,
| | - Jun Lyu
- Department of Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, China
- Guangdong Provincial Key Laboratory of Traditional Chinese Medicine Informatization, Guangzhou, China
- *Correspondence: Jun Lyu,
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11
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Puzio TJ, Meyer DE, Heft N, Nealy W, Osborn L. Continuum of care: a multiagency approach to seamless warmed prehospital whole blood resuscitation of a patient with noncompressible truncal hemorrhage. PREHOSP EMERG CARE 2022:1-4. [PMID: 35867107 DOI: 10.1080/10903127.2022.2104976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BackgroundPrehospital transfusion capabilities vary widely in the United States. Here we describe a case of prehospital resuscitation using warmed, whole blood in a patient with penetrating torso trauma and associated hemorrhagic shock.Case ReportA 68-year-old man sustained a single gunshot wound to the left chest and was found to have a shock index of 1.5 at the time of emergency medical services (EMS) arrival. Rapid peripheral intravenous and central venous access enabled the infusion of warmed low-titer O-positive whole blood. The EMS crew intentionally resuscitated the patient before managing the airway by means of rapid sequence intubation. An air medical services helicopter crew assumed patient care from the ground EMS crew and continued the warmed, whole blood transfusion during the flight to a regional Level 1 trauma center. The patient went directly to the operating room from the helipad, underwent definitive operative management, and was ultimately discharged home on hospital day nine.ConclusionEarly recognition of hemorrhagic shock, implementation of prehospital transfusion protocols that emphasize transfusion of warmed blood without interruption, and an organized, regional approach to trauma care are critical for improving patient survival.
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12
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Jost D, Lemoine S, Lemoine F, Derkenne C, Beaume S, Lanoë V, Maurin O, Louis-Delaurière E, Delacote M, Dang-Minh P, Franchin-Frattini M, Bihannic R, Savary D, Levrat A, Baudouin C, Trichereau J, Salomé M, Frattini B, Ha VHT, Jouffroy R, Seguineau E, Titreville R, Roquet F, Stibbe O, Vivien B, Verret C, Bignand M, Travers S, Martinaud C, Arock M, Raux M, Prunet B, Ausset S, Sailliol A, Tourtier JP. Prehospital Lyophilized Plasma Transfusion for Trauma-Induced Coagulopathy in Patients at Risk for Hemorrhagic Shock: A Randomized Clinical Trial. JAMA Netw Open 2022; 5:e2223619. [PMID: 35881397 PMCID: PMC9327575 DOI: 10.1001/jamanetworkopen.2022.23619] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
IMPORTANCE Blood transfusion is a mainstay of therapy for trauma-induced coagulopathy, but the optimal modalities for plasma transfusion in the prehospital setting remain to be defined. OBJECTIVE To determine whether lyophilized plasma transfusion can reduce the incidence of trauma-induced coagulopathy compared with standard care consisting of normal saline infusion. DESIGN, SETTING, AND PARTICIPANTS This randomized clinical trial was performed at multiple centers in France involving prehospital medical teams. Participants included 150 adults with trauma who were at risk for hemorrhagic shock and associated coagulopathy between April 1, 2016, and September 30, 2019, with a 28-day follow-up. Data were analyzed from November 1, 2019, to July 1, 2020. INTERVENTION Patients were randomized in a 1:1 ratio to receive either plasma or standard care with normal saline infusion (control). MAIN OUTCOMES AND MEASURES The primary outcome was the international normalized ratio (INR) on arrival at the hospital. Secondary outcomes included the need for massive transfusion and 30-day survival. As a safety outcome, prespecified adverse events included thrombosis, transfusion-related acute lung injury, and transfusion-associated circulatory overload. RESULTS Among 150 randomized patients, 134 were included in the analysis (median age, 34 [IQR, 26-49] years; 110 men [82.1%]), with 68 in the plasma group and 66 in the control group. Median INR values were 1.21 (IQR, 1.12-1.49) in the plasma group and 1.20 (IQR, 1.10-1.39) in the control group (median difference, -0.01 [IQR, -0.09 to 0.08]; P = .88). The groups did not differ significantly in the need for massive transfusion (7 [10.3%] vs 4 [6.1%]; relative risk, 1.78 [95% CI, 0.42-8.68]; P = .37) or 30-day survival (hazard ratio for death, 1.07 [95% CI, 0.44-2.61]; P = .89). In the full intention-to-treat population (n = 150), the groups did not differ in the rates of any of the prespecified adverse events. CONCLUSIONS AND RELEVANCE In this randomized clinical trial including severely injured patients at risk for hemorrhagic shock and associated coagulopathy, prehospital transfusion of lyophilized plasma was not associated with significant differences in INR values vs standard care with normal saline infusion. Nevertheless, these findings show that lyophilized plasma transfusion is a feasible and safe procedure for this patient population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02736812.
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | | | | | - Vincent Lanoë
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Emilie Louis-Delaurière
- Direction de la Formation, de la Recherche et de l’Innovation, Service de Santé des Armées, Paris, France
| | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | | | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Dominique Savary
- Emergency Department, Angers University Hospital, Angers, France
- Research Institute for Environmental and Occupational Health–Unité Mixte de Recherche (UMR)_S 1085, France Emergency Department, Angers University Hospital, Angers, France
| | - Albrice Levrat
- Department of Intensive Care, Annecy Hospital, Annecy, France
| | - Clémence Baudouin
- Service Mobile d’Urgence et de Réanimation de Paris, Hôpital Lariboisière, Assistance Publique–Hôpitaux de Paris (AP-HP) and Université de Paris, Paris, France
| | | | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Intensive Care Unit, Ambroise Paré Hospital, AP-HP and Paris Saclay University, Boulogne Billancourt, France
| | | | - Rudy Titreville
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Service d’Anesthésie-Réanimation, Hôpital Européen Georges-Pompidou, AP-HP, Paris, France
- Service de Biostatistique et Informatique Médicale, Unité Institut National de la Santé et de la Recherche Médicale, UMR 1153, Université Paris Diderot, Paris, France
| | - Olivier Stibbe
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Benoit Vivien
- Service d’Aide Médicale Urgente de Paris, Hôpital Necker-Enfants Malades, AP-HP and Université de Paris, Paris, France
| | - Catherine Verret
- Direction de la Formation, de la Recherche et de l’Innovation, Service de Santé des Armées, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | | | - Christophe Martinaud
- Department of Clinical Operations, French Military Blood Institute, Clamart, France
| | - Michel Arock
- Laboratory of Hematology, Pitié-Salpêtrière Hospital, Paris, France
| | - Mathieu Raux
- Département d’Anesthésie Réanimation, AP-HP Groupe Hospitalier Universitaire, AP-HP–Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, Paris, France
| | - Sylvain Ausset
- Department of Anesthesiology and Intensive Care, Percy Military Teaching Hospital, Clamart, France
| | - Anne Sailliol
- Department of Clinical Operations, French Military Blood Institute, Clamart, France
| | - Jean-Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, Paris, France
- Department of Anesthesiology and Intensive Care, Bégin Military Teaching Hospital, Saint-Mandé, France
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Hashemian AM, Baghshani Z, Farzaneh R, Zamani Moghadam H, Maleki F, Bagherian F, Ahmadnezhad S, Foroughian M. Comparison of the Relationship Between SI and RASI Scores With the Outcome of Sepsis Patients. Front Med (Lausanne) 2022; 9:872725. [PMID: 35847795 PMCID: PMC9281559 DOI: 10.3389/fmed.2022.872725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 05/09/2022] [Indexed: 12/21/2022] Open
Abstract
The aim of this study was to compare the relationship between shock index (SI) and respiratory adjusted shock index (RASI) scores with the final outcome of sepsis patients referred to the emergency department. This was prospective research that examined individuals who had been diagnosed with sepsis, determined by the presence of at least two of the three quick sepsis-related organ failure assessment (qSOFA) criteria and the presence of an infectious disease based on a diagnosis made by a hospital physician of Imam Reza and Ghaemshahr of Mashhad in 2019. Demographic information of patients, SI score, RASI score, and information related to the patient's clinical symptoms were recorded in the checklist. The final outcome of this study was considered mortality. Data analysis was performed using descriptive and inferential tests. In the present study, a total of 178 patients, 46 patients (25.8%) were transferred to the intensive care unit, and 98 patients (55.1%) were admitted to the normal wards. Eighty-five patients (47.75%) died and the mean length of hospital stay of all patients was 11.07 ± 9.23 days. Forty-four patients (24.7%) had referred with a decreased level of consciousness and 44 patients (24.7%) presented with confusion. The rest of the patients reported normal levels of consciousness. Kaplan Mir analysis with log-rank was performed to determine the difference in survival distribution in different SI groups: Survival distribution was not statistically different for the four defined groups (based on statistical quartiles (P = 0.320). Receiver operator curves were considered as the date of death in the case of the deceased and the date of discharge from the hospital in the case of the living as censored. The AUC of the RASI scoring system for predicting mortality was 0.614 (P = 0.009) while this value was not significant for SI (P = 0.152). In logistic regression analysis, it was found that by adjusting for the variables of age, sex, sepsis etiology, blood pressure and heart rate, level of consciousness, and gender, patients with the lower respiratory rate (OR 1.6, z = −0.159 p = 0.007), younger age (OR 1.6, z = −0.029 p = 0.006) and higher RASI score are more in risk of mortality (OR 1.29, z = 1.209, p = 0.031). The results of our study showed that RASI scoring can be a good criterion for predicting the chance of mortality in patients with sepsis and could be used complementary to previous criteria such as SI. Patients with high RASI scores should be given more attention to reducing the chance of death.
