Initial Shock Index Research Articles

Trauma Scores Show Limited Utility for Predicting In-Flight Deterioration in Air Medical Patients

ObjectiveThe aim of this study was to determine the utility of the Triage Revised Trauma Score (TRTS), Glasgow Coma Scale/Age/systolic Pressure (GAP) score, and Shock Index (SI) in predicting in-flight hypotension and the need for critical care interventions in air medical trauma patients. MethodsA retrospective review of 3,582 air medical trauma cases from a 3-year period in Queensland was conducted. An initial TRTS, GAP score, and SI were calculated for each patient, and the lowest in-flight mean arterial pressure and systolic blood pressure were determined. The institution of in-flight critical care interventions was also recorded, including fluid resuscitation, vasopressors, and surgical procedures. The utility of the TRTS, GAP score, and SI for predicting in-flight hypotension was then examined using receiver operating characteristic curves. ResultsAll 3 approaches showed minor predictive value, with the GAP score performing slightly better than TRTS and SI for predicting in-flight interventions. The GAP score had a receiver operating characteristic area under the curve of 0.76 compared with 0.74 for the TRTS and SI. ConclusionNo score demonstrated sufficient predictive ability for deterioration in transit to be used clinically.

The shock index predicts in-flight blood transfusion in aeromedical trauma patients.

To define the utility of the Triage Revised Trauma Score (TRTS), GCS/Age/arterial Pressure (GAP) score, and shock index (SI) in predicting the need for in-flight blood product administration in civilian trauma patients transported by an aeromedical platform. A retrospective chart review of 3582 aeromedical trauma cases was conducted. An initial TRTS, GAP score and SI were calculated for each patient, and the administration of in-flight blood products was also recorded. Receiver operating characteristic (ROC) curves were used to quantify the predictive discrimination of the TRTS, GAP score and SI on the need for in-flight blood product administration. The SI showed a superior predictive value compared to the TRTS and GAP score. The SI showed an area under the curve on the ROC curve of 0.85 in both primary and inter-hospital transfer cases, indicating reasonable predictive value. The SI demonstrates favourable test characteristics for predicting the need for in-flight blood product administration. Prospective validation of these results is warranted.

Shock Index as a Predictor of Mortality and Hospital Admission in Prehospital Gastrointestinal Bleeding: A Retrospective Cohort Study

Objective To evaluate the Shock Index (SI) as a predictive tool for triage of gastrointestinal bleeding (GI) in the prehospital setting, assessing its correlation with mortality, admission rates, and hospital length of stay. Methods In this retrospective cohort study, we analyzed data from the ESO Data Collaborative encompassing EMS records from the year 2022, focusing on 1525 patients with a primary GI bleeding diagnosis. The primary measure was the SI, calculated at initial contact and highest recorded prior to ED arrival. Statistical analysis included t-tests, linear regression, and ROC curves, performed using SPSS v29. Results A significantly higher mean SI was observed in patients who died (mean SI 0.997) compared to survivors (mean SI 0.795), p < 0.001. Admission rates also correlated with higher SI values, p < 0.001. However, SI was not predictive of the hospital length of stay. ROC analysis for mortality prediction yielded an AUC of 0.656 for the initial SI and 0.739 for the highest SI. The standard SI cutoff of 0.9 predicted mortality with a sensitivity of 74.14% and specificity of 55.35% for the highest SI. Conclusion The SI is a valuable predictive tool for mortality among prehospital patients with GI bleeding. Its application may improve the triage process, potentially influencing transport decisions and initial hospital care. Despite its predictive capability for mortality, the SI should be supplemented with other clinical assessments to make comprehensive prehospital care decisions. Further research into SI as part of a comprehensive assessment which includes end-title CO2, mentation, and heaviness of bleeding.

Impact of Prehospital Exsanguinating Airway-Breathing-Circulation Resuscitation Sequence on Patients with Severe Hemorrhage.

