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

A Combined Model of Vital Signs and Serum Biomarkers Outperforms Shock Index in the Prediction of Hemorrhage Control Interventions in Surgical Intensive Care Unit Patients

BACKGROUND

Distinguishing surgical intensive care unit (ICU) patients with ongoing bleeding who require hemorrhage control interventions (HCI) can be challenging. Guidelines recommend risk-stratification with clinical variables and prediction tools, however supporting evidence remains mixed.

METHODS

This retrospective study evaluated adult patients admitted to the surgical ICU with concern for ongoing hemorrhage under our institution's "Hemorrhage Watch" (HW) protocol and aimed to derive a clinical prediction model identifying those needing HCI with serial vital signs (VS) and serum biomarkers. The HW protocol included ICU admission followed by a 3-h observation period with VS monitoring every 15 min and hourly biomarkers. The primary outcome was the need for HCI (operative and endovascular interventions) within nine hours of ICU arrival. Secondary outcomes included in-hospital mortality, blood transfusions, and ICU and hospital length-of-stay. A clinical prediction model was developed by utilizing the variables most associated with HCI in a best subsets regression, which was subsequently internally validated using a Bootstrap algorithm.

RESULTS

305 patients were identified for inclusion and 18 (5.9%) required HCI (3 operative, 15 endovascular). The median age was 70 years (IQR 54, 83), 60% had traumatic injuries, and 73% were enrolled from the emergency department. Blood product transfusion and mortality were similar between the HCI and no-HCI groups. Our analysis demonstrated that a model based on the minimum hemoglobin (9.9 vs 8.1 g/dL), minimum diastolic (57 vs 53 mm Hg) and systolic blood pressures (105 vs 90 mm Hg), and minimum respiratory rate (15 vs 18) could predict HCI with an area under the Receiver Operating Characteristics curve (AUROC) of 0.87, outperforming the Shock Index (SI) (AUROC = 0.64).

CONCLUSIONS

In this study of surgical ICU patients with concern for ongoing bleeding, a prediction model using serial VS and biomarkers outperformed the SI and may help identify those requiring HCI.

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

PURPOSE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Comparison of conventional coagulation tests and ROTEM in identifying trauma-induced coagulopathy for massive haemorrhage protocol activation

OBJECTIVES

Trauma-induced coagulopathy (TIC) can be fatal but preventable if recognised early. With emerging uses of rotational thromboelastometry (ROTEM) to guide transfusions in trauma, patient outcomes with TIC-defined by initial ROTEM and conventional coagulation tests (CCTs) during massive haemorrhage protocol (MHP) activations were evaluated at a primary trauma centre in British Columbia.

METHODS

This retrospective observational study included adult trauma patients requiring MHP from June 1, 2020, to May 31, 2022. TIC, defined by initial results including (1) ROTEM-based EXTEM A10 <40 mm, EXTEM CT >100 s, EXTEM ML30 >10%, FIBTEM A10 <10 mm; and (2) CCT-based INR ≥1.8, PTT ≥1.5 times of upper normal limit, platelets <50 x 109/L, and Clauss Fibrinogen <1.5 g/L, was assessed for its correlation with mortality. Modified Poisson regression was used to model 28-day mortality.

RESULTS

Twenty-two of sixty-eight patients (32%) had abnormal ROTEM but normal CCTs. TIC defined by CCTs was associated with increased mortality [24 h: 5/13 (38%) vs. 5/55 (9%), p = 0.025; 28d: 8/13 (62%) vs. 11/55 (20%), p = 0.002]; compared to ROTEM, which was not [24 h: 7/35 (20%) vs. 3/33 (9%), p = 0.307; 28d: 11/35 (31%) vs. 9/33 (27%), p = 0.594], despite requiring significantly higher blood component transfusion within the first 4 and 24 h of MHP (p-values<0.05).

