Shock index in patients with traumatic solid organ injury as a predictor of massive blood transfusion protocol activation

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.

Machine learning models predict triage levels, massive transfusion protocol activation, and mortality in trauma utilizing patients hemodynamics on admission

BACKGROUND

The effective management of trauma patients necessitates efficient triaging, timely activation of Massive Blood Transfusion Protocols (MTP), and accurate prediction of in-hospital outcomes. Machine learning (ML) algorithms have emerged as up-and-coming tools in the domains of optimizing triage decisions, improving intervention strategies, and predicting clinical outcomes, consistently outperforming traditional methodologies. This study aimed to develop, assess, and compare several ML models for the triaging processes, activation of MTP, and mortality prediction.

METHODS

In a 10-year retrospective study, the predictive capabilities of seven ML models for trauma patients were systematically assessed using on-admission patients' hemodynamic data. All patient's data were randomly divided into training (80 %) and test (20 %) sets. Employing Python for data preprocessing, feature scaling, and model development, we evaluated K-Nearest Neighbors (KNN), Logistic Regression (LR), Decision Tree (DT), Support Vector Machines (SVM) with RBF kernels, Random Forest (RF), Extreme Gradient Boosting (XGBoost), and Artificial Neural Network (ANN). We employed various imputation techniques and addressed data imbalance through down-sampling, up-sampling, and synthetic minority for the over-sampling technique (SMOTE). Hyperparameter tuning, coupled with 5-fold cross-validation, was performed. The evaluation included essential metrics like sensitivity, specificity, F1 score, accuracy, Area Under the Receiver Operating Curve (AUC ROC), and Area Under the Precision recall Curve (AUC PR), ensuring robust predictive capability.

RESULT

This study included 17,390 adult trauma patients; of them, 19.5 % (3385) were triaged at a critical level, 3.8 % (664) required MTP, and 7.7 % (1335) died in the hospital. The model's performance improved using imputation and balancing techniques. The overall models demonstrated notable performance metrics for predicting triage, MTP activation, and mortality with F1 scores of 0.75, 0.42, and 0.79, sensitivities of 0.73, 0.82, and 0.9, and AUC ROC values of 0.89, 0.95 and 0.99 respectively.

CONCLUSION

Machine learning, especially RF models, effectively predicted trauma triage, MTP activation, and mortality. Featured critical hemodynamic variables include shock indices, systolic blood pressure, and mean arterial pressure. Therefore, models can do better than individual parameters for the early management and disposition of patients in the ED. Future research should focus on creating sensitive and interpretable models to enhance trauma care.

Modified physiologic criteria for the field triage scheme: Efficacy of major trauma recognition in different age groups in Asia

BACKGROUND

Major trauma is a leading cause of unexpected death globally, with increasing age-adjusted death rates for unintentional injuries. Field triage schemes (FTSs) assist emergency medical technicians in identifying appropriate medical care facilities for patients. While full FTSs may improve sensitivity, step-by-step field triage is time-consuming. A simplified FTS (sFTS) that uses only physiological and anatomical criteria may offer a more rapid decision-making process. However, evidence for this approach is limited, and its performance in identifying all age groups requiring trauma center resources in Asia remains unclear.

METHODS

We conducted a multinational retrospective cohort study involving adult trauma patients admitted to emergency departments in the included countries from 2016 to 2020. Prehospital and hospital data were reviewed from the Pan-Asia Trauma Outcomes Study database. Patients aged ≥18 years transported by emergency medical services were included. Patients lacking data regarding age, sex, physiological criteria, or injury severity scores were excluded. We examined the performance of sFTS in all age groups and fine-tuned physiological criteria to improve sFTS performance in identifying high-risk trauma patients in different age groups.

RESULTS

The sensitivity and specificity of the physiological and anatomical criteria for identifying major trauma (injury severity score ≥ 16) were 80.6% and 58.8%, respectively. The modified sFTS showed increased sensitivity and decreased specificity, with more pronounced changes in the young age group. Adding the shock index further increased sensitivity in both age groups.

CONCLUSIONS

sFTS using only physiological and anatomical criteria is suboptimal for Asian adult patients with trauma of all age groups. Adjusting the physiological criteria and adding a shock index as a triage tool can improve the sensitivity of severely injured patients, particularly in young age groups. A swift field triage process can maintain acceptable sensitivity and specificity in severely injured patients.

Patterns of horse and camel- related injuries: A descriptive analysis from a national trauma registry (2007-2021)

BACKGROUND

The large animal-related injuries are emerging major trauma but remain underestimated public health problem worldwide. We aimed to determine the incidence, clinical characteristics, mechanisms and patterns of horse and camel-related injuries (HCRIs) in a Middle Eastern country.

METHODS

A retrospective analysis of all patients who were hospitalized due to HCRIs was conducted. Data included patient's demographics, mechanism of injury, anatomical location and severity of injury, and hospital outcomes.

