Higher Shock Index Research Articles

Temporal changes in blood pressure following prehospital rapid sequence intubation

BackgroundRapid Sequence intubation (RSI) is an airway procedure that uses sedative and paralytic drugs to facilitate endotracheal intubation. It is known that RSI could impact blood pressure in the peri-intubation...

Endoscopic hemostasis makes the difference: Angiographic treatment in patients with lower gastrointestinal bleeding.

BACKGROUNDThe large majority of gastrointestinal bleedings subside on their own or after endoscopic treatment. However, a small number of these may pose a challenge in terms of therapy because the patients develop hemodynamic instability, and endoscopy does not achieve adequate hemostasis. Interventional radiology supplemented with catheter angiography (CA) and transarterial embolization have gained importance in recent times.AIMTo evaluate clinical predictors for angiography in patients with lower gastrointestinal bleeding (LGIB).METHODSWe compared two groups of patients in a retrospective analysis. One group had been treated for more than 10 years with CA for LGIB (n = 41). The control group had undergone non-endoscopic or endoscopic treatment for two years and been registered in a bleeding registry (n = 92). The differences between the two groups were analyzed using decision trees with the goal of defining clear rules for optimal treatment.RESULTSPatients in the CA group had a higher shock index, a higher Glasgow-Blatchford bleeding score (GBS), lower serum hemoglobin levels, and more rarely achieved hemostasis in primary endoscopy. These patients needed more transfusions, had longer hospital stays, and had to undergo subsequent surgery more frequently (P < 0.001).CONCLUSIONEndoscopic hemostasis proved to be the crucial difference between the two patient groups. Primary endoscopic hemostasis, along with GBS and the number of transfusions, would permit a stratification of risks. After prospective confirmation of the present findings, the use of decision trees would permit the identification of patients at risk for subsequent diagnosis and treatment based on interventional radiology.

Prognostic value of shock index in patients admitted with non-ST-segment elevation myocardial infarction: the ARIC study community surveillance.

Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and predictive of mortality in patients with ST-segment elevation myocardial infarction. However, large-scale evaluations of SI in patients with non-ST-segment elevation myocardial infarction (NSTEMI) are lacking. Hospitalizations for acute myocardial infarction were sampled from four US areas by the Atherosclerosis Risk in Communities (ARIC) study and classified by physician review. Shock index was derived from the HR and SBP at first presentation and considered high when ≥0.7. From 2000 to 2014, 18 301 weighted hospitalizations for NSTEMI were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs. 39%) and had more prevalent chronic kidney disease (40% vs. 32%). TIMI (Thrombolysis in Myocardial Infarction) risk scores were similar between the groups (4.3 vs. 4.2), but GRACE (Global Registry of Acute Coronary Syndrome) score was higher with high SI (140 vs. 118). Angiography, revascularization, and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was higher (13% vs. 5%). Prediction of 28-day mortality by SI as a continuous measurement [area under the curve (AUC): 0.68] was intermediate to that of the GRACE score (AUC: 0.87) and the TIMI score (AUC: 0.54). After adjustments, patients with high SI had twice the odds of 28-day mortality (odds ratio = 2.02; 95% confidence interval: 1.46-2.80). The SI is easily obtainable, performs moderately well as a predictor of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.

Shock Index in the early assessment of febrile children at the emergency department: a prospective multicentre study

Objective(1) To derive reference values for the Shock Index (heart rate/systolic blood pressure) based on a large emergency department (ED) population of febrile children and (2) to determine the diagnostic...

Prehospital shock index and systolic blood pressure are highly specific for pediatric massive transfusion.