CONCLUSIONS

ROTEM is more sensitive in identifying TIC. Patients with abnormal CCTs had a higher death rate, and those with abnormal ROTEM had no significantly increased mortality. A prospective study is required to assess the effects of ROTEM further.

Major Bleeding in the Emergency Department: A Practical Guide for Optimal Management

Major bleeding is a life-threatening condition with high morbidity and mortality. Trauma, gastrointestinal bleeding, haemoptysis, intracranial haemorrhage or other causes of bleeding represent major concerns in the Emergency Department (ED), especially when complicated by haemodynamic instability. Severity and source of bleeding, comorbidities, and prior use of anticoagulants are pivotal factors affecting both the clinical status and the patients' differential response to haemorrhage. Thus, risk stratification is fundamental in the initial assessment of patients with bleeding. Aggressive resuscitation is the principal step for achieving haemodynamic stabilization of the patient, which will further allow appropriate interventions to be made for the definite control of bleeding. Overall management of major bleeding in the ED should follow a holistic individualized approach which includes haemodynamic stabilization, repletion of volume and blood loss, and reversal of coagulopathy and identification of the source of bleeding. The aim of the present practical guide is to provide an update on recent epidemiological data about the most common etiologies of bleeding and summarize the latest evidence regarding the bundles of care for the management of patients with major bleeding of traumatic or non-traumatic etiology in the ED.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Delta shock index predicts injury severity, interventions, and outcomes in trauma patients: A 10-year retrospective observational study

BACKGROUND

Most trauma occurs among young male subjects in Qatar. We examined the predictive values of the delta shock index (DSI), defined as the change in the shock index (SI) value from the scene to the initial reading in the emergency unit (i.e., subtracting the calculated SI at admission from SI at the scene), at a Level 1 trauma center.

AIM

To explore whether high DSI is associated with severe injuries, more interventions, and worse outcomes [i.e., blood transfusion, exploratory laparotomy, ventilator-associated pneumonia, hospital length of stay (HLOS), and in-hospital mortality] in trauma patients.

METHODS

A retrospective analysis was conducted after data were extracted from the National Trauma Registry between 2011 and 2021. Patients were grouped based on DSI as low (≤ 0.1) or high (> 0.1). Data were analyzed and compared using χ 2 and Student's t-tests. Correlations between DSI and injury severity score (ISS), revised trauma score (RTS), abbreviated injury scale (AIS), Glasgow coma scale (GCS), trauma score-ISS (TRISS), HLOS, and number of transfused blood units (NTBU), were assessed using correlation coefficient analysis. The diagnostic testing accuracy for predicting mortality was determined using the validity measures of the DSI. Logistic regression analysis was performed to identify predictors of mortality.

RESULTS

This analysis included 13212 patients with a mean age of 33 ± 14 years, and 24% had a high DSI. Males accounted for 91% of the study population. The trauma activation level was higher in patients with a high DSI (38% vs 15%, P = 0.001). DSI correlated with RTS (r = -0.30), TRISS (r = -0.30), NTBU (r = 0.20), GCS (r = -0.24), ISS (r = 0.22), and HLOS (r = 0.14) (P = 0.001 for all). High DSI was associated with significantly higher rates of intubation, laparotomy, ventilator-associated pneumonia, massive transfusion activation, and mortality than low DSI. For mortality prediction, a high DSI had better specificity, negative predictive value, and negative likelihood ratio (77%, 99%, and 0.49%, respectively). After adjusting for age, emergency medical services time, GCS score, and ISS, multivariable regression analysis showed that DSI was an independent predictor of mortality (odds ratio = 1.9; 95% confidence interval: 1.35-2.76).

CONCLUSION

In addition to sex-biased observations, almost one-quarter of the study cohort had a higher DSI and were mostly young. High DSI correlated significantly with the other injury severity scores, which require more time and imaging to be ready to use. Therefore, DSI is a practical, simple bedside tool for triaging and prognosis in young patients with trauma.