RESULTS

Between November 2007 and December 2021, there were 273 hospitalized patients with HCRIs representing1.3 % of the total trauma admissions. Of these, 145 (53.1 %) and 128 (46.9 %) were horse (HRI) and camel-related injuries (CRI) respectively. The most common presenting age group of the cohort was 20-29 years and 88 % were males. Patients with HRIs were younger (27.5 ± 11 years) than CRIs (34 ± 13.5 years). Injuries to the extremities were the most common (62 % vs. 40 %), followed by the head injury (25.5 % vs. 31 %) among the HRIs and CRIs, respectively. The most common mechanism of injury was falling off followed by getting kicked by the HCRIs. Major trauma (ISS ≥12) was found in 23 % of HRIs (47.5 %) and CRIs (52.5 %). Only 5 % of patients had shock index >0.90 on admission; two thirds were due to CRIs. There were four fatalities (1.5 %), all attributed to traumatic brain injury, of which three were due to HRIs and one due to CRIs.

CONCLUSION

This study reveals that HCRIs predominantly affect young adult males and may involve serious injuries, exhibit distinct injury patterns, however, it is associated with low mortality. Preventive measures need to be revisited.

Extraperitoneal pelvic packing versus angiographic embolization for hemodynamically unstable pelvic fractures: a retrospective single-center analysis

OBJECTIVE

To retrospectively analyze the clinical data and treatment procedures of angiographic embolization (AE) and extraperitoneal pelvic packing (EPP) for traumatic pelvic fractures in our center for the purpose of providing recommendations on the selection of treatment protocols.

METHODS

We analyzed 110 patients with traumatic pelvic fractures treated with AE and EPP from January 2015 to May 2023. The patients were divided into the AE group (69 men, 41 women) and the EPP group (20 men, 12 women). The primary outcomes were the mortality rate and incidence of complications.

RESULTS

The mortality rate was slightly lower in the AE than EPP group (7.3% vs. 9.4%). The overall blood transfusion volume was lower and the length of hospital stay was shorter in the AE than EPP group (7.79 ± 12.04 vs. 9.14 ± 14.21 units and 20.48 ± 11.32 vs. 22.14 ± 10.47 days).

CONCLUSIONS

Both AE and EPP have good treatment effects. AE is preferred for patients in stable condition with severe hemorrhage. This study suggests that EPP should be the primary treatment and that AE should serve as a complementary treatment for critical patients.

Acute Changes in Body Muscle Mass and Fat Depletion in Hospitalized Young Trauma Patients: A Descriptive Retrospective Study

Background: Loss of muscle mass, and its strength, is associated with adverse outcomes in many medical and surgical conditions. Trauma patients may get malnourished during their hospital course due to many interrelated contributing factors. However, there is insufficient knowledge on the acute muscle and fat changes in young trauma patients in the early days post-admission. Objective: to explore the diagnosis, feeding status, and outcome of muscle mass loss among young abdominal polytrauma patients. Methods: It was a retrospective study including hospitalized abdominal trauma patients who underwent an abdominal computerized tomographic (CT) examination initially and a follow-up one week later. CT scan-based automatic and manual analysis of the muscles and fat of the abdominal region was calculated and compared. Also, we evaluated the feeding and nutritional values to explore the adequacy of the provided calories and proteins and the potential influence of enteral feeding on the CT-based parameters for muscle loss and fat depletion. Results: There were 138 eligible subjects with a mean age of 32.8 ± 13.5 years; of them, 92% were males. Operative interventions were performed on two-thirds of the patients, including abdominal surgery (43%), orthopedic surgeries (34%), and neurosurgical procedures (8.1%). On admission, 56% received oral feeding, and this rate slightly increased to 58.4% after the first week. Enteral feed was prescribed for the remaining, except for two patients. The percentage of change in the total psoas muscle area was significantly reduced after one week of admission in patients on enteral feed as compared to those in the oral feeding group (p = 0.001). There were no statistically significant differences in the percentages of changes in the CT scan findings except for the total psoas muscle area (p = 0.001) and para-spinal muscle area (p = 0.02), which reduced significantly in the those who underwent laparotomy as compared to those who did not need laparotomy. Trauma patients who underwent emergency abdominal surgery lost muscle and fat over time. Conclusions: Loss of muscle mass and body fat is not uncommon among young trauma patients. Patients who underwent laparotomy are more likely to be affected. Further larger studies are needed to assess the specific features in the younger trauma population and how far this can be influenced by the nutrition status and its impact on the clinical outcomes. It could be early or impending stages of sarcopenia linked to trauma patients, or just acute changes in the muscle and fat, that need further investigation and follow-up after hospital discharge.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome of post-traumatic acute respiratory distress syndrome in young patients requiring extracorporeal membrane oxygenation (ECMO)