While massive transfusion protocols (MTPs) are associated with decreased mortality in adult trauma patients, there is limited research on the impact of MTP on pediatric trauma patients. The purpose of this study was to compare pediatric trauma patients requiring massive transfusion with all other pediatric trauma patients to identify triggers for MTP activation in injured children. Using our level I trauma center's registry, we retrospectively identified all pediatric trauma patients from January 2015 to January 2018. Massive transfusion (MT) was defined as infusion of 40 mL/kg of blood products in the first 24 hours of admission. Patients missing prehospital vital sign data were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data, prehospital vital signs, prehospital transport times, and Injury Severity Scores. Statistical significance was determined using Mann-Whitney U test and χ2 test. p Values of less than 0.05 were considered significant. Thirty-nine (1.9%) of the 2,035 pediatric patients met the criteria for MT. All-cause mortality in MT patients was 49% (19 of 39 patients) versus 0.01% (20 of 1996 patients) in non-MT patients. The two groups significantly differed in Injury Severity Score, prehospital vital signs, and outcome data.Both systolic blood pressure (SBP) of <100 mm Hg and shock index (SI) of >1.4 were found to be highly specific for MT with specificities of 86% and 92%, respectively. The combination of SBP of <100 mm Hg and SI of >1.4 had a specificity of 94%. The positive and negative predictive values of SBP of <100 mm Hg and SI of >1.4 in predicting MT were 18% and 98%, respectively. Based on positive likelihood ratios, patients with both SBP of <100 mm Hg and SI of >1.4 were 7.2 times more likely to require MT than patients who did not meet both of these vital sign criteria. Pediatric trauma patients requiring early blood transfusion present with lower blood pressures and higher heart rates, as well as higher SIs and lower pulse pressures. We found that SI and SBP are highly specific tools with promising likelihood ratios that could be used to identify patients requiring early transfusion. Therapeutic/care management, level V.

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

BackgroundMassive 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.MethodsWe 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.ResultsA 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%.ConclusionAngioembolization 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.

Association of the age shock index with coronary plaque characteristics in ST-segment elevation myocardial infarction: A 3-vessel optical coherence tomography study.

We investigated whether the age shock index (SI) was associated with coronary plaque characteristics in patients with ST-segment elevation myocardial infarction (STEMI) using optical coherence tomography (OCT). The age SI is a simple clinical parameter that effectively predicts poor clinical outcomes among patients with STEMI. This retrospective study evaluated 408 STEMI patients who underwent 3-vessel OCT during emergency percutaneous coronary interventions at a single center between January 2017 and October 2018. Patients were divided into groups with low or high age SI values (<41 vs. ≥41). Plaque characteristics were compared between the two groups for both culprit lesions (n = 408) and non-culprit lesions (n = 1,077). In culprit lesions, patients with a high age SI (≥41) were more likely to have plaque rupture (61.0% vs. 56.8%, p = .002) and thinner fibrous caps (fibrous cap thickness [FCT]: 40.0 [33.0-53.0] μm vs. 46.0 [36.0-63.8] μm, p = .021). In non-culprit lesions, patients with a high age SI were more likely to have high-risk plaques (29.9% vs. 17.8%, p = .018; simultaneous presence of a minimal lumen area of <3.5 mm2 , maximum lipid arc of >180°, FCT of <75 μm, and macrophage accumulation). Plaque-based analyses revealed that patients with a high age SI had larger lipid cores and lesser FCT. Patients with STEMI and a high age SI had increased risks of culprit plaque rupture and high-risk non-culprit plaques, and vulnerable plaque features at the culprit and non-culprit lesions. Therefore, a high age SI in patients with STEMI may indicate greater pancoronary vulnerability.

Shock index as a predictor for short-term mortality in helicopter emergency medical services: A registry study.

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. 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. 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 30days). 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. 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.

Comparison of shock index-based risk indices for predicting in-hospital outcomes in patients with ST-segment elevation myocardial infarction undergoing percutaneous coronary intervention.

ObjectiveWe aimed to determine whether the prognostic value of the shock index (SI) and its derivatives is better than that of the Thrombolysis In Myocardial Infarction risk index (TRI) for predicting adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI).MethodsA total of 257 patients with STEMI undergoing primary PCI from January 2018 to June 2019 were analyzed in a retrospective cohort study. The SI, modified shock index (MSI), age SI (age × the SI), age MSI (age × the MSI), and TRI at admission were calculated. Clinical endpoints were in-hospital complications, including all-cause mortality, acute heart failure, cardiac shock, mechanical complications, re-infarction, and life-threatening arrhythmia.ResultsMultivariate analyses showed that a high SI, MSI, age SI, age MSI, and TRI at admission were associated with a significantly higher rate of in-hospital complications. The predictive value of the age SI and age MSI was comparable with that of the TRI (area under the receiver operating characteristic curve: z = 1.313 and z = 0.882, respectively) for predicting in-hospital complications.ConclusionsThe age SI and age MSI appear to be similar to the TRI for predicting in-hospital complications in patients with STEMI undergoing primary PCI.

