The Shock Index revisited – a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU®

Critical Care

The TraumaRegister DGU®²  Marc Maegele³  Bertil Bouillon³  Thomas Paffrath³  Herbert Schoechl¹  Christoph Wölfl⁵  Matthias Münzberg⁵  Ulrike Nienaber⁴  Manuel Mutschler⁶ 

[1] Ludwig Boltzmann Institute for Experimental and Clinical Traumatology, Vienna, Austria;Committee of Emergency Medicine, Intensive Care and Trauma Management of the DGU (Section NIS), Berlin, Germany;Department of Trauma and Orthopedic Surgery, Cologne-Merheim Medical Center, University of Witten/Herdecke, Ostmerheimerstr 200, D-51109 Cologne, Germany;Academy for Trauma Surgery, Luisenstr 58/59, D-10117 Berlin, Germany;Department of Trauma and Orthopedic Surgery, BG Hospital Ludwigshafen, Ludwig-Guttmann-Straße 13, D-67071 Ludwigshafen, Germany;Institute for Research in Operative Medicine, University of Witten/Herdecke, Ostmerheimerstr 200, D-51109 Cologne, Germany

关键词: Transfusion;    Base deficit;    Shock index;    Vital signs;    Classification;    Shock;    Trauma;   

Others  :  817928
DOI  :  10.1186/cc12851

 received in 2013-04-03, accepted in 2013-07-24,  发布年份 2013

【 摘 要 】

Introduction

Isolated vital signs (for example, heart rate or systolic blood pressure) have been shown unreliable in the assessment of hypovolemic shock. In contrast, the Shock Index (SI), defined by the ratio of heart rate to systolic blood pressure, has been advocated to better risk-stratify patients for increased transfusion requirements and early mortality. Recently, our group has developed a novel and clinical reliable classification of hypovolemic shock based upon four classes of worsening base deficit (BD). The objective of this study was to correlate this classification to corresponding strata of SI for the rapid assessment of trauma patients in the absence of laboratory parameters.

Methods

Between 2002 and 2011, data for 21,853 adult trauma patients were retrieved from the TraumaRegister DGU® database and divided into four strata of worsening SI at emergency department arrival (group I, SI <0.6; group II, SI ≥0.6 to <1.0; group III, SI ≥1.0 to <1.4; and group IV, SI ≥1.4) and were assessed for demographics, injury characteristics, transfusion requirements, fluid resuscitation and outcomes. The four strata of worsening SI were compared with our recently suggested BD-based classification of hypovolemic shock.

Results

Worsening of SI was associated with increasing injury severity scores from 19.3 (± 12) in group I to 37.3 (± 16.8) in group IV, while mortality increased from 10.9% to 39.8%. Increments in SI paralleled increasing fluid resuscitation, vasopressor use and decreasing hemoglobin, platelet counts and Quick’s values. The number of blood units transfused increased from 1.0 (± 4.8) in group I to 21.4 (± 26.2) in group IV patients. Of patients, 31% in group III and 57% in group IV required ≥10 blood units until ICU admission. The four strata of SI discriminated transfusion requirements and massive transfusion rates equally with our recently introduced BD-based classification of hypovolemic shock.

Conclusion

SI upon emergency department arrival may be considered a clinical indicator of hypovolemic shock in respect to transfusion requirements, hemostatic resuscitation and mortality. The four SI groups have been shown to equal our recently suggested BD-based classification. In daily clinical practice, SI may be used to assess the presence of hypovolemic shock if point-of-care testing technology is not available.