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Affiliation(s)
- Amir Masoud Hashemian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Zahra Baghshani
- Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Roohie Farzaneh
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Hamid Zamani Moghadam
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Fatemeh Maleki
- Department of Emergency Medicine, Faculty of Medicine, Birjand University of Medical Sciences, Birjand, Iran
| | - Farhad Bagherian
- Department of Emergency Medicine, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran
| | - Somayyeh Ahmadnezhad
- Department of Emergency Medicine, Faculty of Medicine, Mazandaran University of Medical Sciences, Sari, Iran
| | - Mahdi Foroughian
- Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
- *Correspondence: Mahdi Foroughian
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14
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Hashmi ZG, Jansen JO, Kerby JD, Holcomb JB. Nationwide estimates of the need for prehospital blood products after injury. Transfusion 2022; 62 Suppl 1:S203-S210. [PMID: 35753065 DOI: 10.1111/trf.16991] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/17/2022] [Accepted: 05/24/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Prehospital blood product resuscitation after injury significantly decreases risk of mortality. However, the number of patients who may potentially benefit from this life-saving intervention is currently unknown. The primary objective of this study was to estimate the number of patients who may potentially benefit from prehospital blood product resuscitation after injury in the United States. The secondary objective was to estimate the amount of blood products needed for prehospital resuscitation of injured patients. METHODS Patients ≥16 years with blunt/penetrating injuries included in National Emergency Medical Services Information System 2019 were identified and classified into four separate cohorts of hemodynamic instability: Cohort 1 (systolic blood pressure [SBP] <90 mmHg), Cohort 2 (SBP <90 and/or heart rate [HR] >120), Cohort 3 (SBP <90 and HR >108 or SBP <70), and Cohort 4 (shock index ≥1). The need for prehospital blood was estimated by multiplying number of patients in each cohort with average number of blood products used for prehospital resuscitation. RESULTS After exclusions, 3.7 million adult trauma patients were included. The number of patients who may potentially benefit from prehospital blood products was estimated as 89,391 (Cohort 1), 901,346 (Cohort 2), 54,160 (Cohort 3), and 300,475 (Cohort 4). Assuming 1 unit of whole blood is needed per patient, a lower-bound estimate of 54,160 additional whole blood units (0.6% of current collections) will be need for prehospital resuscitation of the injured. CONCLUSIONS Annually, between 54,000 and 900,000 patients may potentially benefit from prehospital blood product resuscitation after injury in the United States. Prehospital blood utilization and collection of blood products will need to be increased to scale-up this life-saving intervention nationwide.
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Affiliation(s)
- Zain G Hashmi
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jan O Jansen
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jeffrey D Kerby
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - John B Holcomb
- Center for Injury Science, University of Alabama at Birmingham, Birmingham, Alabama, USA.,Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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15
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McCormick T, Haukoos J, Hopkins E, Trent S, Adelgais K, Platnick B, Cohen M. Predictive accuracy of adding shock index to the American College of Surgeons' minimum criteria for full trauma team activation. Acad Emerg Med 2022; 29:561-571. [PMID: 35138668 DOI: 10.1111/acem.14459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 02/04/2022] [Accepted: 02/07/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND The American College of Surgeons requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation: hypotension, gunshot wound to the neck or torso, Glasgow Coma Scale (GCS) score < 9, respiratory compromise, transfers receiving blood transfusion, or physician discretion. Our goal was to evaluate the effect of adding varying shock index (SI) thresholds to the ACS-6 in an adult trauma population with the hypothesis that SI would significantly improve sensitivity at the expense of an acceptable decrease in specificity. METHODS We performed a secondary analysis of EMS and trauma registry data from an urban Level I trauma center. Consecutive patients > 15 years of age were included from 1993 through 2006. SI at thresholds of ≥0.8, ≥0.85, ≥0.9, and ≥1 were evaluated. Primary outcome was emergency operative (within 1 h of arrival) or procedural (cricothyrotomy or thoracotomy) intervention (EOPI); secondary outcomes were Injury Severity Score (ISS) > 15, ISS > 24, a composite of EOPI or ISS > 15, and urgent operative intervention (within 4 h). RESULTS A total of 20,872 patients were included, 27% with an ISS > 15 and 5% who underwent EOPI. Sensitivity and specificity of the ACS-6 alone for EOPI were 86% (95% confidence interval [CI] = 84% to 88%) and 81% (95% CI = 80% to 81%), respectively. Inclusion of SI thresholds of 0.8, 0.85, 0.9, and 1 resulted in sensitivities of 95% (95% CI = 93% to 96%), 93% (CI = 91% to 94%), 92% (95% CI = 90% to 93%), and 90% (95% CI = 88% to 92%), respectively, and specificities of 52% (95% CI = 51% to 52%), 59% (95% CI = 58% to 59%), 64% (95% CI = 64% to 65%), and 72% (95% CI = 71% to 73%), respectively. Similar trends were found for each secondary outcome. CONCLUSION The addition of SI to the ACS-6 for trauma team activation increased sensitivity for EOPI with a larger decrease in specificity across all thresholds. Inclusion of a SI threshold of ≥0.9 closely aligns with under- and overtriage benchmarks in this trauma registry cohort using a strict definition of trauma team activation need.
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Affiliation(s)
- Taylor McCormick
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Jason Haukoos
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
- Department of Epidemiology Colorado School of Public Health Aurora Colorado USA
| | - Emily Hopkins
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Stacy Trent
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Kathleen Adelgais
- Section of Emergency Medicine Children's Hospital Colorado Aurora Colorado USA
| | - Barry Platnick
- Department of Surgery Denver Health Medical Center Denver Colorado USA
- Department of Surgery University of Colorado School of Medicine Denver Colorado USA
| | - Mitchell Cohen
- Department of Surgery Denver Health Medical Center Denver Colorado USA
- Department of Surgery University of Colorado School of Medicine Denver Colorado USA
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16
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Vang M, Østberg M, Steinmetz J, Rasmussen LS. Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:2559-2566. [PMID: 35258641 DOI: 10.1007/s00068-022-01932-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1. METHODS This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa. RESULTS We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low. CONCLUSIONS This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.
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Affiliation(s)
- Malene Vang
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Maria Østberg
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Danish Air Ambulance, Aarhus, Denmark
| | - Lars S Rasmussen
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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17
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Escobar MF, Nassar AH, Theron G, Barnea ER, Nicholson W, Ramasauskaite D, Lloyd I, Chandraharan E, Miller S, Burke T, Ossanan G, Andres Carvajal J, Ramos I, Hincapie MA, Loaiza S, Nasner D. FIGO recommendations on the management of postpartum hemorrhage 2022. Int J Gynaecol Obstet 2022; 157 Suppl 1:3-50. [PMID: 35297039 PMCID: PMC9313855 DOI: 10.1002/ijgo.14116] [Citation(s) in RCA: 79] [Impact Index Per Article: 39.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Maria Fernanda Escobar
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Anwar H Nassar
- Department of Obstetrics and Gynecology, American University of Beirut Medical Center, Beirut, Lebanon
| | - Gerhard Theron
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa.,Tygerberg Hospital, Cape Town, South Africa
| | - Eythan R Barnea
- Society for Investigation or Early Pregnancy (SIEP), New York, New York, USA
| | - Wanda Nicholson
- Department of Obstetrics and Gynecology, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Diana Ramasauskaite
- Center of Obstetrics and Gynecology, Vilnius University Medical Faculty, Vilnius, Lithuania
| | - Isabel Lloyd
- Department of Obstetrics and Gynecology, Universidad de Panamá, Panama City, Panamá.,Hospital Santo Tomas, Panama City, Panamá
| | - Edwin Chandraharan
- Department of Obstetrics and Gynecology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Suellen Miller
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, California, USA
| | - Thomas Burke
- Division of Global Health and Human Rights, Massachusetts General Hospital, Department of Emergency Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Harvard T.H. Chan School of Public Health, Boston, USA
| | - Gabriel Ossanan
- Department of Obstetrics and Gynecology, Federal University of Minas Gerais, Belo Horizonte, Brazil
| | - Javier Andres Carvajal
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Isabella Ramos
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Maria Antonia Hincapie
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Sara Loaiza
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
| | - Daniela Nasner
- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia.,Department of Obstetrics and Gynecology, School of Medicine, Universidad Icesi, Cali, Colombia
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- Obstetric High Complexity Unit, Fundación Valle del Lili, Cali, Colombia
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Chowdhury S, Parameaswari PJ, Leenen L. Outcomes of Trauma Patients Present to the Emergency Department with a Shock Index of ≥1.0. J Emerg Trauma Shock 2022; 15:17-22. [PMID: 35431481 PMCID: PMC9006726 DOI: 10.4103/jets.jets_86_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 11/11/2021] [Accepted: 11/23/2021] [Indexed: 11/04/2022] Open
Abstract
Introduction The study aimed primarily to evaluate the association between the initial shock index (SI) ≥1.0 with blood transfusion requirement in the emergency department (ED) after acute trauma. The study's secondary aim was to look at the outcomes regarding patients' disposition from ED, intensive care unit (ICU) and hospital length of stay, and deaths. Methods It was a retrospective, cross-sectional study and utilized secondary data from the Saudi Trauma Registry (STAR) between September 2017 and August 2020. We extracted the data related to patient demographics, mechanism of injuries, the intent of injuries, mode of arrival at the hospital, characteristics on presentation to ED, length of stay, and deaths from the database and compared between two groups of SI <1.0 and SI ≥1.0. A P < 0.05 was statistically considered significant. Results Of 6667 patients in STAR, 908 (13.6%) had SI ≥1.0. With SI ≥1.0, there was a significantly higher incidence of blood transfusion in ED compared to SI <1.0 (8.9% vs. 2.4%, P < 0.001). Furthermore, SI ≥ 1.0 was associated with significant ICU admission (26.4% vs. 12.3%, P < 0.001), emergency surgical intervention (8.5% vs. 2.8%, P < 0.001), longer ICU stay (5.0 ± 0.36 vs. 2.2 ± 0.11days, P < 0.001), longer hospital stays (14.8 ± 0.61 vs. 13.3 ± 0.24 days, P < 0.001), and higher deaths (8.4% vs. 2.8%, P < 0.001) compared to the patient with SI <1.0. Conclusions In our cohort, a SI ≥ 1.0 on the presentation at the ED carried significantly worse outcomes. This simple calculation based on initial vital signs may be used as a screening tool and therefore incorporated into initial assessment protocols to manage trauma patients.