Using shock index, pediatric age adjusted (SIPA) to predict prolonged length of stay in perforated appendicitis: a retrospective review

PURPOSE

Hospital length of stay (LOS) following admission for appendicitis is difficult to predict. Shock index, pediatric age adjusted (SIPA) accurately identifies severely injured trauma patients and predicts mortality among children admitted to the ICU. Our aim was to determine if elevated SIPA at presentation, and time to normalization of SIPA, can identify children with perforated appendicitis and predict hospital LOS.

METHODS

This was a retrospective cohort study of children 1-17 years admitted to a quaternary care referral center with appendicitis after appendectomy in 2021. The primary outcomes were presence of perforated appendicitis and hospital LOS. Generalized linear regressions were performed. Covariates included in all models were age, sex, fecalith, initial temperature, and time from diagnosis to OR.

RESULTS

We included 169 patients; 53 (31.4%) had perforated appendicitis. After adjustment, elevated SIPA was associated with presence of perforated appendicitis (p = 0.0002) and longer LOS (p < 0.0001). A patient presenting with appendicitis and elevated SIPA had 5.447 times higher odds of having perforated appendicitis (95% CI: 2.262, 13.826), a mean hospital LOS 2.047 times longer (95% CI: 1.564, 2.683), a mean time to toleration of regular diet 4.995 times longer (95% CI: 2.914, 8.918), and a mean duration of antibiotics that is 1.761 times longer (95% CI: 1.383, 2.243) than a patient with normal SIPA.

CONCLUSION

In children with appendicitis, elevated SIPA at presentation is associated with higher risk of perforation. These findings support the incorporation of SIPA during triage of patients with appendicitis and counseling families after surgery.

LEVEL OF EVIDENCE

Level 3.

Predicting the critical administration threshold in bleeding trauma patients

INTRODUCTION

Delays in promptly recognizing and appropriately managing hemorrhagic injuries contribute to preventable trauma related deaths nationwide. We sought to identify patient variables available at the time of emergency department arrival associated with meeting the critical administration threshold.

METHODOLOGY

We conducted a trauma registry review from September 2016 to March 2020 of trauma team activations at The Ottawa Hospital, a Level 1 Trauma Center. Our primary outcome was the frequency of meeting the critical administration threshold. Secondary outcomes included time to critical administration threshold, 24-h all-cause mortality, and 30-day all-cause mortality. Multivariate logistic regression identified factors independently associated with meeting the critical administration threshold.

RESULTS

We assessed 762 patients, of which 78 (10.2%) met the critical administration threshold. The median time to critical administration threshold was 28.9 min. Mortality at 24 h occurred in 58 (7.6%) patients. Four variables available upon patient arrival predicted the critical administration threshold, including systolic blood pressure ≤ 90 mmHg (OR 6.6; 95% CI 3.7-12.0), Glasgow Coma Scale ≤ 8 (OR 5.9; 95% CI 3.2-10.6), heart rate ≥ 100 beats/minute (OR 4.4; 95% CI 2.4-8.1), and respiratory rate ≥ 20 breaths/min (OR 2.2; 95% CI 1.2-4.0).

CONCLUSION

We identified four clinical variables readily available to physicians upon patient arrival associated with meeting the critical administration threshold: systolic blood pressure ≤ 90 mmHg, Glasgow Coma Scale ≤ 8, heart rate ≥ 100 beats/minute, and respiratory rate ≥ 20 breaths/min. Patients presenting with any of these clinical parameters should prompt physicians to consider ordering blood products immediately.

Emergency cesarean section in pregnant trauma patients presenting after motor vehicle collision

Background

Most pregnant trauma patients (PTPs) present after motor vehicle collision (MVC). The national rate and risk factors for emergency cesarean section (ECS) during the index hospitalization for pregnant trauma patients (PTPs) are unknown. We sought to investigate the national rate of ECS in PTPs presenting after MVC, hypothesizing a higher risk of ECS among those with severe injuries or elevated shock index (SI).

