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On the contrary, SI defined as the ratio of HR to systolic blood pressure has been shown to be a pragmatic and useful tool for diagnosing hypovolemic shock even in the presence of a normal HR or BP.
SI has also been shown to assist in the identification of shock states in polytrauma patients. This classification is based upon an estimated percentage of blood loss and corresponding vital signs, such as the heart rate, systolic blood pressure and the mental status to allocate each patient to their respective shock class.
However, the clinical validity of the ATLS classification of hypovolemic shock has been recently questioned. As an alternative, a classification based on the physiological parameter SI has been proposed by Mutscler et al to differentiate the presence and extent of hypovolemic shock in trauma patients. The purpose of such a classification is to be able to discriminate the patient at risk for early blood transfusions and death more appropriately than the current ATLS classification.
The decision to initiate a massive transfusion protocol in the trauma patient is a risk vs benefit choice often made under duress. There is little evidence to identify which trauma patients will ultimately require activation of a massive transfusion protocol from those who will not. The ability to quickly and accurately identify patients who will benefit and exclude patients at risk of harm is critical.
Mutscler and colleagues have also proposed the utility of SI as a potentially helpful decision aid. This goes along with the notion that the more severely injured a patient is the greater the possibility of that patient presenting to the trauma bay in hypovolemic shock. Zarzaur and colleagues demonstrated that the SI was also a significantly better predictor for 48 hour mortality compared to systolic blood pressure and heart rate. As the percentage of penetrating trauma patients was of Further validation specifically in penetrating injuries is required to assess the accuracy of the application of the SI in these patients.
Shock index may be used to assess the presence of hypovolemic shock, especially if point-of-care testing technology is not available, as is the case in many Latin-American countries. Another short coming of the study was the non-inclusion of the modified shock index MSI which is defined as the ratio of HR to mean arterial blood pressure MAP. Modified shock index is essential because MAP best represents tissue perfusion status. Modified shock index takes into account valuable information related to cardiovascular and hemodynamic stability by incorporating heart rate, systolic and diastolic blood pressure, thus, making it a comprehensive tool for assessing stroke volume and systemic vascular resistance in trauma patients.
The shock index: is it ready for primetime? Crit Care Oct 3;17 5 Crit Care Aug 12;17 4 :R The shock index for pre-hospital identification of trauma patients with early acute coagulopathy and massive bleeding. Crit Care Mar 27;19 1 Shock index and prediction of traumatic hemorrhagic shock day mortality: Data from the DCLHb resuscitation clinical trials. West J Emerg Med Nov;15 7 November Correlation of shock index and modified shock index with the outcome of adult trauma patients: a prospective study of patients.
ABSTRACT Although the literature shows results increasingly suggestive that women traumatized present better outcomes compared to men, some conclusions are still inconsistent. The casuistic consisted of 2, patients, mostly male The most frequent external cause was injured pedestrians Prehospital care was received by the majority of victims The hospital mortality rate was The variables NISS, age and number of body region injured were risk factors for hospital mortality of trauma victims and the length of hospital stay was considered protective factor in the outcome.
The gender, variable of interest of the study, was not a predictor of mortality in this study. In conclusion, variables related to the characteristics and severity of trauma, as well as age, differed between males and females and gender was not considered a risk factor for mortality in this population. Keywords: Comparative study, Gender, Mortality, Wounds and injuries.
Causas externas de morbidade e de mortalidade [texto na Internet]. Morbidade hospitalar por causas externas no Brasil [texto na Internet]. Gender-related outcomes in trauma. J Trauma ;53 3 J Trauma Nurs ;19 2 Characterization of the gender dimorphism after injury and hemorrhagic shock: Are hormonal differences responsible?
Crit Care Med ; 36 6 Baker SP, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma ;14 3 A modification of the injury severity score that both improves accuracy and simplifies scoring.
J Trauma ;43 6 A revision of the trauma score. J Trauma ;29 5 J Trauma ;27 4 The theme is well developed and discussed in the introduction, showing the importance of analyzing these questions when trauma is studied as a disease. The writing is coherent and satisfactory. The aim has a good relation with the problem discussed in the introduction. However it is necessary to discuss some aspects of the manuscript. The statistical method used in the study was appropriate for this type of analysis.