Role of Arterial Serum Lactate as a Predictor of Undifferentiated Shock on Admission and its Outcome- A Cohort Study

Introduction: Patients with elevated serum lactate levels may be at risk for considerable morbidity and mortality and require a prompt, thoughtful and systematic approach for diagnosis and treatment. Aim: To find an association of on admission arterial serum lactate with outcome in Intensive Care Unit (ICU) patients. Materials and Methods: This observational cohort study was conducted on 168 patients at Poona Hospital and Research Centre, Pune, India, between June 2018 to November 2019 after obtaining Institutional Ethical Clearance. The patients included were above 18 years of age who had Systolic Blood Pressure (SBP) &lt;90 mmHg, Heart Rate (HR) &gt;100/min and Respiratory Rate (RR) &gt;20/min. The arterial serum lactate level were examined on the day of admission, 12 hours and 24 hours. The need of ionotropic support, duration of ICU stay and mortality in one month was noted. The primary outcome measures were to study the association of on admission arterial serum lactate level with a duration of ICU stay and in-hospital mortality, whereas the secondary outcome measure was to study the association of on admission arterial serum lactate with the requirement of ionotropic support. Analysis of data was done using Statistical Package for Social Sciences for Windows, version 20.0. Results: The incidence in-hospital mortality was 20 (22.7%) out of 88 and 3 (3.8%) out of 80 in patients whose serum lactate levels on admission were &gt;36 mg/dL and ≤36 mg/dL, respectively (p-value=0.002). The median duration of ICU stay was six and three days in patients whose serum lactate levels on admission were &gt;36 mg/dL and ≤36 mg/dL, respectively (p-value=0.001). A 87 (98.9%) patients whose serum lactate levels &gt;36 mg/dL on admission had the higher requirement of inotropes as compared to 35 (50.7%) patients whose serum lactate levels were ≤36 mg/dL. The percentage of patients whose serum lactate level &gt;36 mg/dL, had a significantly higher Quick Sequential Organ Failure Assessment (qSOFA) scores and higher Shock Index (SI). There was a statistically significant positive correlation between serum lactate levels and qSOFA score (r=0.555) and SI (r=0.559). Conclusion: Initial serum lactate level was associated with higher in-hospital mortality, the higher requirement of inotropic support and longer duration of ICU stay.

Single Institution Trial Comparing Whole Blood vs Balanced Component Therapy: 50 Years Later

Early close ratio transfusion with balanced component therapy (BCT) has been associated with improved outcomes in patients with severe hemorrhage; however, this modality is not comparable with whole blood (WB) constituents. We compared use of BCT vs WB to determine if one yielded superior outcomes in patients with severe hemorrhage. We hypothesized that WB would lead to reduced in-hospital mortality and blood product volume if given in the first 24 hours of admission. This was a 1-year, single institution, prospective, observational study comparing BCT with WB in adult (18+y) trauma patients with active hemorrhage who required blood transfusion upon arrival at the emergency department. Primary endpoint was in-hospital mortality. Secondary endpoints included 24-hour transfusion volumes, in-hospital clinical outcomes, and complications. A total of 253 patients were included; 71.1% received BCT and 29.9% WB. The WB cohort had significantly more penetrating trauma (64.4% vs 48.9%; p= 0.03) and higher Shock Index (1.12 vs 0.92; p= 0.04). WB patients received significantly fewer units of packed red blood cells (PRBCs) (p < 0.001) and fresh frozen plasma (FFP) (p= 0.04), with a lower incidence of ARDS (p= 0.03) and fewer ventilator days (p= 0.03). Kaplan Meier survival analysis revealed no difference in survival between the 2 transfusion strategies (p= 0.80). When adjusted for various markers of injury severity and critical illness in Cox regression analysis, WB remained unassociated with mortality (hazard ratio 1.25; 95% CI 0.60-2.58; p= 0.55). There was no difference in survival rates when comparing BCT with WB. In the WB group, the incidence of ARDS, duration of mechanical ventilation, massive transfusion protocol (MTP) activation, and transfusion volumes were significantly reduced. Further research should be directed at analyzing whether there is a true hemorrhage-related pathophysiologic benefit of WB when compared with BCT.