Methods

The 2020-2021 TQIP was queried for PTPs presenting after MVC. PTPs that underwent ECS were compared to patients that did not undergo ECS. Elevated SI was defined as ≥1. Severe injury was defined by abbreviated injury scale grade ≥3. Bivariate and multivariable logistic regression analyses were performed.

Results

From 1183 PTPs, 95 (8.0 %) underwent ECS. The median time to ECS was 115 min. The ECS group had higher rates of lung (27.4 % vs. 12.2 %, p < 0.001) injury, spleen (18.9 % vs. 5.5 %, p < 0.001) injury, and elevated SI (22.1 % vs. 9.8 %, p < 0.001). ECS patients had higher rates of complication (9.5 % vs. 2.1 %, p < 0.001) and death (4.2 % vs. 1.1 %, p = 0.012). Independently associated risk factors for ECS included severe head (OR 2.65, CI 1.14-6.17, p = 0.023) or abdominal (OR 2.07, CI 1.08-3.97, p = 0.028) injuries and elevated SI (OR 2.17 CI 1.25-3.79, p = 0.006).

Conclusion

The national rate of ECS among PTPs presenting after MVC is 8 % with most occurring within the first 2 hours of arrival. Severe head and abdominal injuries as well as elevated SI are risk factors for ECS.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Massive transfusion in trauma

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of currently recommended treatment approaches for traumatic hemorrhage shock, with a special focus on massive transfusion.

RECENT FINDINGS

Severe trauma patients require massive transfusion, but consensual international definitions for traumatic hemorrhage shock and massive transfusion are missing. Current literature defines a massive transfusion as transfusion of a minimum of 3-4 packed red blood cells within 1 h. Using standard laboratory and/or viscoelastic tests, earliest diagnosis and treatment should focus on trauma-induced coagulopathy and substitution of substantiated deficiencies.

SUMMARY

To initiate therapy immediately massive transfusion protocols are helpful focusing on early hemorrhage control using hemostatic dressing and tourniquets, correction of metabolic derangements to decrease coagulopathy and substitution according to viscoelastic assays and blood gases analysis with tranexamic acid, fibrinogen concentrate, red blood cells, plasma and platelets are recommended. Alternatively, the use of whole blood is possible. If needed, further support using prothrombin complex, factor XIII or desmopressin is suggested.

Reverse shock index multiplied by simplified motor score as a predictor of clinical outcomes for patients with COVID-19

BACKGROUND

The reverse shock index (rSI) combined with the Simplified Motor Score (sMS), that is, the rSI-sMS, is a novel and efficient prehospital triage scoring system for patients with COVID-19. In this study, we evaluated the predictive accuracy of the rSI-sMS for general ward and intensive care unit (ICU) admission among patients with COVID-19 and compared it with that of other measures, including the shock index (SI), modified SI (mSI), rSI combined with the Glasgow Coma Scale (rSI-GCS), and rSI combined with the GCS motor subscale (rSI-GCSM).

METHODS

All patients who visited the emergency department of Taipei Tzu Chi Hospital between January 2021 and June 2022 were included in this retrospective cohort. A diagnosis of COVID-19 was confirmed through a SARS-CoV-2 reverse-transcription polymerase chain reaction test or SARS-CoV-2 rapid test with oropharyngeal or nasopharyngeal swabs and was double confirmed by checking International Classification of Diseases, Tenth Revision, Clinical Modification codes in electronic medical records. In-hospital mortality was regarded as the primary outcome, and sepsis, general ward or ICU admission, endotracheal intubation, and total hospital length of stay (LOS) were regarded as secondary outcomes. Multivariate logistic regression was used to determine the relationship between the scoring systems and the three major outcomes of patients with COVID-19, including. The discriminant ability of the predictive scoring systems was investigated using the area under the receiver operating characteristic curve, and the most favorable cutoff value of the rSI-sMS for each major outcome was determined using Youden's index.