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Affiliation(s)
| | - P J Parameaswari
- Research and Innovation Center, King Saud Medical City, Riyadh, Saudi Arabia
| | - Luke Leenen
- Department of Trauma, University Medical Center Utrecht, Utrecht, Netherlands
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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. Afr J Emerg Med 2021; 11:453-458. [PMID: 34765431 PMCID: PMC8567159 DOI: 10.1016/j.afjem.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Revised: 03/10/2021] [Accepted: 09/16/2021] [Indexed: 01/08/2023] Open
Abstract
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.
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20
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Machine Learning for Military Trauma: Novel Massive Transfusion Predictive Models in Combat Zones. J Surg Res 2021; 270:369-375. [PMID: 34736129 DOI: 10.1016/j.jss.2021.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 09/01/2021] [Accepted: 09/21/2021] [Indexed: 11/21/2022]
Abstract
BACKGROUND Damage control resuscitation has become the standard of care in military and civilian trauma. Early identification of blood product requirements may aid in optimizing the clinical decision-making process while improving trauma related outcomes. This study aimed to assess and compare multiple machine learning models for predicting patients at highest risk for massive transfusion on the battlefield. METHODS Supervised machine learning approaches using logistic regression, support vector machine, neural network, and random forest techniques were used to create predictive models for massive transfusion using standard prehospital and arrival data points from the Department of Defense Trauma Registry, 2008-2016. Seventy percent of the population was used for model development and performance was validated using the remaining 30%. Models were tested for accuracy and compared by standard performance statistics. RESULTS A total of 22,158 patients (97% male, 58% penetrating injury, median age 25-29 y/o, average Injury Severity Score 9, with an overall mortality of 3%) were included in the analysis. Massive transfusion was required by 7.4% of patients. Overall accuracy was found to be above 90% in all models tested. Following cross validation and model training, the random forest model outperformed the alternatively tested models for precision, recall, and area under the curve. CONCLUSION Machine learning techniques may allow for more optimal and rapid identification of combat trauma patients at highest risk for massive transfusion. These powerful approaches may uncover novel correlations and help improve triage, activation of massive transfusion resources, and trauma-related outcomes. Further research seeking to optimize and apply these algorithms to trauma-centered research should be pursued.
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21
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Bryant MK, Portelli Tremont JN, Patel Z, Cook N, Udekwu P, Reid T, Maine RG, Moore SM. "Low initial pre-hospital end-tidal carbon dioxide predicts inferior clinical outcomes in trauma patients". Injury 2021; 52:2502-2507. [PMID: 34289938 DOI: 10.1016/j.injury.2021.07.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 06/18/2021] [Accepted: 07/05/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Current guidelines continue to lead to under- and over-triage of injured patients in the pre-hospital setting. End-tidal carbon dioxide (ETCO2) has been correlated with mortality and hemorrhagic shock in trauma patients. This study examines the correlation between ETCO2 and in-hospital outcomes among non-intubated patients in the pre-hospital setting. METHODS We retrospectively studied a cohort of non-intubated adult trauma patients with initial pre-hospital side-stream capnography-obtained ETCO2 presenting via ground transport from a single North Carolina EMS agency to a level one trauma center from January 2018 to December 2018. Using the Liu method, the optimal threshold for low ETCO2 was ≤ 28.5 mmHg. RESULTS Initial pre-hospital ETCO2 was recorded for 324 (22.0%) of 1473 patients with EMS data. Patients with low ETCO2 (N = 98, 30.3% of cohort) were older (median 58y vs 45y), but mechanisms of injury and scene vital signs were similar (p>0.05) between low and normal/high ETCO2 cohorts. Median injury severity score (ISS) did not differ significantly between the low and normal/high ETCO2 groups (5 vs 8, p=0.48). Compared to normal/high ETCO2, low ETCO2 correlated with increased unadjusted odds of mortality (OR 5.06), in-hospital complications (OR 2.06), and blood transfusion requirement (OR 3.05), p<0.05. Low ETCO2 was associated with 7.25 odds of mortality (95% CI 2.19,23.97, p=0.001) and 3.94 odds of blood transfusion (95% CI 1.32-11.78) after adjusting for age, ISS, and scene GCS. All but one of the massive transfusion patients (N = 8/9) had a low pre-hospital ETCO2. CONCLUSIONS Low initial pre-hospital ETCO2 associates with poor clinical outcomes despite similar ISS and mechanisms of injury. ETCO2 is a potentially useful pre-hospital point-of-care tool to aid triage of trauma patients as it may identify hemorrhaging patients and predict mortality.
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Affiliation(s)
- Mary Kate Bryant
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA; Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Jaclyn N Portelli Tremont
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA; Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Zachary Patel
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Nicole Cook
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Pascal Udekwu
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
| | - Trista Reid
- Department of Surgery, University of North Carolina, Chapel Hill, NC, USA.
| | - Rebecca G Maine
- Department of Surgery, University of Washington, 3024 New Bern Ave, Andrews Center, Suite 302, Seattle 27610, WA, USA.
| | - Scott M Moore
- Department of General Surgery & Trauma, WakeMed Health & Hospitals, Raleigh, NC, USA.
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Yang YC, Hsieh TH, Liu CY, Chang CY, Hou YT, Lin PC, Chen YL, Chien DS, Yiang GT, Wu MY. Analysis of Clinical Outcome and Predictors of Mortality in Pediatric Trauma Population: Evidence from a 10 Year Analysis in a Single Center. CHILDREN-BASEL 2021; 8:children8080688. [PMID: 34438579 PMCID: PMC8392594 DOI: 10.3390/children8080688] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
The shock index (SI) is a useful tool for predicting the injury severity and mortality in patients with trauma. However, pediatric physiology differs from that of adults. In the pediatric trauma population, the shock status may be obscured within the normal range of vital signs. Pediatric age-adjusted SI (SIPA) is reported more accurately compared to SI. In our study, we conducted a 10 year retrospective cohort study of pediatric trauma population to evaluate the SI and SIPA in predicting mortality, intensive care unit (ICU) admission, and the need for surgery. This retrospective cohort study included 1265 pediatric trauma patients from January 2009 to June 2019 at the Taipei Tzu Chi Hospital, who had a history of hospitalization. The primary outcome of this investigation was in-hospital mortality, and the secondary outcomes were the length of hospital and ICU stay, operation times, and ICU admission times. The SIPA group can detect changes in vital signs early to reflect shock progression. In the elevated SIPA group, more severe traumatic injuries were identified, including high injury severity score (ISS), revised trauma score (RTS), and new injury severity score (NISS) scores than SI > 0.9. The odds ratio of elevated SIPA and SI (>0.9) to predict ISS ≥ 16 was 3.593 (95% Confidence interval [CI]: 2.175–5.935, p < 0.001) and 2.329 (95% CI: 1.454–3.730, p < 0.001). SI and SIPA are useful for identifying the compensatory phase of shock in prehospital and hospital settings, especially in corresponding normal to low-normal blood pressure. SIPA is effective in predicting the mortality and severity of traumatic injuries in the pediatric population. However, SI and SIPA were not significant predictors of ICU admission and the need for surgery analysis.
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Affiliation(s)
- Ya-Chih Yang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Tsung-Han Hsieh
- Department of Research, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan;
| | - Chi-Yuan Liu
- Department of Orthopedic Surgery, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan;
- Department of Orthopedics, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Chun-Yu Chang
- Department of Anesthesiology, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan;
- School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yueh-Tseng Hou
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Po-Chen Lin
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Yu-Long Chen
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Da-Sen Chien
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Giou-Teng Yiang
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
| | - Meng-Yu Wu
- Department of Emergency Medicine, Taipei Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, New Taipei 231, Taiwan; (Y.-C.Y.); (Y.-T.H.); (P.-C.L.); (Y.-L.C.); (D.-S.C.); (G.-T.Y.)
- Department of Emergency Medicine, School of Medicine, Tzu Chi University, Hualien 970, Taiwan
- Correspondence: ; Tel.: +886-2-6628-9779; Fax: +886-2-6628-9009
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Racial and ethnic disparities in withdrawal of life-sustaining treatment after non-head injury trauma. Am J Surg 2021; 223:998-1003. [PMID: 34384589 PMCID: PMC8818056 DOI: 10.1016/j.amjsurg.2021.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/21/2021] [Accepted: 08/03/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Little is known about potential disparities in end-of-life care in trauma. We examined racial/ethnic differences in withdrawal of life-sustaining treatment (WLST) in non-head injury trauma. METHODS We retrospectively analyzed the National Trauma Databank (2017-2018), including patients ≥ 18 years without head injury. We performed a bivariate analysis by WLST status and used logistic regression to estimate adjusted odds of WLST by racial/ethnic group. RESULTS Of 942,914 identified, 20,052 (2.1%) died. Of those who died, WLST occurred in 29.9%. The adjusted odds of WLST were lower in Blacks (OR 0.48, 95% CI 0.41-0.57) and Hispanics (OR 0.71, 95% CI 0.57-0.89) than Whites. The predicted probability of WLST in Black patients remained lower than Whites at 30 days. CONCLUSIONS Among non-head injured dying patients, Blacks and Hispanics are less likely to utilize WLST than Whites. Further investigation into the socio-cultural norms and institutional distrust influencing these differences is imperative.