Abstract 13611: Prognostic Value of Shock Index in Patients Admitted With Non ST-Segment Elevation Myocardial Infarction: The ARIC Study Community Surveillance

Introduction: Shock index (SI), defined as the ratio of heart rate (HR) to systolic blood pressure (SBP), is easily obtained and has been reported to predict all-cause mortality in acute myocardial infarction (AMI) hospitalizations, primarily among patients with STEMI. Large-scale investigations examining the prognostic value of SI in patients with NSTEMI are lacking. Methods: Hospitalizations for acute myocardial infarction were sampled from 4 US areas by the ARIC Study and classified by physician review. HR and SBP at first presentation were abstracted from the medical record. Pulseless patients, those with unobtainable SBP, and transfer patients were excluded. An SI value ≥0.7 was considered high. The TIMI risk score for NSTE-ACS was calculated using the established algorithm. Predictions of all-cause 28-day mortality were analyzed using receiver operating characteristics (ROC). Results: From 2000-2014, 18,301 weighted hospitalizations for NSTEMI patients were sampled and had vitals successfully obtained. Of these, 5753 (31%) had high SI (≥0.7). Patients with high SI were more often female (46% vs 39%) and older (65 vs 63 years), with more prevalent chronic kidney disease (40% vs. 32%), pneumonia (16% vs 8%), and complication by acute heart failure (42% vs 30%). However, the TIMI risk score was comparable for the 2 groups (4.3 vs. 4.2). Angiography (36% vs 58%), revascularization (19% vs 41%), and guideline-directed medications were less often administered to patients with high SI, and the 28-day mortality was nearly 3 times higher (13% vs 5%). Continuous values of SI were more predictive of 28-day mortality than the TIMI risk score, both overall (ROC-AUC: 0.68 vs 0.54; P &lt;0.0001) and among the subset of patients who were revascularized (ROC-AUC: 0.72 vs. 0.56; P &lt;0.0001). Conclusion: The SI outperformed the TIMI risk score for prediction of short-term mortality in patients hospitalized with NSTEMI, and may be useful for risk stratification in emergency settings.

Shock index is associated with mortality in canine vehicular trauma patients.

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. Retrospective study from April 2016 to February 2018. Twenty-four-hour tertiary referral level II trauma center. One hundred twenty-one dogs presented to the emergency service for VT and 60 healthy control dogs. None. 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, 1.0vs 0.75; P< 0.0001). SI was significantly higher in those that died versus those that survived to discharge (median, 1.27vs 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). 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.

Association of age-adjusted shock index with mortality in children with trauma: a single-center study in Korea

Purpose This study was performed to investigate the association of high age-adjusted shock index (AASI) with mortality in Korean children with trauma. Methods The data of children (aged < 15 years) with trauma who visited a university hospital in Korea from 2010 through 2018 were reviewed. High AASI was defined by age groups as follows: < 12 months, ≥ 2.7; 12-23 months, ≥ 2.1; 2-4 years, ≥ 1.9; 5-11 years, ≥ 1.5; and 12-14 years, ≥ 1.1. Age, sex, transfer status, injury mechanism, hypotension, tachycardia, base deficit, hemoglobin concentration, trauma scores, hemorrhage-related procedures (transfusion and surgical interventions), and severe traumatic brain injury were compared according to high AASI and in-hospital mortality. The association of high AASI with the mortality was analyzed using logistic regression. Results Of the 363 enrolled children, 29 (8.0%) had high AASI and 24 (6.6%) died. The children with high AASI showed worse trauma scores and underwent hemorrhage-related procedures more frequently, without a difference in the rate of the traumatic brain injury. High AASI was associated with in-hospital mortality (survivors, 6.5% vs. non-survivors, 29.2%; P = 0.001). This association remained significant after adjustment (adjusted odds ratio, 6.42; 95% confidence interval, 1.38-29.82). The other predictors were Glasgow Coma Scale (for increment of 1 point; 0.62; 0.53-0.72) and age (for increment of 1 year; 0.84; 0.73-0.97). High AASI showed a 29.2% sensitivity and 93.5% specificity for the mortality. Conclusion High AASI is associated with mortality, and have a high specificity but low sensitivity in Korean children with trauma. This predictor of mortality can be used prior to obtaining the results of laboratory markers of shock. Key Words: Accidental Injuries; Age Groups; Child; Mortality; Multiple Trauma; Shock, Hemorrhagic

Retrospective evaluation of acute kidney injury in dogs with pit viper envenomation (2008-2017): 56 cases.

