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

Delta shock index in the emergency department as a predictor of clinical outcomes in traumatic injury

OBJECTIVES

The shock index (SI) is widely used to screen for patients in shock, and the dSI is created by utilizing prehospital SI and emergency department SI to enhance predictive accuracy. However, few have compared dSI with prehospital SI and SI at ED, and even fewer have explored the directional changes in dSI. This study aims to evaluate the prediction accuracy of prehospital SI, SI at ED, and delta SI in trauma patients, proposing that the delta scoring systems provide a more precise tool for field triage.

PATIENTS AND METHODS

This study conducted a cohort analysis involving 48,524 patients from the trauma registry data at Tzu Chi Hospital. The three primary outcomes assessed were in-hospital mortality, intensive care unit (ICU) admission, and prolonged total length of hospital stay (≥ 30 days). The area under the receiver operating characteristic curve (AUROC) for these scores was calculated and compared using the DeLong test. The delta SI was calculated as the difference between prehospital SI and SI at the emergency department (ED). The dSI was categorized into five groups: dSI < -0.5, -0.5 ≤ dSI < -0.1, -0.1 ≤ dSI < 0.1, 0.1 ≤ dSI < 0.5, and 0.5 ≤ dSI.

RESULTS

Prehospital SI, SI at ED, and dSI were significant predictors of in-hospital mortality, ICU admission, and prolonged length of stay (LOS) of ≥30 days. Compared to prehospital SI and SI at ED, dSI demonstrated significantly higher AUROC values in discriminating major injury, prolonged ICU stay, and in-hospital mortality. The groups with dSI < -0.5 and dSI ≥ 0.5 exhibited a significantly higher risk of in-hospital mortality compared to other dSI group with adjusted odds ratio (aOR) of 2.170 and 2.976. A J-shaped relationship in aOR values was observed across different dSI ranges for in-hospital mortality. The dSI ≥ 0.5 group had an increased risk of in-hospital mortality among elderly patients, those with major or minor injuries, and both TBI and non-TBI groups. The dSI ≥ 0.1 demonstrated accuracies of 80.94 % for predicting ISS ≥ 16, 72.91 % for ICU admission, 87.14 % for prolonged LOS ≥ 30 days, and 89.33 % for predicting mortality.

CONCLUSIONS

The dSI demonstrated significantly better discriminative ability for major injury, prolonged ICU stay, and in-hospital mortality. A potential J-shaped relationship has been identified between dSI and mortality, indicating that both the dSI < -0.5 and dSI ≥ 0.5 groups have a significantly higher risk of in-hospital mortality. It is anticipated that dSI will be integrated into clinical practice for the field triage of trauma patients in the future.

Validation of the FASILA Score for Predicting Interventions and Outcomes in Traumatic Abdominal and Pelvic Injuries: A Prospective Clinical Study

BACKGROUND

The FASILA score is a 7-point scale comprising the FAST (focused assessment with sonography in trauma), shock index, and serum lactate. We aimed to validate this score prospectively in patients with abdominal and pelvic trauma to predict the need for massive blood transfusion, laparotomy, and inhospital mortality.

METHODS

This prospective study included all adult patients who sustained abdominal and/or pelvic trauma. Pediatric patients, prehospital cardiac arrest, and severe head injury were excluded. Data were analyzed and compared with low (< 4) versus high (≥ 4) FASILA scores.

RESULTS

A total of 400 patients (mean age 36.3 ± 12.7; 90% male; and 96% had blunt trauma) were enrolled between 2022 and 2024. Patients with higher FASILA scores (19.3%) had higher rates of exploratory laparotomy and radiological interventions and received more blood transfusions. They also had longer hospital stays, higher rates of sepsis, and mortality (p = 0.001). The FASILA scores significantly correlated with shock index (r = 0.75), ISS (r = 0.38), SOFA score (r = 0.36), and abdominal AIS (r = 0.27), TRISS (r = -0.19), RTS (r = -0.26), and fibrinogen levels (r = -0.12). A FASILA score ≥ 4 had a high specificity (85.5%) and negative predictive value (80%) for predicting the need for surgery. The FASILA score was an independent predictor of blood transfusion (odds ratio 1.92 and 95% CI 1.43-2.58) after adjusting for abdominal AIS, ISS, SOFA score, and fibrinogen level. AUROC curves were better for the FASILA score than ABC score and "SI alone" for the prediction of MTP and surgical interventions.