RESULTS

After 74,183 patients younger than 20 years (n = 11,572) and without COVID-19 (n = 62,611) were excluded, 9,282 patients with COVID-19 (median age: 45 years, interquartile range: 33-60 years, 46.1% men) were identified as eligible for inclusion in the study. The rate of in-hospital mortality was determined to be 0.75%. The rSI-sMS scores were significantly lower in the patient groups with sepsis, hyperlactatemia, admission to a general ward, admission to the ICU, total length of stay ≥ 14 days, and mortality. Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS exhibited a significantly higher accuracy for predicting general ward admission, ICU admission, and mortality but a similar accuracy to that of the rSI-GCS. The optimal cutoff values of the rSI-sMS for predicting general ward admission, ICU admission, and mortality were calculated to be 3.17, 3.45, and 3.15, respectively, with a predictive accuracy of 86.83%, 81.94%%, and 90.96%, respectively.

CONCLUSIONS

Compared with the SI, mSI, and rSI-GCSM, the rSI-sMS has a higher predictive accuracy for general ward admission, ICU admission, and mortality among patients with COVID-19.

The Factors Associated With Decreasing Hemoglobin Levels and Platelet Counts After Trauma

Objective In this study, we investigated the factors related to anemia and platelet reduction in patients with moderate to severe trauma to gain a deeper understanding of these phenomena. Methods Our study spanned the period from April 2021 to September 2023, and it involved a retrospective review of the hospital medical charts of all emergency outpatients of all ages who were transported by a physician-staffed helicopter and treated at our hospital and were diagnosed with an Injury Severity Score (ISS) of >8 by CT on arrival. The following data were analyzed: sex; age; mechanism of injury; vital signs upon arrival at the hospital; ISS; hemoglobin level and platelet count on arrival and day two; fibrin degradation product (FDP) level, lactate dehydrogenase (LDH) level, and diameter of the inferior vena cava (IVC) on arrival; and infusion volume on day one. We then statistically calculated the independent risk factors for differences between hemoglobin levels and platelet counts on arrival and those on day two. Results The study included a total of 209 subjects, with an average age of 58 years and a male predominance. Multivariate analysis showed that the FDP level, IVC diameter, and age were significantly associated with changes in hemoglobin levels on arrival and day two, whereas the IVC diameter, LDH, age, systolic blood pressure, and sex were significantly associated with changes in the platelet count on arrival and day two. Conclusions A noteworthy correlation was found between certain factors and changes in hemoglobin levels and platelet counts between the initial assessment and the second day in our cohort. We recommend further prospective research to determine whether our findings hold true for a larger population of trauma patients.

Investigating Factors Affecting Mortality Due to Spinal Cord Trauma in Patients Admitted to the Intensive Care Unit

Objectives

This study was conducted to investigate the factors affecting mortality due to spinal cord trauma in patients admitted to the intensive care unit (ICU).

Methods

This study was conducted in a group of patients who were admitted to the ICU with a Traumatic Spinal Injuries (TSI) diagnosis. The researcher started sampling by assessing the documents of the patients hospitalized in the ICU, and the diagnosis of TSI was confirmed for them. Besides, utilizing a researcher-made checklist, factors affecting the mortality of patients were identified. The data were analyzed using the SPSS software version 16. P<0.05 was considered statistically significant.

Results

About 412 (64.2%) patients were men, about 213 (33.2%) of the patients had GCS between 3-8 grade. There were injuries in the pelvis area. Moreover, there was a significant relationship between GCS score status and the number of injury follow-ups in addition to TSI. Therefore, the mortality rate was higher in patients who had lower GCS (Odds ratio=2.32, p<0.001). There was also a significant relationship between the number of injuries and the mortality rate, and patients who had multiple traumas had a higher mortality rate. Besides, a significant relationship was observed between the complications caused by trauma, including cerebrovascular accident, cardiac arrest, acute respiratory distress syndrome (ARDS), pneumonia, and the mortality of patients hospitalized in the SICU (p<0.05).

