Skip to main content

Advertisement

SpringerLink
Log in

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

  • Review Article
  • Published:
European Journal of Trauma and Emergency Surgery Aims and scope Submit manuscript

Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusions

This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

References

  1. Geneva WHO. Global Health Estimates 2016: Deaths by Cause, Age, Sex, by Country and by Region, 2000–2016. 2018.

  2. Sobrino J, Shafi S. Timing and causes of death after injuries. Proc (Bayl Univ Med Cent). 2013;26(2):120–3. https://doi.org/10.1080/08998280.2013.11928934.

    Article  Google Scholar 

  3. Kauvar DS, Lefering R, Wade CE. Impact of Hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations. J Trauma Acute Care Surg. 2006;60(6):S3–11.

    Article  Google Scholar 

  4. Pacagnella RC, Souza JP, Durocher J, et al. A systematic review of the relationship between blood loss and clinical signs. PLoS One. 2013;8(3):e57594–e57594. https://doi.org/10.1371/journal.pone.0057594.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  5. Frank M, Schmucker U, Stengel D, et al. Proper estimation of blood loss on scene of trauma: tool or tale? J Trauma Acute Care Surg. 2010;69(5):1191–5.

    Article  Google Scholar 

  6. ATLS—Advanced Trauma Life Support Guidelines 10th Edition

  7. Birkhahn RH, Gaeta TJ, Terry D, et al. Shock index in diagnosing early acute hypovolemia. Am J Emerg Med. 2005;23(3):323–6. https://doi.org/10.1016/j.ajem.2005.02.029.

    Article  PubMed  Google Scholar 

  8. Mutschler M, Nienaber U, Münzberg M, et al. The Shock Index revisited—a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU. Crit Care. 2013;17(4):R172. https://doi.org/10.1186/cc12851.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Pandit V, Rhee P, Hashmi A, et al. Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care Surg. 2014;76(4):1111–5. https://doi.org/10.1097/TA.0000000000000160.

    Article  PubMed  Google Scholar 

  10. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ. 2009;339: b2700. https://doi.org/10.1136/bmj.b2700.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Page MJ, McKenzie JE, Bossuyt PM, The PRISMA, et al. statement: An updated guideline for reporting systematic reviews. BMJ. 2020;2021:372. https://doi.org/10.1136/bmj.n71.

    Article  Google Scholar 

  12. Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev. 2015;4(1):1. https://doi.org/10.1186/2046-4053-4-1.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Covidence—Better systematic review management. https://www.covidence.org/. Accessed 1 May 2021.

  14. Ottawa Hospital Research Institute. http://www.ohri.ca/programs/clinical_epidemiology/oxford.asp. Accessed 1 May 2021.

  15. Londoño J, Niño C, Díaz J, et al. Association of clinical hypoperfusion variables with lactate clearance and hospital mortality. Shock. 2018;50(3):286–92. https://doi.org/10.1097/SHK.0000000000001066.

    Article  CAS  PubMed  Google Scholar 

  16. Salottolo KM, Mains CW, Offner PJ, et al. A retrospective analysis of geriatric trauma patients: venous lactate is a better predictor of mortality than traditional vital signs. Scand J Trauma Resusc Emerg Med. 2013;21:7. https://doi.org/10.1186/1757-7241-21-7.

    Article  PubMed  PubMed Central  Google Scholar 

  17. Fröhlich M, Driessen A, Böhmer A, et al. Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?—An analysis of the TraumaRegister DGU(®). Scand J Trauma Resusc Emerg Med. 2016;24(1):148. https://doi.org/10.1186/s13049-016-0340-2.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Bhandarkar P, Munivenkatappa A, Roy N, et al. Pattern and distribution of shock index and age shock index score among trauma patients in towards improved trauma care outcomes (TITCO) dataset. Bull Emerg Trauma. 2018;6(4):313–7. https://doi.org/10.29252/beat-060407.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Kim SY, Hong KJ, Shin SD, et al. Validation of the shock index, modified shock index, and age shock index for predicting mortality of geriatric trauma patients in emergency departments. J Korean Med Sci. 2016;31(12):2026–32. https://doi.org/10.3346/jkms.2016.31.12.2026.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Lai W-H, Wu S-C, Rau C-S, et al. Systolic blood pressure lower than heart rate upon arrival at and departure from the emergency department indicates a poor outcome for adult trauma patients. Int J Environ Res Public Health. 2016. https://doi.org/10.3390/ijerph13060528.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Mitra B, Fitzgerald M, Chan J. The utility of a shock index ≥ 1 as an indication for pre-hospital oxygen carrier administration in major trauma. Injury. 2014;45(1):61–5. https://doi.org/10.1016/j.injury.2013.01.010.

    Article  PubMed  Google Scholar 

  22. Huang J-F, Tsai Y-C, Rau C-S, et al. Systolic blood pressure lower than the heart rate indicates a poor outcome in patients with severe isolated traumatic brain injury: a cross-sectional study. Int J Surg. 2019;61:48–52. https://doi.org/10.1016/j.ijsu.2018.11.030.