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Björkman J, Raatiniemi L, Setälä P, Nurmi J. Shock index as a predictor for short-term mortality in helicopter emergency medical services: A registry study. Acta Anaesthesiol Scand 2021; 65:816-823. [PMID: 33340090 DOI: 10.1111/aas.13765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 11/26/2020] [Accepted: 11/29/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND The value of shock-index has been demonstrated in hospital triage, but few studies have evaluated its prehospital use. The aim of our study was to evaluate the association between shock-index in prehospital critical care and short-term mortality. METHODS We analyzed data from the national helicopter emergency medical services database and the Population Register Centre. The shock-index was calculated from the patients' first measured parameters. The primary outcome measure was 1- and 30-day mortality. RESULTS A total of 22 433 patients were included. The 1-day mortality was 7.5% and 30-day mortality was 16%. The median shock-index was 0.68 (0.55/0.84) for survivors and 0.67 (0.49/0.93) for non-survivors (P = .316) at 30-days. Association between shock-index and mortality followed a U-shaped curve in trauma (shock-index < 0.5: odds ratio 2.5 [95% confidence interval 1.8-3.4], shock-index > 1.3: odds ratio 4.4 [2.7-7.2] at 30 days). Patients with neurological emergencies with a low shock-index had an increased risk of mortality (shock-index < 0.5: odds ratio 1.8 [1.5-2.3]) whereas patients treated after successful resuscitation from out-of-hospital cardiac arrest, a higher shock-index was associated with higher mortality (shock-index > 1.3: odds ratio 3.5 [2.3-5.4). The association was similar for all ages, but older patients had higher mortality in each shock-index category. CONCLUSION The shock-index is associated with short time mortality in most critical patient categories in the prehospital setting. However, the marked overlap of shock-index in survivors and non-survivors in all patient categories limits its predictive value.
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Affiliation(s)
- Johannes Björkman
- FinnHEMS Research and Development Unit Vantaa Finland
- University of Helsinki Helsinki Finland
| | - Lasse Raatiniemi
- Centre for Emergency Medical Services Oulu University Hospital Oulu Finland
| | - Piritta Setälä
- Emergency Medical Services Tampere University Hospital Tampere Finland
| | - Jouni Nurmi
- FinnHEMS Research and Development Unit Vantaa Finland
- Emergency Medicine and Services Helsinki University Hospital and Emergency MedicineUniversity of Helsinki Helsinki Finland
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Cassignol A, Bertein P, Botti P, Renard A, Cotte J, Bordes J. Early packed red blood cell transfusion in major trauma patients: Evaluation and comparison of different prediction scores for massive transfusion. Vox Sang 2021; 117:227-234. [PMID: 34155653 DOI: 10.1111/vox.13171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 05/29/2021] [Accepted: 06/03/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVES Our study sought to evaluate and compare different prediction scores for massive transfusion in-hospital packed red blood cell (PRBC) transfusions. MATERIALS AND METHODS Between January 2013 and December 2018, 1843 trauma patients were enrolled in the registry of a level-1 trauma centre. All prehospital and in-hospital variables needed to calculate the Shock Index and RED FLAG, Assessment of Blood Consumption (ABC) and Trauma Associated Severe Hemorrhage (TASH) scores were prospectively collected in the registry. The primary endpoint was the initiation of transfusion within the first hour of the patient's arrival at the hospital. RESULTS A total of 1767 patients were included for analysis with a mean age of 43 years (±19) and a mean Injury Severity Score of 15 (±14). The in-hospital TASH score had the highest predictive performance overall (area under the curve [AUC] = 0.925, 95% confidence interval [CI] [0.904-0.946]), while the RED FLAG score (AUC = 0.881, 95% CI [0.854-0.908]) had the greatest prehospital predictive performance compared to the ABC score (AUC = 0.798, 95% CI [0.759-0.837]) and Shock Index (AUC = 0.795, 95% CI [0.752-0.837]). Using their standard thresholds, the RED FLAG score was the most efficient in predicting early transfusion (sensitivity: 87%, specificity: 76%, positive predictive value: 25%, negative predictive value: 99%, Youden index: 0.63). CONCLUSION The RED FLAG score appears to outperform both the ABC score and the Shock Index in predicting early in-hospital transfusion in trauma patients managed by pre-hospital teams. If adopted, this score could be used to give advance warning to trauma centres or even to initiate early transfusion during pre-hospital care.
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Affiliation(s)
| | - Pauline Bertein
- SMUR Department, Sainte-Musse Public Hospital, Toulon, France
| | - Paul Botti
- Radiology Department, University Hospital of Geneva, Genève, Switzerland
| | - Aurélien Renard
- Emergency Department, Sainte-Anne Military Hospital, Toulon, France
| | - Jean Cotte
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, Toulon, France
| | - Julien Bordes
- Anesthesia and Intensive Care Department, Sainte-Anne Military Hospital, Toulon, France
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Weichselbaum N, Oberladstätter D, Schlimp CJ, Zipperle J, Voelckel W, Grottke O, Zimmermann G, Osuchowski M, Schöchl H. High Interleukin-6 Plasma Concentration upon Admission Is Predictive of Massive Transfusion in Severely Injured Patients. J Clin Med 2021; 10:jcm10112268. [PMID: 34073768 PMCID: PMC8197216 DOI: 10.3390/jcm10112268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 05/11/2021] [Accepted: 05/18/2021] [Indexed: 11/30/2022] Open
Abstract
Severe bleeding remains a prominent cause of early in-hospital mortality in major trauma patients. Thus, prompt prediction of patients at risk of massive transfusion (MT) is crucial. We investigated the ability of the inflammatory marker interleukin (IL)-6 to forecast MT in severely injured trauma patients. IL-6 plasma levels were measured upon admission. Receiver operating characteristic curves (ROCs) were calculated, and sensitivity and specificity were determined. In this retrospective study, a total of 468 predominantly male (77.8%) patients, with a median injury severity score (ISS) of 25 (17–34), were included. The Youden index for the prediction of MT within 6 and 24 h was 351 pg/mL. Patients were dichotomized into two groups: (i) low-IL-6 < 350 pg/mL and (ii) high-IL-6 ≥ 350 pg/mL. IL-6 ≥ 350 pg/mL was associated with a lower prothrombin time index, a higher activated partial thromboplastin time, and a lower fibrinogen concentration compared with IL-6 < 350 pg/mL (p <0.0001 for all). Thromboelastometric parameters were significantly different between groups (p <0.03 in all). More patients in the high-IL-6 group received MT (p <0.0001). The ROCs revealed an area under the curve of 0.76 vs. 0.82 for the high-IL-6 group for receiving MT in the first 6 and 24 h. IL-6 ≥ 350 pg/mL predicted MT within 6 and 24 h with a sensitivity of 45% and 58%, respectively, and a specificity of 89%. IL-6 ≥ 350 pg/mL appears to be a reasonable early predictor for coagulopathy and MT within the first 6 and 24 h intervals. Large-scale prospective studies are warranted to confirm these findings.
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Affiliation(s)
- Nadja Weichselbaum
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.W.); (D.O.); (W.V.)
- Paracelsus Medical University, 5020 Salzburg, Austria
| | - Daniel Oberladstätter
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.W.); (D.O.); (W.V.)
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, 1020 Vienna, Austria; (C.J.S.); (J.Z.); (M.O.)
| | - Christoph J. Schlimp
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, 1020 Vienna, Austria; (C.J.S.); (J.Z.); (M.O.)
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Linz, 4010 Linz, Austria
| | - Johannes Zipperle
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, 1020 Vienna, Austria; (C.J.S.); (J.Z.); (M.O.)
| | - Wolfgang Voelckel
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.W.); (D.O.); (W.V.)
| | - Oliver Grottke
- Department of Anaesthesiology, RWTH Aachen University Hospital, 52074 Aachen, Germany;
| | - Georg Zimmermann
- Team Biostatistics and Big Medical Data, IDA Lab Salzburg, Paracelsus Medical University, 5020 Salzburg, Austria;
- Department of Research and Innovation, Paracelsus Medical University, 5020 Salzburg, Austria
| | - Marcin Osuchowski
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, 1020 Vienna, Austria; (C.J.S.); (J.Z.); (M.O.)
| | - Herbert Schöchl
- Department of Anaesthesiology and Intensive Care Medicine, AUVA Trauma Centre Salzburg, Academic Teaching Hospital of the Paracelsus Medical University, 5020 Salzburg, Austria; (N.W.); (D.O.); (W.V.)
- Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, AUVA Trauma Research Centre, 1020 Vienna, Austria; (C.J.S.); (J.Z.); (M.O.)
- Correspondence: ; Tel.: +43-59393-44-357
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Kheirbek T, Martin TJ, Cao J, Hall BM, Lueckel S, Adams CA. Prehospital shock index outperforms hypotension alone in predicting significant injury in trauma patients. Trauma Surg Acute Care Open 2021; 6:e000712. [PMID: 33907716 PMCID: PMC8051366 DOI: 10.1136/tsaco-2021-000712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The American College of Surgeons Resources for Optimal Care of the Injured Patient recommends using hypotension, defined as systolic blood pressure ≤90 mm Hg, as an indicator of a full team trauma activation. We hypothesized that an elevated shock index (SI) predicts significant traumatic injuries better than hypotension alone. METHODS This is a retrospective cohort study analyzing full team trauma activations between February 2018 and January 2020, excluding transfers and those who had missing values for prehospital blood pressure or heart rate. We reviewed patients' demographics, prehospital and emergency department vitals, injury pattern, need for operation, and clinical outcomes. The primary outcome was rate of significant injury defined as identified injured liver, spleen, or kidney, pelvis fracture, long bone fracture, significant extremity soft tissue damage, hemothorax, or pneumothorax. RESULTS Among 544 patients, 82 (15.1%) had prehospital hypotension and 492 had normal blood pressure. Of the patients with prehospital hypotension, 34 (41.5%) had a significant injury. There was no difference in age, gender, medical history, or injury pattern between the two groups. There was no difference between the two groups in rate of serious injury (41.5% vs. 46.1%, NS), need for emergent operation (31.7% vs. 28.1%, NS) or death (20.7% vs. 18.8%, NS). On the other hand, SI ≥1 was associated with increased rate of serious injury (54.6% vs. 43.4%, p=0.04). On a logistic regression analysis, prehospital hypotension was not associated with significant injury or need for emergent operation (OR 0.83, 95% CI 0.51 to 1.33 and OR 1.32, 95% CI 0.79 to 2.25, respectively). SI ≥1 was associated with both increased odds of significant injury and need for emergent operation (OR 1.57, 95% CI 1.01 to 2.44 and OR 1.64, 95% CI 1.01 to 2.66). DISCUSSION SI was a better indicator and could replace hypotension to better categorize and triage patients in need of higher level of care. LEVEL OF EVIDENCE Prognostic and epidemiologic, level III.