CONCLUSION

The significant association between high FASILA scores and blood transfusions, surgical interventions, and mortality indicates its usefulness in early risk stratification in abdominopelvic trauma. Multicenter studies are recommended to enhance external validity across diverse populations and settings.

Nomogram establishment for gastrointestinal bleeding prediction in ICU patients with traumatic brain injury based on the MIMIC-IV database

Objectives

This study aimed to develop a robust nomogram for predicting the occurrence of gastrointestinal bleeding (GIB) in patients with traumatic brain injury (TBI) during their ICU stay, thereby facilitating the optimization of intervention strategies and enabling personalized treatment approaches.

Methods

Patient data were extracted from the publicly available MIMIC-IV (Medical Information Mart for Intensive Care IV) database. In this retrospective cohort study, a total of 2,774 patients with traumatic brain injury (TBI) were included. A 7:3 ratio was applied to allocate patients into the training and validation cohorts. A LASSO logistic regression model was constructed using the training set to identify potential predictors of gastrointestinal bleeding (GIB). The selected features were subsequently utilized to develop a nomogram model. The performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration curves, and decision curve analysis (DCA).

Results

A nomogram model comprising six variables-gender, blood urea nitrogen (BUN), Shock Index (SI), albumin, SOFA score, and diabetes mellitus-was developed. These variables were identified as independent risk factors for gastrointestinal bleeding (GIB) in patients with traumatic brain injury (TBI) (p < 0.05). The area under the receiver operating characteristic curve (AUC) for the derivation cohort and validation cohort was 0.8541 (95% CI: 0.833 to 0.911) and 0.8381 (95% CI: 0.752 to 0.863), respectively. The calibration curve demonstrated good agreement between the predicted probabilities and actual observations, while decision curve analysis (DCA) highlighted the clinical utility of the predictive model.

Conclusion

This study developed a predictive model for GIB in patients with TBI, which may assist clinicians in early identification of high-risk patients and help mitigate the burden of GIB in susceptible populations.

Survival Rate in Emergency Thoracotomy for Penetrating Trauma: A Retrospective Cross-Sectional Study

Background Emergency thoracotomy (ET) is a critical intervention for traumatic thoracic injuries, often required in patients with penetrating trauma. The survival outcomes and the factors that influence survival in these patients remain an area of interest for trauma care providers. Objective The objective of the study is to assess the survival rate and factors influencing the survival of patients undergoing emergency thoracotomy due to penetrating thoracic trauma. Methods This retrospective cross-sectional study was conducted in the thoracic surgery, accident, and emergency department of Lady Reading Hospital, Peshawar, Pakistan. A total of 85 patients who underwent emergency thoracotomy following penetrating trauma between July 2019 and June 2024 were included. Data were extracted from the health information management system (HIMS) and analyzed using SPSS. The study reviewed demographic details, severity of injury, operative details, and postoperative outcomes. Statistical analyses included univariate analysis using chi-square and Fisher's exact tests for categorical data and independent t-tests for continuous variables. Results The study included 85 patients with a mean age of 25.72±7.84 years. The majority of patients were male (81/85, 95.29%), while females accounted for a smaller proportion (4/85, 4.71%), and gunshot trauma accounted for the most frequent cause of penetrating injury (50/85, 58.8%). The time to thoracotomy was within 60 minutes of admission, with a mean time of 48±16.5 minutes. A total of 61/85 (71.5%) patients had isolated thoracic injuries, and 24/85 (28.2%) had associated injuries, with 24/85 (28.2%) patients requiring concomitant laparotomy. The overall mortality rate was 9/85 (10.5%), with 7/9 (77.7%) of deaths occurring intraoperatively. Mortality was significantly higher in patients with combined thoracotomy and laparotomy procedures. Prolonged hospital stays and higher transfusion requirements were observed in gunshot wound victims (50/85, 58.8%). Conclusions Emergency thoracotomy for penetrating thoracic trauma has a significant mortality rate in patients with combined thoracic and abdominal injuries. Factors such as the mechanism of injury, associated injuries, and the need for additional procedures (e.g., laparotomy) influence survival outcomes. Early intervention and proper management of associated injuries are crucial for improving survival rates in these patients.