The results found by the study were interesting, but they were presented in a confusing way making it difficult to do a more detailed analysis. In addition, the reading would be more advantageous if the authors provided a table with results of both genders men and women allowing the reader to understand, more easily, the results presented. Considering the conclusion of this manuscript and the others studies mentioned in the introduction, it is noticed that the topic of gender as a risk factor for mortality in trauma by external causes is controversial and deserves further research for a better evaluation of its influence.
Placement of unnecessary TT exposes patients to avoidable morbidity and may prolong hospitalization. Any patient with an associated significant hemothorax or those patients who were moribund were excluded. All PTXs were measured by measuring the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure.
Results: Out of PTXs, 17 Of the remaining PTXs, Six 4. Only one of those six had manifested ongoing desaturations prior to TT. A cutoff measurement of 35 mm demonstrated a. Keywords: Chest tube, Drainage, Pneumothorax. Source of support: Nil Conflict of interest: None.
De los restantes, Seis 4. El punto de corte de 35 mm tuvo un valor predictivo negativo VPN de Aside from rib fractures and pulmonary contusions, a pneumothorax PTX is the most common injury in blunt thoracic trauma. Management of these patients either by observation or with TT has long been dictated by practitioner discretion rather than objective criteria.
This study includes and investigates the management of both overt and occult PTXs. Many physicians elect to routinely perform TT for a traumatic PTX, particularly when patients undergo positive pressure ventilation. The PTX measurement in centimeters spanned the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure. Excluded patients were those whom were moribund, were younger than 16 years old, did not undergo chest CT or for whom electronic chest CT image was unavailable, had an ipsilateral hemothorax, received TT before undergoing a chest CT, or for those with an indeterminate reason for TT after initial observational management.
Management of each PTX was categorized according to the initial management, and was described as either observation or immediate tube thoracostomy. The primary outcome was success of observation. Failure was defined as a PTX initially observed which eventually required TT for either enlargement of the PTX or physiological deterioration of the patient. The study was approved by our institutional review board. Two hundred and ninety-six PTXs were excluded for the following reasons: died within 24 hours 19 , did not undergo chest CT , electronic chest CT unavailable 40 , age less than 16 years old 2 , ipsilateral hemothorax 9 , TT before chest CT 64 , and unable to determine reason for TT after initial observational management.
The PTXs were almost evenly distributed among left-sided 83 vs rightsided Mean size of all PTXs were Sorted by size Flow Chart 2 , 17 Of those PTXs, A cutoff measurement of 35 mm demonstrated a negative predictive value NPV of Tube thoracostomy was performed for each of these patients due to progression in size of the PTX, while only one of those six had manifested ongoing desaturations prior to TT.
Median time until TT removal was 2. The question of whether observation of a PTX is safe, especially in the setting of positive pressure ventilation, has remained an unanswered one. Moreover, in the absence of physiologic derangement, no standard protocol currently exists to dictate when to invasively intervene in a stable patient.
In summary, we have created a predictive model to determine safe and successful observation of a PTX while avoiding TT. This model demonstrates that when measuring the perpendicular distance of the largest air pocket between the chest wall and the mediastinal or pulmonary structure, a cutoff measurement of 35 mm demonstrates a negative predictive value of While some institutions have described their individual schemas to standardize management of PTXs, the relative complexity and low predictability of these models have not resulted in widespread adoption by the critical care community.
Garramone et al7 utilized volumetric measurements, requiring longitudinal measurements on axial CT, which we believe to be more difficult and time consuming. Moreover, in their study, CT scans were limited to abdominal scans and therefore, do not necessarily reveal the entire PTX. Our method, on the other hand, is relatively simple, consisting of a single measurement with no calculation required, and utilizes chest CT scans to visualize the entirety of the thorax.
Our results and the relative simplicity of our model designate ours as a rapid and clinician-friendly tool.