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Affiliation(s)
- Tareq Kheirbek
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Thomas J Martin
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Jessica Cao
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Benjamin M Hall
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Stephanie Lueckel
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
| | - Charles A Adams
- Department of Surgery, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
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Ångerman S, Kirves H, Nurmi J. Characteristics of Nontrauma Patients Receiving Prehospital Blood Transfusion with the Same Triggers as Trauma Patients: A Retrospective Observational Cohort Study. PREHOSP EMERG CARE 2021; 26:263-271. [PMID: 33428489 DOI: 10.1080/10903127.2021.1873472] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Objective: While prehospital blood transfusion (PHBT) for trauma patients has been established in many services, the literature on PHBT use for nontrauma patients is limited. We aimed to describe and compare nontrauma and trauma patients receiving PHBT who had similar hemodynamic triggers. Methods: We analyzed 3.5 years of registry data from a single prehospital critical care unit. The PHBT protocol included two packed red blood cell units and was later completed with two freeze-dried plasma units. The transfusion triggers were a strong clinical suspicion of massive hemorrhage and systolic blood pressure below 90 mmHg or absent radial pulse. Results: Thirty-six nontrauma patients and 96 trauma patients received PHBT. The nontrauma group had elderly patients (median 65 [interquartile range, IQR, 56-73] vs 37 [IQR 25-57] years, p < 0.0001) and included patients with gastrointestinal bleeding (n = 15; 42%), vascular catastrophes (n = 9; 25%), postoperative bleeding (n = 6; 17%), obstetrical bleeding (n = 4; 11%) and other (n = 2; 6%). Cardiac arrest occurred in nine (25%) nontrauma and in 15 (16%) trauma patients. Of these, 5 (56%) and 10 (67%) survived to hospital admission and 3 (33%) and 2 (13%) to hospital discharge. On admission, the nontrauma patients had lower hemoglobin (median 95 [84-119] vs 124 [108-133], p < 0.0001), higher pH (median 7.40 [7.27-7.44] vs 7.30 [7.19-7.36], p = 0.0015) and lower plasma thromboplastin time (median 55 [45-81] vs 72 [58-86], p = 0.0261) than the trauma patients. Conclusions: We identified four nontrauma patient groups in need of PHBT, and the patients appeared to be seriously ill. Efficacy of prehospital transfusion in nontrauma patients should be evaluated futher in becoming studies.
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Hanna K, Harris C, Trust MD, Bernard A, Brown C, Hamidi M, Joseph B. Multicenter Validation of the Revised Assessment of Bleeding and Transfusion (RABT) Score for Predicting Massive Transfusion. World J Surg 2021; 44:1807-1816. [PMID: 32006133 DOI: 10.1007/s00268-020-05394-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients. METHODS We performed a (2015-2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score's predictive power compared to the Assessment of Blood Consumption (ABC) score. RESULTS We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22-36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score. CONCLUSION The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.
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Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA
| | - Charles Harris
- Divsion of Trauma, Acute Care Surgery, and Critical Care, Tulane University School of Medicine, New Orleans, LA, USA
| | - Marc D Trust
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Andrew Bernard
- Section of Trauma and Acute Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Carlos Brown
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA.
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A Simple Cardiovascular Model for the Study of Hemorrhagic Shock. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2020; 2020:7936895. [PMID: 33425003 PMCID: PMC7781723 DOI: 10.1155/2020/7936895] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/08/2020] [Accepted: 11/25/2020] [Indexed: 11/29/2022]
Abstract
Hemorrhagic shock is the number one cause of death on the battlefield and in civilian trauma as well. Mathematical modeling has been applied in this context for decades; however, the formulation of a satisfactory model that is both practical and effective has yet to be achieved. This paper introduces an upgraded version of the 2007 Zenker model for hemorrhagic shock termed the ZenCur model that allows for a better description of the time course of relevant observations. Our study provides a simple but realistic mathematical description of cardiovascular dynamics that may be useful in the assessment and prognosis of hemorrhagic shock. This model is capable of replicating the changes in mean arterial pressure, heart rate, and cardiac output after the onset of bleeding (as observed in four experimental laboratory animals) and achieves a reasonable compromise between an overly detailed depiction of relevant mechanisms, on the one hand, and model simplicity, on the other. The former would require considerable simulations and entail burdensome interpretations. From a clinical standpoint, the goals of the new model are to predict survival and optimize the timing of therapy, in both civilian and military scenarios.
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Marenco CW, Lammers DT, Morte KR, Bingham JR, Martin MJ, Eckert MJ. Shock Index as a Predictor of Massive Transfusion and Emergency Surgery on the Modern Battlefield. J Surg Res 2020; 256:112-118. [DOI: 10.1016/j.jss.2020.06.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2019] [Accepted: 06/16/2020] [Indexed: 10/23/2022]
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Lau MT, Wong CLW. Utility of triage shock index in predicting patient outcome in calcium channel blocker poisoning. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920973561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Shock index is defined as heart rate divided by systolic blood pressure. It is reported as a predictor of morbidity and mortality in trauma and acute myocardial infarction in previous studies. It may be valuable in evaluation of calcium channel blocker poisoning. The objective of this study is to examine the probability of serious outcome based on first measured shock index in patients who presented to emergency department with calcium channel blocker poisoning. Methods: A retrospective chart review was conducted on calcium channel blocker poisoning cases in Hong Kong Poison Information Centre from 1 July 2008 to 30 June 2017. Shock index was calculated with blood pressure and pulse measurement at emergency department triage. Odds ratios of various variables for major outcome, mortality, intensive care unit admission, length of stay in acute hospital were calculated by multivariate analysis or negative binomial regression where appropriate. The performance of shock index in predicting major outcome was evaluated with receiver operating characteristic curve. Results: A total of 390 cases were identified, of whom 25.1% developed major outcome and 5.6% died. Shock index showed significant association with major outcome (odds ratio: 17.017, 95% confidence interval: 5.521–52.455). The area under the receiver operating characteristic curve for shock index in predicting major outcome was 0.7008 (95% confidence interval: 0.64–0.76). Conclusion: Higher shock index is associated with worse patient outcome in calcium channel blocker poisoning. However, shock index alone is not reliable in predicting patient outcome. Further research is needed before shock index can be incorporated for use in patient management in poisoning with calcium channel blocker or other anti-hypertensives.
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Affiliation(s)
- Man Ting Lau
- Accident and Emergency Department, North Lantau Hospital, Tung Chung, Hong Kong
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Kamikawa Y, Hayashi H. Equivalency between the shock index and subtracting the systolic blood pressure from the heart rate: an observational cohort study. BMC Emerg Med 2020; 20:87. [PMID: 33129277 PMCID: PMC7603662 DOI: 10.1186/s12873-020-00383-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 10/27/2020] [Indexed: 11/28/2022] Open
Abstract
Background Although the shock index is known to predict mortality and other severe outcomes, deriving it requires complex calculations. Subtracting the systolic blood pressure from the heart rate may produce a simple shock index that would be a clinically useful substitute for the shock index. In this study, we investigated whether the simple shock index was equivalent to the shock index. Methods This observational cohort study was conducted at 2 tertiary care hospitals. Patients who were transported by ambulance were recruited for this study and were excluded if they were aged < 15 years, had experienced prehospital cardiopulmonary arrest, or had undergone inter-hospital transfer. Pearson’s product-moment correlation coefficient and regression equation were calculated, and two one-sided tests were performed to examine their equivalency. Results Among 5429 eligible patients, the correlation coefficient between the shock index and simple shock index was extremely high (0.917, 95% confidence interval 0.912 to 0.921, P < .001). The regression equation was estimated as sSI = 258.55 log SI. The two one-sided tests revealed a very strong equivalency between the shock index and the index estimated by the above equation using the simple shock index (mean difference was 0.004, 90% confidence interval 0.003 to 0.005). Conclusion The simple shock index strongly correlated with the shock index.
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Affiliation(s)
- Yohei Kamikawa
- Department of Emergency Medicine, University of Fukui Hospital, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan.
| | - Hiroyuki Hayashi
- Department of General Medicine, University of Fukui Hospital, 23-3 Matsuoka Shimoaizuki, Eiheiji-cho, Yoshida-gun, Fukui, 910-1193, Japan
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Kraenzlin MN, Cortes Y, Fettig PK, Bailey DB. Shock index is associated with mortality in canine vehicular trauma patients. J Vet Emerg Crit Care (San Antonio) 2020; 30:706-711. [PMID: 33084223 DOI: 10.1111/vec.13013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 04/21/2019] [Accepted: 05/10/2019] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To calculate and compare shock index (SI) in healthy dogs and vehicular trauma dogs (VT), determine the prognostic value of SI in VT dogs, and to assess the correlation between SI and the animal trauma triage score, modified Glasgow Coma Scale score, and lactate in VT dogs. DESIGN Retrospective study from April 2016 to February 2018. SETTING Twenty-four-hour tertiary referral level II trauma center. ANIMALS One hundred twenty-one dogs presented to the emergency service for VT and 60 healthy control dogs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Heart rate and systolic blood pressure were measured on each patient and used to calculate SI. SI was significantly higher in VT dogs compared to healthy control dogs (median SI, 1.0 vs 0.75; P < 0.0001). SI was significantly higher in those that died versus those that survived to discharge (median, 1.27 vs 0.96; P = 0.017). SI positively correlated with animal trauma triage score (95% confidence interval, 0.039-0.49; P = 0.019; r = 0.26) but did not with plasma lactate level at presentation (P = 0.068; r = 0.22) or modified Glasgow Coma Scale (P = 0.85; r = -0.021, 95% confidence interval, -0.24 to 0.20). CONCLUSIONS SI is easy to calculate during triage of a trauma patient. Given its significant relationship with mortality, higher SIs should prompt the clinician to pursue additional monitoring, diagnostics, and intervention.