【 授权许可】

   
2013 Mutschler et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Evans JA, Van Wessem KJP, McDougall D, Lee KA, Lyons T, Balogh ZJ: Epidemiology of traumatic deaths: comprehensive population-based assessment. World J Surg 2010, 34:158-163.
• [2]Anderson ID, Woodford M, De Dombal FT, Irving M: Retrospective study of 1000 deaths from injury in England and Wales. Br Med J 1988, 296:1305-1308.
• [3]American College of Surgeons: Advanced Trauma Life Support for Doctors – Student Course Manual. 8th edition. Chicago: American College of Surgeons; 2008.
• [4]Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Wyen H, Peiniger S, Paffrath T, Bouillon B, Maegele M: A critical reappraisal of the ATLS classification of hypovolaemic shock: does it really reflect clinical reality? Resuscitation 2012, 84:309-313.
• [5]Guly HR, Bouamra O, Little R, Dark P, Coats T, Driscoll P, Lecky FE: Testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation 2010, 81:1142-1147.
• [6]Guly HR, Bouamra O, Spiers M, Dark P, Coats T, Lecky FE: Vital signs and estimated blood loss in patients with major trauma: testing the validity of the ATLS classification of hypovolaemic shock. Resuscitation 2011, 82:556-559.
• [7]Mutschler M, Nienaber U, Brockamp T, Wafaisade A, Fabian T, Paffrath T, Bouillon B, Maegele M, Dgu T: Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU. Crit Care 2013, 17:R42. BioMed Central Full Text
• [8]Allgöwer M, Burri C: Shock index. Dtsch Med Wochenschr 1967, 92:1947-1950.
• [9]Allgöwer M, Burri C: Shock-index. Ger Med Mon 1968, 13:14-19.
• [10]Brasel KJ, Guse C, Gentilello LM, Nirula R: Heart rate: is it truly a vital sign? J Trauma 2007, 62:812-817.
• [11]Victorino GP, Battistella FD, Wisner DH: Does tachycardia correlate with hypotension after trauma? J Am Coll Surg 2003, 196:679-684.
• [12]Mutschler M, Nienaber U, Munzberg M, Fabian T, Paffrath T, Wolfl C, Bouillon B, Maegele M: Assessment of hypovolaemic shock at scene: is the PHTLS classification of hypovolaemic shock really valid. Emerg Med J 2013. Epub ahead of print
• [13]Caputo N, Fraser R, Paliga A, Kanter M, Hosford K, Madlinger R: Triage vital signs do not correlate with serum lactate or base deficit, and are less predictive of operative intervention in penetrating trauma patients: a prospective cohort study. Emerg Med J 2013. Epub ahead of print
• [14]Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M: Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 2009, 67:1426-1430.
• [15]Zarzaur BL, Croce M, Fischer PE, Magnotti LJ, Fabian TC: New vitals after injury: shock index for the young and age x shock index for the old. J Surg Res 2008, 147:229-236.
• [16]Zarzaur BL, Croce MA, Magnotti LJ, Fabian TC: Identifying life-threatening shock in the older injured patient: an analysis of the national trauma data bank. J Trauma 2010, 68:1134-1138.
• [17]Vandromme MJ, Griffin RL, Kerby JD, McGwin G, Rue LW, Weinberg JA: Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma 2011, 70:384-388. discussion 388–390
• [18]Little RA, Kirkman P, Driscoll P, Hanson J, Mackway-Jones K: Preventable deaths after injury: why are the traditional vital signs poor indicators of blood loss? J Accid Emerg Med 1995, 12:1-14.
• [19]Birkhahn R, Gaeta T, Terry D, Bove J, Tloczkowski J: Shock index in diagnosing early acute hypovolemia. Am J Emerg Med 2005, 23:323-326.
• [20]Rady MY, Smithline HA, Blake H, Nowak R, Rivers E: A comparison of the shock index and conventional vital signs to identify acute, critical illness in the emergency department. Ann Emerg Med 1994, 24:685-690.
• [21]Scoring Study Committee of the German Society of Trauma Surgery: Trauma register of the German Society of Trauma Surgery. Unfallchirurgie 1994, 97:230-237.
• [22]Teasdale G, Jennett B: Assessment of coma and impaired consciousness. Lancet 1974, 2:81-84.
• [23]Baker S, O‘Neill B, Haddon W, Long W: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974, 14:187-196.
• [24]Greenspan L, McLellan B, Greig H: Abbreviated injury scale and injury severity score: a scoring chart. J Trauma 1985, 25:60-64.
• [25]Wafaisade A, Lefering R, Tjardes T, Wutzler S, Simanski C, Paffrath T, Fischer P, Bouillon B, Maegele M: Acute coagulopathy in isolated blunt traumatic brain injury. Neurocrit Care 2010, 12:211-219.
• [26]Wafaisade A, Wutzler S, Lefering R, Tjardes T, Banerjee M, Paffrath T, Bouillon B, Maegele M: Drivers of acute coagulopathy after severe trauma: a multivariate analysis of 1987 patients. Emerg Med J 2010, 27:934-939.
• [27]Members of the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992, 20:864-874.
• [28]Birkhahn RH, Gaeta TJ, Bei R, Bove JJ: Shock index in the first trimester of pregnancy and its relationship to ruptured ectopic pregnancy. Acad Emerg Med 2002, 9:115-119.
• [29]Birkhahn RH, Gaeta TJ, Van Deusen SK, Tloczkowski J: The ability of traditional vital signs and shock index to identify ruptured ectopic pregnancy. Am J Obstet Gynecol 2003, 189:1293-1296.
• [30]Rady MY: The role of central venous oximetry, lactic acid concentration and shock index in the evaluation of clinical shock: a review. Resuscitation 1992, 24:55-60.
• [31]Rady MY, Nightingale P, Little RA, Edwards JD: Shock index: a re-evaluation in acute circulatory failure. Resuscitation 1992, 23:227-234.
• [32]Rady MY, Rivers EP, Martin GB, Smithline H, Appelton T, Nowak RM: Continuous central venous oximetry and shock index in the emergency department: use in the evaluation of clinical shock. Am J Emerg Med 1992, 10:538-541.
• [33]Eastridge BJ, Salinas J, McManus JG, Blackburn L, Bugler EM, Cooke WH, Convertino VA, Concertino VA, Wade CE, Holcomb JB: Hypotension begins at 110 mm Hg: redefining ‘hypotension’ with data. J Trauma 2007, 63:291-297. discussion 297–299
• [34]Hasler RM, Nuesch E, Jüni P, Bouamra O, Exadaktylos AK, Lecky F: Systolic blood pressure below 110 mm Hg is associated with increased mortality in blunt major trauma patients: multicentre cohort study. Resuscitation 2011, 82:1202-1207.
• [35]Hasler RM, Nüesch E, Jüni P, Bouamra O, Exadaktylos AK, Lecky F: Systolic blood pressure below 110 mmHg is associated with increased mortality in penetrating major trauma patients: multicentre cohort study. Resuscitation 2012, 83:476-481.
• [36]Bruns B, Gentilello L, Elliott A, Shafi S: Prehospital hypotension redefined. J Trauma 2008, 65:1217-1221.