At the 2023 ATLS symposium, the priority of circulation was emphasized through the "x-airway-breathing-circulation (ABC)" sequence, where "x" stands for exsanguinating hemorrhage control. With growing evidence from military and civilian studies supporting an x-ABC approach to trauma care, a prehospital advanced resuscitative care (ARC) bundle emphasizing early transfusion was developed in our emergency medical services (EMS) system. We hypothesized that prioritization of prehospital x-ABC through ARC would reduce in-hospital mortality. This was a single-year prospective analysis of patients with severe hemorrhage. These patients were combined with our institution's historic controls before prehospital blood implementation. Included were patients with systolic blood pressure (SBP) less than 90 mmHg. Excluded were patients with penetrating head trauma or prehospital cardiac arrest. Two-to-one propensity matching for x-ABC to ABC groups was conducted, and the primary outcome, in-hospital mortality, was compared between groups. A total of 93 patients (x-ABC = 62, ABC = 31) met the inclusion criteria. There was no difference in patient age, sex, initial SBP, initial Glasgow Coma Score, and initial shock index between groups. When compared with the ABC group, x-ABC patients had significant improvement in vitals at emergency department admission. Overall mortality was lower in the x-ABC group (13% vs 47%, p < 0.001). Multivariable regression revealed that prehospital circulation-first prioritization was independently associated with decreased in-hospital mortality (odds ratio 0.15, 95% CI 0.04 to 0.54, p = 0.004). This is the first analysis to demonstrate a prehospital survival benefit of x-ABC in this subset of patient with severe injury and hemorrhagic shock. Standardization of prehospital x-ABC management in this patient population warrants special consideration.

Time and Risk Factors of Trauma-Related Mortality: A 5-Year Retrospective Analysis From a National Level I Trauma Center.

Background: We aimed to analyze in-hospital timing and risk factors for mortality in a level 1 trauma center. Methods: This is a retrospective analysis of all trauma-related mortality between 2013 and 2018. Patients were divided and analyzed based on the time of mortality (early (≤48 h) vs late (>48 h)), and within different age groups. Multivariate regression analysis was performed to predict in-hospital mortality. Results: 8624 trauma admissions and 677 trauma-related deaths occurred (47.7% at the scene and 52.3% in-hospital). Among in-hospital mortality, the majority were males, with a mean age of 35.8 ± 17.2 years. Most deaths occurred within 3-7 days (35%), followed by 33% after 1 week, 20% on the first day, and 12% on the second day of admission. Patients with early mortality were more likely to have a lower Glasgow coma scale, a higher shock index, a higher chest and abdominal abbreviated injury score, and frequently required exploratory laparotomy and massive blood transfusion (P < .005). The injury severity scores and proportions of head injuries were higher in the late mortality group than in the early group. The severity of injuries, blood transfusion, in-hospital complications, and length of intensive care unit stay were comparable among the age groups, whereas mortality was higher in the age group of 19 to 44. The higher proportions of early and late in-hospital deaths were evident in the age group of 24 to 29. In multivariate analysis, the shock index (OR 2.26; 95%CI 1.04-4.925; P = .04) was an independent predictor of early death, whereas head injury was a predictor of late death (OR 4.54; 95%CI 1.92-11.11; P = .001). Conclusion: One-third of trauma-related mortalities occur early after injury. The initial shock index appears to be a reliable hemodynamic indicator for predicting early mortality. Therefore, timely hemostatic resuscitation and appropriate interventions for bleeding control may prevent early mortality.

RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK

BackgroundA relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. ObjectiveThe aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). MethodsFrom April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. ResultsSS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01–1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06–1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01–1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63–5.38; p < 10–6). ConclusionsSI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.

300 LITERATURE CASE SERIES REVIEW ON LANDIOLOL IN ACUTE DECOMPENSATED HEART FAILURE SECONDARY TO TACHYARRHYTHMIAS

Abstract Introduction Landiolol is a recently innovated ultra-short-acting beta-blocker. Landiolol is the only beta-blocker with a specific dose recommendation for patients with cardiac dysfunction and acute atrial fibrillation (Class I recommendation according to the ESC guidelines). Landiolol has a shorter elimination half-life than any other beta-blocker, and it can be administered safely to patients with various tachyarrhythmias. The short duration of action and titratability of landiolol makes it ideal for use in critically ill patients. Purpose of the Study Review the case reports in the literature on the administration of landiolol in critically ill patients with acute decompensated heart failure (ADHF) secondary to tachyarrhythmias. Methods 11 case reports of ADHF secondary to tachyarrhythmias were identified. Personal, clinical and humoral data were collected. The heart rate and systolic pressure values in the time before and after the administration of Landiolol were plotted in a summary graph. Results The mean age of the 11 patients was 55 years old with high proBNP values at admission. The etiological diagnosis of heart failure was heterogeneous but tachyarrhythmia was the trigger event in all patients. Patients were critically ill with a mean EF of 26 ± 16% and an initial shock index of 1.4 ±0.5. Landiolol administered together with other antiarrhythmic drugs (amiodarone in 4/11 patients), epinephrine/norepinephrine (9/11) and levosimendan (4/11) favoured heart rate lowering and an increase in systolic blood pressure.At discharge, 4/11 had improved EF, in 10/11 sinus rhythm was restored, and all patients recovered hemodynamic stability without adverse events related to Landiolol (Figure 1). Conclusion In this case series review, Landiolol was a useful strategy in patients with ADHF refractory to conventional therapy by facilitating rate/rhythm control, limiting the toxicity of inotropic drugs and improving the hemodynamic profile. Figure 1