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Affiliation(s)
- Mara N Kraenzlin
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, New Jersey
| | - Yonaira Cortes
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, New Jersey
| | - Pamela K Fettig
- Emergency and Critical Care Department, Oradell Animal Hospital, Paramus, New Jersey
| | - Dennis B Bailey
- Oncology Department, Oradell Animal Hospital, Paramus, New Jersey
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Puzio TJ, Kalkwarf K, Cotton BA. Predicting the need for massive transfusion in the prehospital setting. Expert Rev Hematol 2020; 13:983-989. [PMID: 32746651 DOI: 10.1080/17474086.2020.1803735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Massive transfusion (MT) prediction scores allowed for the early identification of patients with massive hemorrhage likely to require large volumes of blood products. Despite their utility, very few MT scoring systems have shown promise in the pre-hospital setting due to their complexity and resource limitations. AREAS COVERED Pub med database was utilized to identify supporting literature for this review which discusses the importance of blood-based resuscitation and highlights the utility of scoring systems to predict the need of massive transfusion. MTP scoring systems effective in the prehospital setting are specifically discussed. EXPERT OPINION Massive transfusions scores are useful in alerting hospitals to the severity of trauma patients and organizing resources necessary for appropriate patient care but should not completely replace clinical . The opportunity exists to extend their use to the pre-hospital setting to allow for even earlier notification and to triage patients to trauma centers best able to treat severely injured.
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Affiliation(s)
- Thaddeus J Puzio
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
| | - Kyle Kalkwarf
- Department of Surgery, University of Arkansas Medical Sciences , Little Rock, AR, USA
| | - Bryan A Cotton
- Department of Surgery and the Center for Translational Injury Research, University of Texas Health Science Center , Houston, TX, USA
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Gandhi G, Claiborne MK, Gross T, Sussman BL, Davenport K, Ostlie D, Bulloch B. Predictive value of the shock index (SI) compared to the age-adjusted pediatric shock index (SIPA) for identifying children that needed the highest-level trauma activation based on the presence of consensus criteria. J Pediatr Surg 2020; 55:1761-1765. [PMID: 31676079 DOI: 10.1016/j.jpedsurg.2019.09.032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Revised: 08/14/2019] [Accepted: 09/01/2019] [Indexed: 11/26/2022]
Abstract
OBJECTIVES In previous studies, SIPA was shown to be better than the SI in identifying children who have an elevated ISS, required transfusion, or were at a high risk of death. No comparison has been made to the consensus-based criteria that identify patients requiring the highest-level trauma activation. The objective of this study was to determine if the SIPA was more accurate than the SI in identifying children with increased need for trauma team activation as defined by the criterion standard definition, and secondly the sensitivity and specificity of the SI and SIPA. METHODS Retrospective review of prospectively collected trauma based data. Children aged 1-17 years admitted to a pediatric level 1 trauma center between 1/1/16 and 12/31/17 and met the prehospital criteria for level 1 or 2 trauma activation were included. We evaluated the ability of SI > 0.9 at ED presentation and elevated SIPA to predict need for trauma activation based on consensus criteria. SIPA cutoffs were > 1.22 (age 4-6), >1.0 (age 7-12), and > 0.9 (age 13-17). RESULTS Among 3378 children, 1486 (44%) had an elevated SI and 590 (18%) had an elevated SIPA. There were 160 (5%) patients who met at least one consensus criterion. Broadly, sensitivity and specificity analyses reveal poor sensitivity for both SI and SIPA (59.4% versus 43.1% respectively) measures but a moderate specificity for SIPA (83.8%). Both SI and SIPA have a poor PPV (6.4% versus 11.7%) but high NPV (96.6% versus 96.7%). Overall, SIPA has higher accuracy than SI in predicting consensus criteria 82% versus 57%). CONCLUSION SIPA is more accurate than the SI in identifying children who meet a consensus criterion defining the need for highest-level trauma activation. The low PPV and sensitivity suggest that SIPA alone, while somewhat less likely to lead to overtriage than SI is not ideal for ruling in the need for level one resources as defined by the consensus criteria. Prognosis study, retrospective. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Geet Gandhi
- Phoenix Children's Hospital, Department of Emergency Medicine.
| | | | - Toni Gross
- Children's Hospital, New Orleans, Department of Emergency Medicine.
| | | | | | - Daniel Ostlie
- Phoenix Children's Hospital, Department of Trauma & Surgery.
| | - Blake Bulloch
- Phoenix Children's Hospital, Department of Emergency Medicine.
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Pulse Oximeter Plethysmograph Variation During Hemorrhage in Beta-Blocker-Treated Swine. J Surg Res 2020; 256:468-475. [PMID: 32798994 DOI: 10.1016/j.jss.2020.07.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/25/2020] [Accepted: 07/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Beta-blockers blunt the stress response to hemorrhage. Our aim was to investigate the feasibility of noninvasive pulse oximeter plethysmographic waveform variation (PoPV) for predicting blood volume loss in an esmolol-treated swine hemorrhagic shock model. MATERIALS AND METHODS Controlled hemorrhage was induced in eight male domestic pigs. In four pigs, a total of 15% and 30% blood volume was drawn step-by-step over 10 min in each step (controlled hemorrhage-only pigs). In the other four pigs, the heart rate (HR) was reduced and maintained by 30% from baseline by esmolol infusion before controlled hemorrhage (esmolol-treated pigs). Diagnostic abilities of HR, pulse pressure variation (PPV), PoPV, and mean arterial pressure for 15% and 30% blood volume loss were determined by the area under the receiver operating characteristic curve (AUC). RESULTS PoPV was well correlated with PPV in controlled hemorrhage-only pigs (r = 0.717) and esmolol-treated pigs (r = 0.532). In controlled hemorrhage-only pigs, HR (AUC = 0.841 and 0.864), PPV (0.878 and 0.843), and PoPV (0.779 and 0.793) accurately predicted 15% and 30% of blood volume loss. In esmolol-treated pigs, the diagnostic ability of HR was decreased (AUC = 0.766 and 0.733). However, diagnostic abilities of PPV (0.848 and 0.804) and PoPV (0.808 and 0.842) were not deteriorated. CONCLUSIONS The diagnostic ability of HR for blood volume loss was blunted by esmolol. However, those of PPV and PoPV were not altered. PoPV may be considered to be a useful noninvasive tool to predict blood volume loss in injured patients taking beta-blockers.
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Cuenca CM, Borgman MA, April MD, Fisher AD, Schauer SG. Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan. Mil Med Res 2020; 7:33. [PMID: 32616047 PMCID: PMC7331217 DOI: 10.1186/s40779-020-00262-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 06/24/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting. METHODS We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9). RESULTS From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87. CONCLUSIONS Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.
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Affiliation(s)
- Camaren M Cuenca
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA
| | - Matthew A Borgman
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA.,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA
| | - Andrew D Fisher
- Texas Army National Guard, Austin, TX, USA.,Department of Surgery, UNM School of Medicine, Albuquerque, NM, USA
| | - Steven G Schauer
- US Army Institute of Surgical Research, 3698 Chambers Pass, JBSA Fort Sam Houston, San Antonio, TX, 78234-7767, USA. .,Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, TX, USA. .,Uniformed Services University of the Heath Sciences, Bethesda, MD, USA. .,59th Medical Wing, JBSA Lackland, San Antonio, TX, USA.
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Lammers D, Conner J, Marenco C, Morte K, Martin M, Eckert M, Bingham J. Optimal Prospective Predictors of Mortality in Austere Environments. J Surg Res 2020; 255:297-303. [PMID: 32585467 DOI: 10.1016/j.jss.2020.05.040] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 04/18/2020] [Accepted: 05/03/2020] [Indexed: 01/29/2023]
Abstract
BACKGROUND Prospective predictors of trauma-related outcomes have been validated to guide management in low-resource settings. The primary objective of this study was to determine the optimal prospective prediction method for mortality within combat and humanitarian trauma. MATERIALS AND METHODS Retrospective review of the Department of Defense Trauma Registry from 2008 to 2016 was performed for adult patients. Areas under receiver operating characteristic curves (AUROCs) were calculated to assess the predictability of shock index (SI), reverse SI × Glasgow Coma Scale (rSIG), SI × Glasgow Coma Scale (SIG), Revised Trauma Score, and Trauma and Injury Severity Score (TRISS) on mortality at point of injury, arrival in emergency department (ED), and the difference in vital signs between those time points. RESULTS A total of 22,218 patients were included. Overall, 97.1% were male, median age range 25-29 y, Injury Severity Score 9.4 ± 0.07, with predominantly penetrating injuries (58.1%), and mortality of 3.4%. ED vitals yielded higher predictability of mortality for all tests based on higher AUROCs. TRISS and rSIG demonstrated the highest AUROCs (0.955 and 0.923, respectively). The optimal cutoff value for rSIG was 14.1 (sensitivity 89% and specificity 87%). rSIG values <14.1 were significantly associated with mortality (P < 0.01; odds ratio = 5.901). CONCLUSIONS Initial ED vital signs represented a better predictor of early mortality compared with point of injury vital signs for all predictive tools assessed. TRISS and rSIG proved to be most predictive of mortality. However, of the prospective tools assessed, rSIG may be optimal scoring tool because of its ease of calculation and its increased ability to predict mortality.