We aimed to evaluate the outcomes of post-traumatic acute respiratory distress syndrome (ARDS) in young patients with and without Extracorporeal membrane oxygenation (ECMO) support. A retrospective analysis was conducted for trauma patients who developed ARDS at a level I trauma facility between 2014 and 2020. Data were analyzed and compared between ECMO and non-ECMO group. We identified 85 patients with ARDS (22 patients had ECMO support and 63 matched patients managed by the conventional mechanical ventilation; 1:3 matching ratio). The two groups were comparable for age, sex, injury severity score, abbreviated injury score, shock index, SOFA score, and head injury. Kaplan Meier survival analysis showed that the survival in the ECMO group was initially close to that of the non-ECMO, however, during follow-up, the survival rate was better in the ECMO group, but did not reach statistical significance (Log-rank, p = 0.43 and Tarone-Ware, p = 0.37). Multivariable logistic regression analysis showed that acute kidney injury (AKI) (Odds ratio 13.03; 95% CI 3.17–53.54) and brain edema (Odds ratio 4.80; 95% CI 1.10–21.03) were independent predictors of mortality. Sub-analysis showed that in patients with severe Murray Lung Injury (MLI) scores, non-ECMO group had higher mortality than the ECMO group (100% vs 36.8%, p = 0.004). Although ARDS is uncommon in young trauma patients, it has a high mortality. ECMO therapy was used in a quarter of ARDS cases. AKI and brain edema were the predictors of mortality among ARDS patients. ECMO use did not worsen the outcome in trauma patients; however, the survival was better in those who had severe MLI and ECMO support. Further prospective study is needed to define the appropriate selection criteria for the use of ECMO to optimize the outcomes in trauma patients.

Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries

INTRODUCTION

Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children.

MATERIALS AND METHODS

Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1.

RESULTS

There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P < 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions.

CONCLUSIONS

Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.

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

Introduction

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

Methods

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

Results

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

Conclusion

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

•

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

•

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

•

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

•

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

Utility of Angioembolization in Patients with Abdominal and Pelvic Traumatic Bleeding: Descriptive Observational Analysis from a Level 1 Trauma Center

Background

Massive bleeding is a major preventable cause of early death in trauma. It often requires surgical and/or endovascular intervention. We aimed to describe the utilization of angioembolization in patients with abdominal and pelvic traumatic bleeding at a level 1 trauma center.

Methods

We conducted a retrospective analysis for all trauma patients who underwent angioembolization post-traumatic bleeding between January 2012 and April 2018. Patients’ data and details of injuries, angiography procedures and outcomes were extracted from the Qatar national trauma registry.

Results

A total of 175 trauma patients underwent angioembolization during the study period (103 for solid organ injury, 51 for pelvic injury and 21 for other injuries). The majority were young males. The main cause of injury was blunt trauma in 95.4% of the patients. The most common indication of angioembolization was evident active bleeding on the initial CT scan (contrast pool or blushes). Blood transfusion was needed in two-third of patients. The hepatic injury cases had higher ISS, higher shock index and more blood transfusion. Absorbable particles (Gelfoam) were the most commonly used embolic material. The overall technical and clinical success rate was 93.7% and 95%, respectively, with low rebleeding and complication rates. The hospital and ICU length of stay were 13 and 6 days, respectively. The median injury to intervention time was 320 min while hospital arrival to intervention time was 274 min. The median follow-up time was 215 days. The overall cohort mortality was 15%.

Conclusion

Angioembolization is an effective intervention to stop bleeding and support nonoperative management for both solid organ injuries and pelvic trauma. It has a high success rate with a careful selection and proper implementation.

The FASILA Score: A Novel Bio-Clinical Score to Predict Massive Blood Transfusion in Patients with Abdominal Trauma

Background

Early identification of patients who may need massive blood transfusion remains a major challenge in trauma care. This study proposed a novel and easy-to-calculate prediction score using clinical and point of care laboratory findings in patients with abdominal trauma (AT).

Methods

Patients with AT admitted to a trauma center in Qatar between 2014 and 2017 were retrospectively analyzed. The FASILA score was proposed and calculated using focused assessment with sonography in trauma (0 = negative, 1 = positive), Shock Index (SI) (0 = 0.50–0.69, 1 = 0.70–0.79, 2 = 0.80–0.89, and 3 ≥ 0.90), and initial serum lactate (0 ≤ 2.0, 1 = 2.0–4.0, and 2 ≥ 4.0 mmol/l). Outcome variables included mortality, laparotomy, and massive blood transfusion (MT). FASILA was compared to other prediction scores using receiver operating characteristics and areas under the curves. Bootstrap procedure was employed for internal validation.

Results

In 1199 patients with a mean age of 31 ± 13.5 years, MT, MT protocol (MTP) activation, exploratory laparotomy (ExLap), and hospital mortality were related linearly with the FASILA score, Injury Severity Score, and total length of hospital stay. Initial hemoglobin, Revised Trauma Score (RTS), and Trauma Injury Severity Score (TRISS) were inversely proportional. FASILA scores correlated significantly with the Assessment of Blood Consumption (ABC) (r = 0.65), Revised Assessment of Bleeding and Transfusion (RABT) (r = 0.63), SI (r = 0.72), RTS (r = − 0.34), and Glasgow Coma Scale (r = − 0.32) and outperformed other predictive systems (RABT, ABC, and SI) in predicting MT, MTP, ExLap, and mortality.

Conclusions

The novel FASILA score performs well in patients with abdominal trauma and offers advantages over other scores.

Electronic supplementary material

The online version of this article (10.1007/s00268-019-05289-0) contains supplementary material, which is available to authorized users.