When in Doubt Give Blood Out: Transfusion of an Emergency Release Quick Pack does not Increase Late Mortality

Introduction: Differentiating patients with hemorrhage from those with other causes of hypotension in the early post-injury period can be challenging. It remains unclear what effect these small volume transfusions have on outcomes. We evaluated patient outcomes after early blood transfusion in the form of an emergency release quick pack (QP: up to 2U RBC + 2U FFP) for presumed hemorrhage. Methods: Retrospective review of trauma patients with initial shock index >0.9 admitted to our Level 1 trauma center from 2019-2021. Patients were categorized by blood products transfused in the first 24h: none or QP only. A Cox regression assuming equal time at risk was used to estimate risk ratios (RRs) for the association between blood product category and complication (including death). Models were adjusted for age, race, sex, blunt injury mechanism, thorax or abdominal AIS ≥3. Results: A total of 1176 patients were included. There was no significant difference in mortality after 72h between the QP and no product groups (RR 1.77, 95% CI 0.91-3.45). Compared with the no product group, QP patients were more likely to have a VTE (RR 2.08, 95% CI 1.11-3.88) but they had a similar risk of stroke and infectious complication. Conclusion: Compared with no transfusion, a small volume transfusion in the form of a quick pack while evaluating hemodynamic stability is not associated with increased late mortality. Given the high risk of mortality from massive hemorrhage, early empiric blood resuscitation should commence while attempts to determine the etiology of shock are ongoing.

Effects of growth trajectory of shock index within 24 h on the prognosis of patients with sepsis.

BackgroundSepsis is a serious disease with high clinical morbidity and mortality. Despite the tremendous advances in medicine and nursing, treatment of sepsis remains a huge challenge. Our purpose was to explore the effects of shock index (SI) trajectory changes on the prognosis of patients within 24 h after the diagnosis of sepsis.MethodsThis study was based on Medical Information Mart for Intensive Care IV (MIMIC- IV). The effects of SI on the prognosis of patients with sepsis were investigated using C-index and restricted cubic spline (RCS). The trajectory of SI in 24 h after sepsis diagnosis was classified by latent growth mixture modeling (LGMM). Cox proportional hazard model, double robust analysis, and subgroup analysis were conducted to investigate the influence of SI trajectory on in-hospital death and secondary outcomes.ResultsA total of 19,869 patients were eventually enrolled in this study. C-index showed that SI had a prognostic value independent of Sequential Organ Failure Assessment for patients with sepsis. Moreover, the results of RCS showed that SI was a prognostic risk factor. LGMM divided SI trajectory into seven classes, and patients with sepsis in different classes had notable differences in prognosis. Compared with the SI continuously at a low level of 0.6, the SI continued to be at a level higher than 1.0, and the patients in the class whose initial SI was at a high level of 1.2 and then declined had a worse prognosis. Furthermore, the trajectory of SI had a higher prognostic value than the initial SI.ConclusionBoth initial SI and trajectory of SI were found to be independent factors that affect the prognosis of patients with sepsis. Therefore, in clinical treatment, we should closely monitor the basic vital signs of patients and arrive at appropriate clinical decisions on basis of their change trajectory.

Association between prehospital shock index variation and 28-day mortality among patients with septic shock