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Affiliation(s)
- Daniel Lammers
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jeffrey Conner
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington.
| | - Chris Marenco
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Kaitlin Morte
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Matthew Martin
- Department of Trauma and Critical Care, Scripps Mercy Hospital, San Diego, California
| | - Matthew Eckert
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
| | - Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, Tacoma, Washington
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Leichtle SW, Poulos NG, Whelan J, Aboutanos M. Field Triage of Motor Vehicle Crashes: Which Factors Predict High Injury Severity? Am Surg 2020. [DOI: 10.1177/000313481908500740] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Patient physiology and crash characteristics are essential components of field triage for motor vehicle crashes. We aimed to identify prehospital information that predicted high injury severity or critical patient condition on hospital arrival. The association of demographics, shock index (SI), Glasgow Coma Scale, and 10 crash characteristics of trauma activations for motor vehicle crashes with injury severity score (ISS) ≥ 16 and a composite of hypotension, need for blood transfusions, or immediate operation was determined using univariate and multivariate analyses. A total of 133 of 498 patients (27%) had ISS ≥ 16; SI ≥ 0.9, Glasgow Coma Scale ≤, 8, speed ≥ 55 mph, seatbelt use, airbag deployment, ambulatory patient, severe vehicle damage, ejection, and extrication were associated with ISS ≥ 16. Only abnormal SI and high speed remained independent predictors for ISS ≥ 16 with Odds Ratio (OR) = 10.76 (95% confidence interval (CI), 1.14-101, P = 0.04) and OR = 10.37 (95% CI, 1.48–72.93, P = 0.02), respectively. SI ≥ 0.9 predicted the composite outcome with OR = 5.92 (95% CI, 2.32–15.08, P < 0.01). Many commonly reported crash characteristics did not predict clinically important outcomes. Improvements in road and vehicle safety may be resulting in lower injury severity despite major crash mechanisms.
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Affiliation(s)
- Stefan W. Leichtle
- Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Nicholas G. Poulos
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - James Whelan
- Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Michel Aboutanos
- Division of Acute Care Surgical Services, Department of Surgery, Virginia Commonwealth University, Richmond, Virginia
- School of Medicine, Virginia Commonwealth University, Richmond, Virginia
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Rojas-Suarez J, Paternina-Caicedo Á, Tolosa JE, Guzmán-Polanía L, Gonzalez N, Pomares F, Maza A, Miranda J. The impact of maternal anemia and labor on the obstetric Shock Index in women in a developing country. Obstet Med 2020; 13:83-87. [DOI: 10.1177/1753495x19837127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 02/05/2019] [Indexed: 11/17/2022] Open
Abstract
Background The Shock Index is a clinical tool to evaluate the hemodynamic status during hemorrhage. The impact of labor and pre-existing anaemia is unknown. The objective was to describe and discuss its clinical utility in this context. Methods This was a prospective cross-sectional study. The Shock Index (ratio between heart rate and systolic blood pressure) was measured in pregnant women at term, before or during labor. They were stratified according to the presence of anemia. Results The median Shock Index was significantly lower in women in labor than in those not in labor (0.72 (IQR: 0.64–0.83) vs. 0.85 (IQR: 0.80–0.94); p < 0.001). In women in labor, the Shock Index was not significantly different if anemia was present (0.72 (0.63–0.83) vs. 0.73 (0.65–0.82); p = 0.67). Conclusions Values of the Shock Index are affected by labor, which may hinder its utility in identifying hemorrhage during this period. However, the values were not altered by maternal anaemia. Therefore, an abnormal postpartum Shock Index should not be attributed to an abnormal antepartum Shock Index due to mild/moderate anemia.
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Affiliation(s)
- José Rojas-Suarez
- Department of Internal Medicine, Universidad de Cartagena, Cartagena, Colombia
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
- Unidad de Cuidados Intensivos Gestión Salud, Cartagena, Colombia
- ESE Clínica de Maternidad Rafael Calvo (CMRC), Cartagena de Indias, Colombia
| | | | - Jorge E Tolosa
- Global Network for Perinatal and Reproductive Health, Oregon Health and Science University, Portland, USA, FUNDARED-MATERNA, Bogotá, Colombia
- Department of Obstetrics and Gynecology, Oregon Health and Science University, Portland, OR, USA
- Department of Obstetrics and Gynecology, Universidad de Antioquia, Medellin, Colombia
| | - Leidy Guzmán-Polanía
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
| | - Nataly Gonzalez
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
| | - Fredy Pomares
- Department of Internal Medicine, Universidad de Cartagena, Cartagena, Colombia
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
| | - Augusto Maza
- Department of Internal Medicine, Universidad de Cartagena, Cartagena, Colombia
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
| | - Jezid Miranda
- Grupo de Investigación en Cuidado Intensivo y Obstetricia (GRICIO), Cartagena, Colombia
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Cumming SH, Martinez-Taboada F. Blood Loss Estimation in Small Animals and Assessment of a Pictorial Tool to Improve Accuracy in a Global Population of Veterinary Anesthesia Staff. Front Vet Sci 2020; 7:212. [PMID: 32457920 PMCID: PMC7221018 DOI: 10.3389/fvets.2020.00212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 03/30/2020] [Indexed: 11/13/2022] Open
Abstract
Visual estimation of blood loss is the most common form of evaluating intraoperative hemorrhage, and is also the most inaccurate. This study investigated the visual estimation accuracy of a global population of anesthesia staff and students as an initial estimation and also with the assistance of a pictorial guide. A voluntary, two-part, online, anonymous survey was distributed to members of two email databases with an interest in anesthesia, including students, nurses, interns, residents, general practitioners, and specialists. The survey consisted of visual and brief descriptive depictions of blood loss scenarios involving small animals, principally including images of common surgical items and receptacles containing a blood-like substance. Each participant estimated the blood volume (in mL) for each scenario twice, initially (Pre-Guide [PGD]) and then with the aid of a pictorial guide (With-Guide [WGD]). The pictorial guide used similar images labeled with corresponding volumes. Data was analyzed for normality with the Shapiro-Wilks test, corrected to absolute error and compared for statistical significance using the Wilcoxon signed-ranks test or the Kruskal-Wallis test as appropriate. The overall raw PGD phase median estimation error was−27 mL (range −99 to 248 mL). The PGD raw median error increased with scenario complexity. There were no differences between role, gender, experience, or country of origin. The overall median raw estimation error for the WGD phase was 13 mL (range −80 ml to 143 mL) (p = 0.0128). Visual blood loss estimation is inaccurate amongst veterinary anesthetists and associated staff, showing decreasing accuracy with increasing complexity. A pictorial guide improves the accuracy generally, and specifically for more complex scenarios which are likely to reflect the clinical situation.
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Affiliation(s)
- Scott H Cumming
- Anaesthesia Department, The Veterinary Teaching Hospital Sydney, The University of Sydney, Camperdown, NSW, Australia
| | - Fernando Martinez-Taboada
- Anaesthesia Department, The Veterinary Teaching Hospital Sydney, The University of Sydney, Camperdown, NSW, Australia
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Prehospital Vital Signs Accurately Predict Initial Emergency Department Vital Signs. Prehosp Disaster Med 2020; 35:254-259. [PMID: 32127060 DOI: 10.1017/s1049023x2000028x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Prehospital vital signs are used to triage trauma patients to mobilize appropriate resources and personnel prior to patient arrival in the emergency department (ED). Due to inherent challenges in obtaining prehospital vital signs, concerns exist regarding their accuracy and ability to predict first ED vitals. HYPOTHESIS/PROBLEM The objective of this study was to determine the correlation between prehospital and initial ED vitals among patients meeting criteria for highest levels of trauma team activation (TTA). The hypothesis was that in a medical system with short transport times, prehospital and first ED vital signs would correlate well. METHODS Patients meeting criteria for highest levels of TTA at a Level I trauma center (2008-2018) were included. Those with absent or missing prehospital vital signs were excluded. Demographics, injury data, and prehospital and first ED vital signs were abstracted. Prehospital and initial ED vital signs were compared using Bland-Altman intraclass correlation coefficients (ICC) with good agreement as >0.60; fair as 0.40-0.60; and poor as <0.40). RESULTS After exclusions, 15,320 patients were included. Mean age was 39 years (range 0-105) and 11,622 patients (76%) were male. Mechanism of injury was blunt in 79% (n = 12,041) and mortality was three percent (n = 513). Mean transport time was 21 minutes (range 0-1,439). Prehospital and first ED vital signs demonstrated good agreement for Glasgow Coma Scale (GCS) score (ICC 0.79; 95% CI, 0.77-0.79); fair agreement for heart rate (HR; ICC 0.59; 95% CI, 0.56-0.61) and systolic blood pressure (SBP; ICC 0.48; 95% CI, 0.46-0.49); and poor agreement for pulse pressure (PP; ICC 0.32; 95% CI, 0.30-0.33) and respiratory rate (RR; ICC 0.13; 95% CI, 0.11-0.15). CONCLUSION Despite challenges in prehospital assessments, field GCS, SBP, and HR correlate well with first ED vital signs. The data show that these prehospital measurements accurately predict initial ED vitals in an urban setting with short transport times. The generalizability of these data to settings with longer transport times is unknown.
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Wang IJ, Bae BK, Park SW, Cho YM, Lee DS, Min MK, Ryu JH, Kim GH, Jang JH. Pre-hospital modified shock index for prediction of massive transfusion and mortality in trauma patients. Am J Emerg Med 2020; 38:187-190. [PMID: 30738590 DOI: 10.1016/j.ajem.2019.01.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Modified shock index (MSI) is a useful predictor in trauma patients. However, the value of prehospital MSI (preMSI) in trauma patients is unknown. The aim of this study was to investigate the accuracy of preMSI in predicting massive transfusion (MT) and hospital mortality among trauma patients. METHODS This was a retrospective, observational, single-center study. Patients presenting consecutively to the trauma center between January 2016 and December 2017, were included. The predictive ability of both prehospital shock index (preSI) and preMSI for MT and hospital mortality was assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). RESULTS A total of 1007 patients were included. Seventy-eight (7.7%) patients received MT, and 30 (3.0%) patients died within 24 h of admission to the trauma center. The AUROCs for predicting MT with preSI and preMSI were 0.773 (95% confidence interval [CI], 0.746-0.798) and 0.765 (95% CI, 0.738-0.791), respectively. The AUROCs for predicting 24-hour mortality with preSI and preMSI were 0.584 (95% CI, 0.553-0.615) and 0.581 (95% CI, 0.550-0.612), respectively. CONCLUSIONS PreSI and preMSI showed moderate accuracy in predicting MT. PreMSI did not have higher predictive power than preSI. Additionally, in predicting hospital mortality, preMSI was not superior to preSI.