    Article  PubMed  Google Scholar 

  23. Ono Y, Yokoyama H, Matsumoto A, et al. Is preoperative period associated with severity and unexpected death of injured patients needing emergency trauma surgery? J Anesth. 2014;28(3):381–9. https://doi.org/10.1007/s00540-013-1727-0.

    Article  PubMed  Google Scholar 

  24. El-Menyar A, Abdelrahman H, Alhammoud A, et al. Prognostic role of shock index in traumatic pelvic fracture: a retrospective analysis. J Surg Res. 2019;243:410–8. https://doi.org/10.1016/j.jss.2019.05.062.

    Article  PubMed  Google Scholar 

  25. Haider A, Con J, Prabhakaran K, et al. Developing a simple clinical score for predicting mortality and need for ICU in trauma patients. Am Surg. 2019;85(7):733–7.

    Article  Google Scholar 

  26. Odom SR, Howell MD, Gupta A, et al. Extremes of shock index predicts death in trauma patients. J Emerg Trauma Shock. 2016;9(3):103–6. https://doi.org/10.4103/0974-2700.185272.

    Article  PubMed  PubMed Central  Google Scholar 

  27. Cannon CM, Braxton CC, Kling-Smith M, et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma. 2009;67(6):1426–30. https://doi.org/10.1097/TA.0b013e3181bbf728.

    Article  PubMed  Google Scholar 

  28. Chiu WC, Powers DB, Hirshon JM, et al. Impact of trauma centre capacity and volume on the mortality risk of incoming new admissions. BMJ Mil Health. 2020. https://doi.org/10.1136/bmjmilitary-2020-001483.

    Article  PubMed  Google Scholar 

  29. Lammers D, Conner J, Marenco C, et al. Optimal prospective predictors of mortality in austere environments. J Surg Res. 2020;255:297–303. https://doi.org/10.1016/j.jss.2020.05.040.

    Article  PubMed  Google Scholar 

  30. McNab A, Burns B, Bhullar I, et al. A prehospital shock index for trauma correlates with measures of hospital resource use and mortality. Surgery. 2012;152(3):473–6. https://doi.org/10.1016/j.surg.2012.07.010.

    Article  PubMed  Google Scholar 

  31. Singh A, Ali S, Agarwal A, et al. Correlation of shock index and modified shock index with the outcome of adult trauma patients: a prospective study of 9860 patients. N Am J Med Sci. 2014;6(9):450–2. https://doi.org/10.4103/1947-2714.141632.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Wan-Ting C, Chin-Hsien L, Cheng-Yu L, et al. Reverse shock index multiplied by Glasgow Coma Scale (rSIG) predicts mortality in severe trauma patients with head injury. Sci Rep. 2020;10(1):2095. https://doi.org/10.1038/s41598-020-59044-w.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  33. Thom O, Taylor DM, Wolfe RE, et al. Pilot study of the prevalence, outcomes and detection of occult hypoperfusion in trauma patients. Emerg Med J. 2010;27(6):470–2. https://doi.org/10.1136/emj.2009.073254.

    Article  PubMed  Google Scholar 

  34. Pouraghaei M, Vahdati S, Moharamzadeh P, et al. The impact of prehospital emergency services on the outcome of trauma patients. Arch Trauma Res. 2020;9(3):139–42. https://doi.org/10.4103/atr.atr_75_19.

    Article  Google Scholar 

  35. Vandromme MJ, Griffin RL, Kerby JD, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma. 2011;70(2):384–90. https://doi.org/10.1097/TA.0b013e3182095a0a.

    Article  PubMed  Google Scholar 

  36. Jehan F, Con J, McIntyre M, et al. Pre-hospital shock index correlates with transfusion, resource utilization and mortality; the role of patient first vitals. Am J Surg. 2019;218(6):1169–74. https://doi.org/10.1016/j.amjsurg.2019.08.028.

    Article  PubMed  Google Scholar 

  37. Lai W-H, Rau C-S, Hsu S-Y, et al. Using the reverse shock index at the injury scene and in the emergency department to identify high-risk patients: a cross-sectional retrospective study. Int J Environ Res Public Health. 2016;13(4):357. https://doi.org/10.3390/ijerph13040357.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Kheirbek T, Thomas JM, Cao J, et al. Prehospital shock index outperforms hypotension alone in predicting significant injury in trauma patients. Trauma Surg Acute Care Open. 2021;6(1): e000712. https://doi.org/10.1136/tsaco-2021-000712.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Pottecher J, Ageron F-X, Fauché C, et al. Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma: retrospective analysis of a large regional trauma database. J Trauma Acute Care Surg. 2016;81(4):713–22. https://doi.org/10.1097/TA.0000000000001191.

    Article  PubMed  Google Scholar 

  40. Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 2018;49(1):15–9. https://doi.org/10.1016/j.injury.2017.09.015.