PurposeSeptic shock (SS) hyperdynamic phase is characterized by tachycardia and low-blood pressure reflecting the relative hypovolemia. Shock index (SI), the ratio between heart rate and systolic blood pressure, is a simple objective tool, usable for SS prognosis assessment.This study aims to evaluate the relationship between prehospital SI variation and 28-day mortality of SS patients initially cared for in prehospital setting by a mobile intensive care unit (mICU).MethodsFrom April 6th, 2016 to December 31st, 2020, 406 patients with SS requiring prehospital mICU were retrospectively analyzed. Initial SI, i.e. first measurement after mICU arrival to the scene, and final SI, i.e. last measurement of the prehospital stage, were used to calculate delta SI (initial SI—final SI) and to define positive and negative delta SI. A survival analysis after propensity score matching compared the 28-day mortality of SS patients with positive/negative delta SI.ResultsThe main suspected origins of infection were pulmonary (42%), digestive (25%) and urinary (17%). The 28-day overall mortality reached 29%.Cox regression analysis revealed a significant association between 28-day mortality and delta SI. A negative delta SI was associated with an increase in mortality (adjusted hazard ratio (HRa) of 1.88 [1.07–3.31] (p = 0.03)), whereas a positive delta SI was associated with a mortality decrease (HRa = 0.53 [0.30–0.94] (p < 10–3)).ConclusionPrehospital hemodynamic delta SI among SS patients cared for by a mICU is associated with 28-day mortality. A negative prehospital delta SI could help physicians to identify SS with higher risk of 28-day mortality.

Association between prehospital shock index and mortality among patients with COVID-19 disease

BackgroundThere exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting. MethodsWe retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia. ResultsWe analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years].Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10−3).Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30.The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l−1.Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93–0.98;p = 10−3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02–1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03–1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87–0.98;p = 0.01 P < 10−3) and GCSi (aOR, 0.90; 95% CI: 0.82–0.99;p = 0.04).Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality. ConclusionNeither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.

Shock index as a predictor for mortality in trauma patients

Background: Traumatic injury accounts for 7.8% of all deaths globally, and 30% to 40% of those deaths are due to hemorrhage. Shock Index (SI) has been found to be useful in the recognition of hemorrhage but no definite threshold for predicting mortality has been determined. Our aim was to determine whether a SI ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to a SI &lt; 1.&#x0D; Methods: We conducted a systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EMBASE, MEDLINE, and Cochrane Library were searched using controlled vocabulary, and retrospective observational studies were included. Studies were included if they reported in-hospital mortality in trauma patients aged ≥ 16 years, with a measurement of SI from the emergency department or trauma center, dividing patients in groups of SI ≥ 1 and SI &lt; 1. Risk of bias was assessed by using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence was assessed according to GRADE. Data was pooled using a random effects model.Results: We screened 1239 citations with an inter-rater reliability (Cohen’s kappa) of 0.90 (95% CI 0.88-0.93). Thirteen comparative cohort studies including 639210 patients were included. All studies reported a significant higher in-hospital mortality in adult trauma patients with a SI ≥ 1 compared to those having a SI &lt; 1 at first assessment in the emergency department or trauma center. Eleven studies were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was RR 4.29 (95% confidence interval 3.00 - 6.12). The overall quality of evidence was low.&#x0D; Conclusion: This systematic review found a fourfold risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis.

The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1. This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa. We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low. This systematic review found a fourfoldincreased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Outcomes of Trauma Patients Present to the Emergency Department with a Shock Index of ≥1.0.

Introduction:The study aimed primarily to evaluate the association between the initial shock index (SI) ≥1.0 with blood transfusion requirement in the emergency department (ED) after acute trauma. The study's secondary aim was to look at the outcomes regarding patients’ disposition from ED, intensive care unit (ICU) and hospital length of stay, and deaths.Methods:It was a retrospective, cross-sectional study and utilized secondary data from the Saudi Trauma Registry (STAR) between September 2017 and August 2020. We extracted the data related to patient demographics, mechanism of injuries, the intent of injuries, mode of arrival at the hospital, characteristics on presentation to ED, length of stay, and deaths from the database and compared between two groups of SI <1.0 and SI ≥1.0. A P < 0.05 was statistically considered significant.Results:Of 6667 patients in STAR, 908 (13.6%) had SI ≥1.0. With SI ≥1.0, there was a significantly higher incidence of blood transfusion in ED compared to SI <1.0 (8.9% vs. 2.4%, P < 0.001). Furthermore, SI ≥ 1.0 was associated with significant ICU admission (26.4% vs. 12.3%, P < 0.001), emergency surgical intervention (8.5% vs. 2.8%, P < 0.001), longer ICU stay (5.0 ± 0.36 vs. 2.2 ± 0.11days, P < 0.001), longer hospital stays (14.8 ± 0.61 vs. 13.3 ± 0.24 days, P < 0.001), and higher deaths (8.4% vs. 2.8%, P < 0.001) compared to the patient with SI <1.0.Conclusions:In our cohort, a SI ≥ 1.0 on the presentation at the ED carried significantly worse outcomes. This simple calculation based on initial vital signs may be used as a screening tool and therefore incorporated into initial assessment protocols to manage trauma patients.