To describe the clinicopathological characteristics of dogs that develop acute kidney injury (AKI) secondary to pit viper envenomation, and to describe the association between development of AKI and clinical course and outcome. Retrospective study. University teaching hospital. Client-owned dogs treated with at least 1 vial of antivenom following pit viper envenomation and that had at least 2 plasma creatinine concentrations measured during the course of hospitalization. None. Sixty-three dogs met the inclusion criteria. One was excluded due chronic kidney disease, and 6 were excluded due to nonsteroidal anti-inflammatory drug administration. Of the 56 dogs included in the study, 16 developed AKI (29%). Dogs with AKI received a significantly higher dose of antivenom, 8.7 ± 6.8 total vials versus dogs in the non-AKI group that received 4.2 ± 2.6 vials (P=0.006). Dogs in the AKI group were significantly more tachycardic (P=0.028), hypotensive (P=0.002), had a higher shock index (P=0.012), and were more likely to receive transfusions with packed red blood cells (P=0.042) than dogs in the non-AKI group. No significant association was identified between the development of AKI and length of hospitalization. The only factors that were significantly associated with degree of severity of AKI included the receipt of blood transfusion (P=0.006) and number of vials of antivenom administered (P=0.03). The development of AKI was significantly associated with outcome (P<0.001), with 5 of 16 (31%) dogs in the AKI group surviving to discharge, 7 of 16 (44%) dying, and 4 of 16 (25%) being euthanized versus 39 of 40 (98%) surviving to discharge in the non-AKI group and 1 of 40 (2%) dying in hospital. Development of AKI in dogs following pit viper envenomation carries an increased risk of mortality that is associated with severity of shock at presentation and increased doses of antivenom administration.

Utility of shock index in 24,636 patients presenting with acute coronary syndrome.

Shock index is a bedside reflection of integrated response of the cardiovascular and nervous systems. We aimed to evaluate the utility of shock index (heart rate/systolic blood pressure) in patients presenting with acute coronary syndrome (ACS). We analyzed pooled data from seven Arabian Gulf registries; these ACS registries were carried out in seven countries (Qatar, Bahrain, Kuwait, UAE, Saudi Arabia, Oman and Yemen) between 2005 and 2017. A standard uniform coding strategy was used to recode each database using each registry protocol and clinical research form. Patients were categorized into two groups based on their initial shock index (low vs. high shock index). Optimal shock index cutoff was determined according to the receiver operating characteristic curve (ROC). Primary outcome was hospital mortality. A total of 24,636 ACS patients met the inclusion criteria with a mean age 57±13 years. Based on ROC analysis, the optimal shock index was 0.80 (83.5% had shock index <0.80 and 16.5% had shock index ≥0.80). In patients with high shock index, 55% had ST-elevation myocardial infarction and 45% had non-ST-elevation myocardial infarction. Patients with high shock index were more likely to have diabetes mellitus, late presentation, door to electrocardiogram >10 min, symptom to Emergency Department > 3 h, anterior myocardial infarction, impaired left ventricular function, no reperfusion post-therapy, recurrent ischemia/myocardial infarction, tachyarrhythmia and stroke. However, high shock index was associated significantly with less chest pain, less thrombolytic therapy and less primary percutaneous coronary intervention. Shock index correlated significantly with pulse pressure (r= -0.52), mean arterial pressure (r= -0.48), Global Registry of Acute Coronary Events score (r =0.41) and Thrombolysis In Myocardial Infarction simple risk index (r= -0.59). Shock index ≥0.80 predicted mortality in ACS with 49% sensitivity, 85% specificity, 97.6% negative predictive value and 0.6 negative likelihood ratio. Multivariate regression analysis showed that shock index was an independent predictor for in-hospital mortality (adjusted odds ratio (aOR) 3.40, p<0.001), heart failure (aOR 1.67, p<0.001) and cardiogenic shock (aOR 3.70, p<0.001). Although shock index is the least accurate of the ones tested, its simplicity may argue in favor of its use for early risk stratification in patients with ACS. The utility of shock index is equally good for ST-elevation myocardial infarction and non-ST-elevation acute coronary syndrome. High shock index identifies patients at increased risk of in-hospital mortality and urges physicians in the Emergency Department to use aggressive management.

Characteristics of Febrile Children Admitted to the ICU Following an Unscheduled ED Revisit Within 72 h, a Case-Control Study.