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Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols. J Trauma Acute Care Surg 2020; 87:717-729. [PMID: 31454339 DOI: 10.1097/ta.0000000000002372] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP. METHODS MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic. RESULTS Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. CONCLUSION The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed. LEVEL OF EVIDENCE Systematic review, level III.
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Gandhi G, Claiborne MK, Gross T, Sussman BL, Davenport K, Bulloch B. Comparison of Prehospital Calculated Age-Adjusted Pediatric Shock Index (SIPA) to Those Calculated in the ED for Identifying Trauma Patients That Needed the Highest-Level Activation Based on Consensus Criteria. PREHOSP EMERG CARE 2020; 24:778-782. [PMID: 31961754 DOI: 10.1080/10903127.2020.1718812] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Background: The shock index (SI) is defined as the ratio of the heart rate to systolic blood pressure and a pediatric age-adjusted SI (SIPA) is more specific than the standard adult cutoff of 0.9 in identifying the sickest children presenting to a trauma center.Goal: To utilize prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay to determine if they have the same validity in identifying critically ill children as determined by the consensus based standard criteria for trauma activation.Methods: Retrospective study using a cohort of patients transferred by EMS to a free standing, urban, level one, pediatric trauma center aged 1 to 16 years inclusive, and seen between January 1, 2016 and December 31, 2017. Vital signs collected during the patch call from the EMS agency were used to calculate the EMS SIPA. The first set of vital signs collected in the trauma bay was used to calculate the ED SIPA. Patients were dichotomized to an elevated or non-elevated ED SIPA and an elevated or non-elevated EMS SIPA.Results: Our cohort consisted of 2651 patients. 546 (20.6%) patients had an elevated EMS SIPA and 438 (16.5%) had an elevated ED SIPA. When compared to their non-elevated counterparts, EMS and ED SIPA were both able to identify patients who met consensus criteria in all areas except the need for IR intervention, and unstable spinal fracture/spinal cord injury. For these criteria, the ED SIPA was better than the EMS SIPA. Sensitivity and specificity analysis reveal poor sensitivity for both measures but a high specificity for ED and EMS SIPA. Both SI and SIPA have a poor PPV but high NPV.Conclusions: This study utilized prehospital vital signs to calculate the SIPA score and compare them to the SIPA calculated in the trauma bay. Both scores had similar test metrics when based on the consensus based standard trauma criteria and could be utilized in the triage traumatic injuries.
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Jost D, Lemoine S, Lemoine F, Lanoe V, Maurin O, Derkenne C, Franchin Frattini M, Delacote M, Seguineau E, Godefroy A, Hervault N, Delhaye L, Pouliquen N, Louis-Delauriere E, Trichereau J, Roquet F, Salomé M, Verret C, Bihannic R, Jouffroy R, Frattini B, Hong Tuan Ha V, Dang-Minh P, Travers S, Bignand M, Martinaud C, Garrabe E, Ausset S, Prunet B, Sailliol A, Tourtier JP. French lyophilized plasma versus normal saline for post-traumatic coagulopathy prevention and correction: PREHO-PLYO protocol for a multicenter randomized controlled clinical trial. Trials 2020; 21:106. [PMID: 31969168 PMCID: PMC6977230 DOI: 10.1186/s13063-020-4049-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Accepted: 01/06/2020] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Post-trauma bleeding induces an acute deficiency in clotting factors, which promotes bleeding and hemorrhagic shock. However, early plasma administration may reduce the severity of trauma-induced coagulopathy (TIC). Unlike fresh frozen plasma, which requires specific hospital logistics, French lyophilized plasma (FLYP) is storable at room temperature and compatible with all blood types, supporting its use in prehospital emergency care. We aim to test the hypothesis that by attenuating TIC, FLYP administered by prehospital emergency physicians would benefit the severely injured civilian patient at risk for hemorrhagic shock. METHODS/DESIGN This multicenter randomized clinical trial will include adults severely injured and at risk for hemorrhagic shock, with a systolic blood pressure < 70 mmHg or a Shock Index > 1.1. Two parallel groups of 70 patients will receive either FLYP or normal saline in addition to usual treatment. The primary endpoint is the International Normalized Ratio (INR) at hospital admission. Secondary endpoints are transfusion requirement, length of stay in the intensive care unit, survival rate at day 30, usability and safety related to FLYP use, and other biological coagulation parameters. CONCLUSION With this trial, we aim to confirm the efficacy of FLYP in TIC and its safety in civilian prehospital care. The study results will contribute to optimizing guidelines for treating hemorrhagic shock in civilian settings. TRIAL REGISTRATION ClinicalTrials.gov, NCT02736812. Registered on 13 April 2016. The trial protocol has been approved by the French ethics committee (CPP 3342) and the French Agency for the Safety of Medicines and Health Products (IDRCB 2015-A00866-43).
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Affiliation(s)
- Daniel Jost
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France.
| | - Sabine Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Frederic Lemoine
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vincent Lanoe
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Olga Maurin
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Clément Derkenne
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | | | - Maëlle Delacote
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Edouard Seguineau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Anne Godefroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Hervault
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Ludovic Delhaye
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Nicolas Pouliquen
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Emilie Louis-Delauriere
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - Julie Trichereau
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Florian Roquet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Marina Salomé
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Catherine Verret
- Department of Education, Research and Innovation, Service de Santé des Armées, 1 Place Alphonse Laveran, 75230, Paris, France
| | - René Bihannic
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Romain Jouffroy
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Benoit Frattini
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Vivien Hong Tuan Ha
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Pascal Dang-Minh
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Stéphane Travers
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Michel Bignand
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
| | - Christophe Martinaud
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Eliane Garrabe
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
| | - Sylvain Ausset
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anesthesiology and Intensive Care, Percy military teaching hospital, 101 avenue Henri Barbusse, BP 406, 92141, Clamart, Cedex, France
| | - Bertrand Prunet
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
| | - Anne Sailliol
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- French army blood transfusion center, 1 Rue du Lieutenant Raoul Batany, 92140, Clamart, France
- French Military Research Institute, 1 place Valérie Andre, BP 73, 91223, Brétigny sur Orge, France
| | - Jean Pierre Tourtier
- Paris Fire Brigade Medical Emergency Department, 1 place Jules Renard, 75017, Paris, France
- French Military Health Service, Val de Grâce military hospital, 1, Place Alphonse Laveran, 75230, Paris, France
- Department of Anaesthesiology and Intensive Care, Begin military teaching hospital, 94160, Saint-Mande, France
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Saffouri E, Blackwell C, Laursen SB, Laine L, Dalton HR, Ngu J, Shultz M, Norton R, Stanley AJ. The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding. Aliment Pharmacol Ther 2020; 51:253-260. [PMID: 31642558 DOI: 10.1111/apt.15541] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 08/10/2019] [Accepted: 09/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute upper gastrointestinal bleeding (UGIB) remains a major cause of hospital admission worldwide. The recent UK National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report on severe gastrointestinal bleeding used the Shock Index to assess bleeding severity and found an association between Shock Index and mortality. However, this has never been prospectively validated as a predictor of outcome in UGIB. AIMS To compare the Shock Index with existing pre-endoscopic UGIB risk scores in predicting outcomes after UGIB METHODS: In an international, prospective study of 3012 consecutive patients with UGIB, we compared the Shock Index with existing scores including the Glasgow Blatchford score (GBS), admission Rockall score, AIMS65, and the newly described "ABC" score. Pre-determined endpoints were need for major (≥4 units red cells) transfusion, need for endoscopic therapy and 30-day mortality. RESULTS The Shock Index was inferior to the GBS in predicting need for major transfusion (area under the receiver operator characteristic curve [AUROC] 0.655 vs 0.836, P < 0.001) and need for endotherapy (AUROC 0.606 vs 0.747, P < 0.001). The Shock Index was inferior to all other scores for 30-day mortality: for example, AUROC 0.611 vs 0.863 for ABC score (P < 0.001). Adding the Shock Index to the ABC score did not improve accuracy of the ABC score in predicting mortality (AUROC 0.864 vs 0.863, P = 0.95). CONCLUSION The Shock Index performed poorly with AUROCs <0.66 and was inferior to existing pre-endoscopy scores at predicting major clinical endpoints after UGIB. We found no clear evidence that the Shock Index is clinically useful at predicting outcomes in UGIB. [Correction added on 20 December 2019, after first online publication: Summary section has been changed for clarification.].
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Affiliation(s)
| | | | | | | | | | - Jing Ngu
- Singapore General Hospital, Singapore, Singapore
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Vasudeva M, Mathew JK, Fitzgerald MC, Cheung Z, Mitra B. Hypocalcaemia and traumatic coagulopathy: an observational analysis. Vox Sang 2019; 115:189-195. [DOI: 10.1111/vox.12875] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/10/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Mayank Vasudeva
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
| | - Joseph K. Mathew
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
- Software & Innovation Lab Deakin University Melbourne VIC Australia
| | - Mark C. Fitzgerald
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
- Software & Innovation Lab Deakin University Melbourne VIC Australia
| | - Zoe Cheung
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
| | - Biswadev Mitra
- National Trauma Research Institute Melbourne VIC Australia
- Emergency & Trauma Centre The Alfred Hospital Melbourne VIC Australia
- Department of Epidemiology & Preventive Medicine Monash University Melbourne VIC Australia
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Jehan F, Con J, McIntyre M, Khan M, Azim A, Prabhakaran K, Latifi R. Pre-hospital shock index correlates with transfusion, resource utilization and mortality; The role of patient first vitals. Am J Surg 2019; 218:1169-1174. [DOI: 10.1016/j.amjsurg.2019.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
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