    Article  PubMed  Google Scholar 

  41. Yumoto T, Iida A, Hirayama T, et al. Immediate screening method for predicting the necessity of massive transfusions in trauma patients: a retrospective single-center study. J Intensive Care. 2014;2(1):54. https://doi.org/10.1186/s40560-014-0054-3.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Campos-Serra A, Montmany-Vioque S, Rebasa-Cladera P, et al. The use of the Shock Index as a predictor of active bleeding in trauma patients. Cir Esp. 2018;96(8):494–500. https://doi.org/10.1016/j.ciresp.2018.04.004.

    Article  PubMed  Google Scholar 

  43. Joseph B, Khan M, Truitt M, et al. Massive transfusion: the revised assessment of bleeding and transfusion (RABT) score. World J Surg. 2018;42(11):3560–7. https://doi.org/10.1007/s00268-018-4674-y.

    Article  PubMed  Google Scholar 

  44. Olaussen A, Peterson EL, Mitra B, et al. Massive transfusion prediction with inclusion of the pre-hospital Shock Index. Injury. 2015;46(5):822–6. https://doi.org/10.1016/j.injury.2014.12.009.

    Article  PubMed  Google Scholar 

  45. Plewa MC, Ewing M, Vyas N, et al. A clinical rule for predicting massive transfusion in trauma victims. Ann Emerg Med. 2013;62(4 Suppl. 1):S116. https://doi.org/10.1016/j.annemergmed.2013.07.150.

    Article  Google Scholar 

  46. Kim MJ, Park JY, Kim MK, et al. Usefulness of shock index to predict outcomes of trauma patient: a retrospective cohort study. J Trauma Inj. 2019;32(1):17–25. https://doi.org/10.20408/jti.2018.034.

    Article  Google Scholar 

  47. Jouini S, Jebali A, Hedhli H, et al. Predictive value of shock index ≥ 1 in severe trauma patients in emergency department. Tunis Med. 2019;97(6):802–7.

    PubMed  Google Scholar 

  48. Björkman J, Raatiniemi L, Setälä P, et al. Shock index as a predictor for short-term mortality in helicopter emergency medical services: a registry study. Acta Anaesthesiol Scand. 2021;65(6):816–23. https://doi.org/10.1111/aas.13765.

    Article  PubMed  Google Scholar 

  49. Zarzaur BL, Croce MA, Fischer PE, et al. New vitals after injury: shock index for the young and age x shock index for the old. J Surg Res. 2008;147(2):229–36. https://doi.org/10.1016/j.jss.2008.03.025.

    Article  PubMed  Google Scholar 

  50. Martín-Rodríguez F, López-Izquierdo R, Del Pozo VC, et al. Accuracy of National Early Warning Score 2 (NEWS2) in prehospital triage on in-hospital early mortality: a multi-center observational prospective cohort study. Prehosp Disaster Med. 2019;34(6):610–8. https://doi.org/10.1017/S1049023X19005041.

    Article  PubMed  Google Scholar 

  51. Zhang X, Wang Z, Wang Z, et al. The prognostic value of shock index for the outcomes of acute myocardial infarction patients: a systematic review and meta-analysis. Med (United States). 2017. https://doi.org/10.1097/MD.0000000000008014.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Middleton DJ, Smith TO, et al. Shock index predicts outcome in patients with suspected sepsis or community-acquired pneumonia: a systematic review. J Clin Med. 2019. https://doi.org/10.3390/jcm8081144.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Balhara KS, Hsieh YH, Hamade B, et al. Clinical metrics in emergency medicine: the shock index and the probability of hospital admission and inpatient mortality. Emerg Med J. 2017;34(2):89–94. https://doi.org/10.1136/emermed-2015-205532.

    Article  PubMed  Google Scholar 

Download references

Funding

This study was funded by Department of Anesthesia, Centre of Head and Orthopaedics, Rigshospitalet, Denmark.

Author information

Authors and Affiliations

  1. Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark

    Malene Vang, Maria Østberg, Jacob Steinmetz & Lars S. Rasmussen

  2. Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark

    Lars S. Rasmussen

  3. Danish Air Ambulance, Aarhus, Denmark

    Jacob Steinmetz

Authors
  1. Malene Vang
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Maria Østberg
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jacob Steinmetz
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Lars S. Rasmussen
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

MV, MØ, JS, and LSR have contributed to the conception and design of the study. MV and MØ screened articles, collected data, and assessed risk of bias. All the authors were involved in the analysis and interpretation of data as well as drafting and revising the manuscript.

Corresponding author

Correspondence to Malene Vang.

Ethics declarations

Conflict of interest

The authors declare no conflict of interest.

Registration and protocol

The protocol was registered in PROSPERO database of systematic reviews and can be accessed through their database. Registration number: CRD42021226881. An amendment was made when the inclusion criteria of age ≥ 18 years, was changed to age ≥ 16 years.

Ethics approval

Not applicable.

Consent for publication

Not applicable.

Supplementary Information

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Vang, M., Østberg, M., Steinmetz, J. et al. Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 48, 2559–2566 (2022). https://doi.org/10.1007/s00068-022-01932-z

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00068-022-01932-z

Keywords

Search

Navigation