Emergency medical services shock index is the most accurate predictor of patient outcomes after blunt torso trauma.

Shock index (SI) and delta shock index (∆SI) predict mortality and blood transfusion in trauma patients. This study aimed to evaluate the predictive ability of SI and ∆SI in a rural environment with prolonged transport times and transfers from critical access hospitals or level IV trauma centers. We completed a retrospective database review at an American College of Surgeons verified level 1 trauma center for 2 years. Adult subjects analyzed sustained torso trauma. Subjects with missing data or severe head trauma were excluded. For analysis, poisson regression and binomial logistic regression were used to study the effect of time in transport and SI/∆SI on resource utilization and outcomes. p < 0.05 was considered significant. Complete data were available on 549 scene patients and 127 transfers. Mean Injury Severity Score was 11 (interquartile range, 9.0) for scene and 13 (interquartile range, 6.5) for transfers. Initial emergency medical services SI was the most significant predictor for blood transfusion and intensive care unit care in both scene and transferred patients (p < 0.0001) compared with trauma center arrival SI or transferring center SI. A negative ∆SI was significantly associated with the need for transfusion and the number of units transfused. Longer transport time also had a significant relationship with increasing intensive care unit length of stay. Cohorts were analyzed separately. Providers must maintain a high level of clinical suspicion for patients who had an initially elevated SI. Emergency medical services SI was the greatest predictor of injury and need for resources. Enroute SI and ∆SI were less predictive as time from injury increased. This highlights the improvements in en route care but does not eliminate the need for high-level trauma intervention. Therapeutic/care management, level IV.

6 Evaluation of the Shock Index for Out-of-Hospital Sepsis Recognition

The purpose of this study was to assess the utility of sepsis suspicion and field vital signs, including calculation of SI and MSI in the out-of-hospital setting as a predictor for sepsis and sepsis-related outcomes including hyperlactatemia ≥2 mmol, as a marker of sepsis severity and a surrogate indicator for poor prognosis, and as a predictor for ICU admission and 28-day mortality. The authors present their real-world experience in a county EMS system evaluating the correlation of out-of-hospital shock index with hospital lactate, considered a marker for sepsis. This was a prospective observational study conducted as part of our county EMS system’s quality and research program. Our IRB-approved out-of-hospital research registry uses a comprehensive database and record-keeping system that prospectively identifies and collects relevant data for all potential sepsis cases. Patients with abnormal vital signs meeting SIRS criteria and either having suspected infection, or a shock index (defined as heart rate [HR]/systolic blood pressure [SBP] >1.0) or modified shock index [MSI] (defined as HR/mean arterial pressure <0.7 or > 1.3), or having high risk factors such as being from a nursing home or having human immunodeficiency virus, are called in as sepsis alerts (figure 1). Data were analyzed using JMP Pro 14.0. Contingency analyses with Fisher’s exact test and Pearson correlation were performed on serum lactate vs. sepsis diagnosis and in-hospital death, with relative risks calculated. A total of 1426 patients over the 24-month period were transported to five main receiving hospitals. The median age was 71 years, with an interquartile range of 60-80 years. The cohort was 45% female, 85% Caucasian, 14% Black, and 1% Hispanic. The initial shock index (SI1) ranged from 0.260 to 2.840 with a median of 1.11, and an IQR of 0.94 to 1.34. Sixty-eight percent had a “positive” SI1 (>1.0). The initial modified shock index ranged from 0.336 to 3.727, with a median of 1.465 and an IQR of 1.26 to 1.72. Seventy-four percent of the cohort had a “positive” MSI (<0.7, or >1.3). Three percent had MSI <0.7, while 71% had MSI > 1.3. 1321 patients (92%) had repeat vitals during transport, so a second SI was also calculated. The second SI (SI2) was elevated in 41%. All patients with elevated serum lactate were admitted to the hospital for sepsis. An elevated serum lactate was significantly associated with being diagnosed with sepsis (Pearson correlation, P<0.0001) with a relative risk of 38 (95% CI 20-72). Patients who were had an elevated SI were significantly more likely to be admitted for sepsis (P<0.0001, 95% CI 0.1038 to 0.2714). An elevated shock index mirrors an elevated lactate and as such appears to provide a reliable “invisible lactate” surrogate for use in the field.