Conclusion

The patients' mortality was influenced by factors such as their level of consciousness, the number of traumas caused in the spinal cord, and the occurrence of comorbidities such as cerebrovascular accident, cardiac arrest, ARDS, and pneumonia. Therefore, it is necessary to take the essential measures to reduce these complications.

Can cardiovascular reserve index (CVRI) on arrival to the trauma unit detects massive hemorrhage and predicts developing hemorrhage? observational prospective cohort study

BACKGROUND

The detection of haemorrhage in trauma casualties may be delayed owing to compensatory mechanisms. This study aimed to evaluate whether the cardiovascular reserve index (CVRI) on arrival detects massive haemorrhage and predicts haemorrhage development in trauma casualties.

METHODS

This was an observational prospective cohort study of adult casualties (≥18 years) who were brought to a single level-1 trauma centre, enroled upon arrival and followed until discharge. Vital signs were monitored on arrival, from which the CVRI and shock index were retrospectively calculated (blinded to the caregivers). The outcome measure was the eventual haemorrhage classification group: massive haemorrhage on arrival (MHOA) (defined by massive transfusion on arrival of ≥6 [O+] packed cells units), developing haemorrhage (DH) (defined by a decrease in haemoglobin >1 g/dl in consecutive tests), and no significant haemorrhage noted throughout the hospital stay. The means of each variable on arrival by haemorrhage group were evaluated using the analysis of variance. The authors evaluated the detection of MHOA in the entire population and the prediction of DH in the remainders (given that MHOA had already been detected and treated) by C-statistic predefined strong prediction by area under the curve (AUC) greater than or equal to 0.8, P less than or equal to 0.05.

RESULTS

The study included 71 patients (after exclusion): males, 82%; average age 37.7 years. The leading cause of injuries was road accident (61%). Thirty-nine (54%) patients required hospital admission; distribution by haemorrhage classification: 5 (7%) MHOA, 5 (7%) DH, and 61 (86%) no significant haemorrhage. Detection of MHOA found a strong predictive model by CVRI and most variables (AUC 0.85-1.0). The prediction of DH on arrival showed that only lactate (AUC=0.88) and CVRI (0.82) showed strong predictive model.

CONCLUSIONS

CVRI showed a strong predictive model for detection of MHOA (AUC>0.8) as were most other variables. CVRI also showed a strong predictive model for detection of DH (AUC=0.82), only serum lactate predicted DH (AUC=0.88), while all other variables were not found predictive. CVRI has advantages over lactate in that it is feasible in pre-hospital and mass casualty settings. Moreover, its repeatability enables detection of deteriorating trend. The authors conclude that CVRI may be a useful additional tool in the evaluation of haemorrhage.

Traumatic pancreas, kidney, liver, spleen, gastric and diaphragma rupture with enterothorax after blunt trauma caused by falling in an adolescent: a case report

Injury of almost all intra-abdominal organs in blunt trauma without bone and brain injury is very rare. This is the case report of a 16-year-old adolescent with severe abdominal trauma who was hit on his abdomen by a falling maytree. After admission to a Level I trauma center, emergency room treatment according to ATLS and after this emergency surgery was performed. Blood coagulation diagnostics was done using thrombo-elastography and factors and blood products have been applied according to its results keeping guidelines in mind. Damage-control surgery stopped the bleeding, and he was admitted to ICU. After second and third look surgery, the abdomen was closed. Structured diagnostics and treatment were crucial in this case. The education of trauma surgeons should include general surgery skills. These skills and knowledge of blood coagulation diagnostics and therapy saved the patient's life in this case.