Objective: The purpose of this article was to demonstrate related characteristics of intensive care unit (ICU) admission after an unscheduled revisit by febrile children visiting the emergency department (ED).Method: We performed a retrospective study in a tertiary medical center from 2010 to 2016. Patients whose chief complaint was fever and who were admitted to the ICU following a 72-h return visit to the ED were included, and we selected patients who were discharged from the same emergency department for comparison.Results: During the study period, 54 (0.03%) patients met the inclusion criteria, and 216 patients were selected for the matched control group. Regarding clinical variables on initial ED visit, visiting during the night shift (66.7 vs. 46.8%, p = 0.010), shorter length of 1st ED stay (2.5 ± 2.63 vs. 3.5 ± 3.44 h, p = 0.017), and higher shock index (SI) (1.6 ± 0.07 vs. 1.4 ± 0.02, p = 0.008) were associated with ICU admission following a return visit. On the return ED visit, we found that clinical variables such as elevated heart rate, SI, white blood cell count, and C-reactive protein level were all associated with ICU admission. Furthermore, elevated SI and pediatric age-adjusted (SIPA) values were observed in the study group in both the initial (42.2 vs. 20.1%, OR:2.3 (1.37–4.31), p = 0.002) and return ED visits (29.7 vs. 6.9%, OR: 4.6 (2.42–8.26), p < 0.001).Conclusion: For children who visited the emergency department with a febrile complaint, elevated SIPA values on the initial ED visit were associated with ICU admission following an unscheduled ED revisit within 72 h.

Shock Index as a Marker for Mortality Rates in Those Admitted to the Medical Intensive Care Unit from the Emergency Department.

ObjectiveShock index (SI) is defined as the heart rate divided by systolic blood pressure. Studies have shown a correlation between the shock index and mortality in trauma patients in prehospital settings and in the emergency department (ED). The objective of this study was to identify the utility of SI in predicting mortality in the medical intensive care unit (MICU) patients admitted from the ED and transfers from the floor to MICU. DesignWe performed a retrospective analysis of adult patients admitted to the MICU at our urban trauma hospital between January 2015 through August 2015 using ED vital signs to calculate the shock index and identify inpatient deaths. Similar data were examined for inpatient transfers to the MICU.ResultsNine hundred and fifty patients were included in the study; 743 had an SI ≤ 0.99 with a mortality rate of 15.9%. Two hundred and seven patients had a SI ≥ 1.00 with a mortality rate of 22.7%. A higher SI was significant for mortality. There was no statistical significance in SI and mortality rate for patients transferred from the medical floor to the ICU.ConclusionsPatients with an SI ≥ 1.00 from initial ED vital signs correlated with a higher mortality rate. In patients transferred from the floor to MICU, SI ≥ 1.00 did not correlate with a higher mortality rate.

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

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

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

PurposeWe aimed to assess the utility of shock index (SI) to predict the need for massive transfusion protocol (MTP) in patients with solid organ injury (SOI) in a Level 1 Trauma center.MethodsWe conducted a retrospective analysis for patients with SOI between 2011 and 2014. Patients were categorized according to on-admission SI into low (< 0.8) and high SI (≥0.8) group.ResultsA total of 4500 patients were admitted with trauma, of them 572 sustained SOIs (289 patients had SI ≥0.8). In comparison to low SI, patients with high SI were younger, had higher injury severity scores (ISS) and lower Trauma and Injury Severity Score (TRISS); (p < 0.001). The proportion of exploratory laparotomy (EXLap), blood transfusion (BT), MTP activation, sepsis and hospital mortality were significantly higher in patients with high SI. Serum lactate (r = 0.34), hematocrit (r = − 0.34), ABC score (r = 0.62), ISS (r = 0.35), and amount of transfused blood (r = 0.22) were significantly correlated with SI. On multivariable regression analysis using 9 relevant variables (age, sex, ISS, ED GCS, serum lactate, hematocrit, Abdomen AIS and Focused assessment with sonography in trauma (FAST) and SI), SI ≥ 0.8 was an independent predictor of BT (OR 2.80; 95%CI 1.56–4.95) and MTP (OR 2.81;95% CI 1.09–7.21) .ConclusionsIn patients with SOI, SI is a simple bedside predictor for BT and MTP activation. Further prospective studies are needed to support our findings.