本邦のER型救急病院における救急車搬入患者のショックインデックスの有用性(Shock index as a predictor of inpatient mortality and hospital admission at the emergency department in Japan)

要旨【目的】ショックインデックス（shock index: SI）は救急患者の在院死亡の予測や入院予測に有用とされている。本邦においては救急車で来院した患者の在院死亡の予測や入院予測に来院時SIが有用であるか否かの報告はなく，これを検討した。【対象】2018年4月から2019年3月までに福岡徳洲会病院を救急車で受診した18歳以上の患者。主要評価項目を在院死亡，副次評価項目を入院の有無とした。心拍数または収縮期血圧に欠損が含まれる症例，明らかにバイタルサインの入力間違いと推察される症例は除外した。【結果】7,739名が解析対象となった。在院死亡は255名（3.3%），入院は2,679名（34.6%）であった。SI 1.1を超える患者は237名（3.1%）であった。SI 1.1を閾値としたときに在院死亡の陽性尤度比は6.88，入院の陽性尤度比は4.08であった。主病名が不整脈であった103名を除外したところ，SI 1.0以上の各閾値における入院の陽性尤度比はすべて5を超えていた。【結語】救急搬入患者の在院死亡の予測や入院予測において来院時SIが臨床的に有用であることが示唆された。SI&gt;1.1は在院死亡の尤度上昇と関連しており，この閾値に該当する患者ではトリアージレベルを上げて対応することが望まれる。

Prehospital end-tidal carbon dioxide predicts hemorrhagic shock upon emergency department arrival.

In addition to reflecting gas exchange within the lungs, end-tidal carbon dioxide (ETCO2) also reflects cardiac output based on CO2 delivery to the pulmonary parenchyma. We hypothesized that low prehospital ETCO2 values would be predictive of hemorrhagic shock in intubated trauma patients. A retrospective observational study of adult trauma patients intubated in the prehospital setting and transported to a single Level I trauma center from 2016 to 2019. Continuous prehospital ETCO2 data were linked with patient care registries. We developed a novel analytic approach that allows for reflection of prehospital ETCO2 over the entire prehospital course of care. The primary outcome was hemorrhagic shock on emergency department (ED) presentation, defined as either initial ED systolic blood pressure of 90 mm Hg or less or initial Shock Index (SI) > 0.9, and transfusion of at least one unit of blood product during their ED stay. Prehospital ETCO2 less than 25 mm Hg was evaluated for predictive value of hemorrhagic shock. Three hundred and seven patients (82% men, 34% penetrating injury, 42% in hemorrhagic shock on ED arrival, 27% mortality) were included in the study. Patients in hemorrhagic shock had lower median ETCO2 values (26.5 mm Hg vs. 32.5 mm Hg; p < 0.001) than those not in hemorrhagic shock. Patients with prehospital ETCO2 less than 25 mm Hg were 3.0 times (adjusted odds ratio = 3.0; 95% confidence interval, 1.1-7.9) more likely to be in hemorrhagic shock upon ED arrival than patients with ETCO2 ≥ 25 mm Hg. Intubated patients with hemorrhagic shock upon ED arrival had significantly lower prehospital ETCO2 values. Incorporating ETCO2 assessment into prehospital care for trauma patients could support decisions regarding prehospital blood transfusion, and triage to higher-level trauma centers, and trauma team activation. Prognostic, level III.

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.

Variation in management of pediatric post-traumatic urine leaks

High-grade pediatric renal trauma may be associated with a urine leak and appropriate management remains unclear. Data on patients with a traumatic renal injury were retrieved from the trauma registry and data warehouse of a pediatric level 1 trauma center over a 15-year period. Demographics, diagnoses, imaging, interventions performed, and follow-up information on patients with a urine leak were analyzed. 187 renal injuries were identified and 32 (17%) were high grade. There were 21 (11%) diagnoses of urine leak, comprising the study population. Leaks were identified 0-10day post-injury. All patients underwent initial computerized tomography (CT); however, 10 (48%) lacked excretory-phase imaging, leading to repeat CT. Ten patients (48%) did not undergo an intervention for their leak, and 11 (52%) underwent at least one, most commonly stent placement (10). Comparing non-intervention and intervention groups: Injury Severity Score (ISS) and initial Shock Index - Pediatric Adjusted (SIPA) were similar, but there was variation in antibiotic prophylaxis (60% vs 100%), average number of imaging studies performed (6.4 vs 8.1) and average length of hospital stay in days (7.7 vs 8.6). Traumatic urine leaks are unusual, and half require no intervention. Management is variable and the development of care guidelines could decrease variation. Given their infrequency a multi-institutional study is required to generate sufficient patient volume.