Modifying effects of alcohol use and age on the predictive performance of prehospital shock index for functional and survival outcomes in severe trauma patients

This study investigated whether the prehospital shock index (SI) could predict clinical outcomes in trauma patients, with or without pre-injury alcohol consumption, and whether this predictive capacity varied by age. We conducted a retrospective study on severe trauma patients transported to a level-1 trauma center by emergency medical services from 2015 to 2021. Our primary exposure was abnormal SI, defined as an SI ≥0.9, with in-hospital mortality and poor functional outcomes as study outcomes of interest. Multivariable logistic regression analysis estimated the effect of SI on clinical outcomes. Our findings indicated a significant association between abnormal SI and poor functional outcomes in all trauma patients (adjusted odds ratio: 2.15; 95%confidence interval: 1.41–3.28), notably pronounced in the older age group (adjusted odds ratio: 3.56; 95% confidence interval: 1.55–8.30). However, no association was found with in-hospital mortality. Importantly, among severe trauma patients who did not consume alcohol, abnormal SI was significantly associated with poor functional outcomes, irrespective of age, and with increased in-hospital mortality exclusively in the older age group. Thus, abnormal SI significantly predicted clinical outcomes in non-alcohol-consuming severe trauma patients, with the predictive power for in-hospital mortality being specifically significant in older, non-alcohol-consuming patients.

Shock index; Trauma; Alcohol

[1] Hong KJ, Song KJ, Shin SD, Ro YS, Park JH, Lee SC, et al. Development of a modified trauma and injury severity score to predict disability in acute trauma patients. Clinical and Experimental Emergency Medicine. 2020; 7: 281–289.

[2] Putera HD, Halim V, Panghiyangani R. The impact of COVID-19 on mortality in trauma patients undergoing orthopedic surgery: a systematic review and meta-analysis. To be published in Clinical and Experimental Emergency Medicine. 2023. [Preprint].

[3] de Munter L, Polinder S, Lansink KW, Cnossen MC, Steyerberg EW, de Jongh MA. Mortality prediction models in the general trauma population: a systematic review. Injury. 2017; 48: 221–229.

[4] Tohira H, Jacobs I, Mountain D, Gibson N, Yeo A. Systematic review of predictive performance of injury severity scoring tools. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2012; 20: 63.

[5] 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. Annals of Emergency Medicine. 1994; 24: 685–690.

[6] King RW, Plewa MC, Buderer NM, Knotts FB. Shock index as a marker for significant injury in trauma patients. Academic Emergency Medicine. 1996; 3: 1041–1045.

[7] 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. The Journal of Trauma: Injury, Infection, and Critical Care. 2009; 67: 1426–1430.

[8] Ospina-Tascón GA, García-Gallardo G, Orozco N. Using the diastolic shock index to determine when to promptly administer vasopressors in patients with septic shock. Clinical and Experimental Emergency Medicine. 2022; 9: 367–369.

[9] Luckscheiter A, Zink W, Lohs T, Eisenberger J, Thiel M, Viergutz T. Machine learning for the prediction of preclinical airway management in injured patients: a registry-based trial. Clinical and Experimental Emergency Medicine. 2022; 9: 304–313.

[10] Spampinato MD, Covino M, Passaro A, Benedetto M, D’Angelo L, Galizia G, et al. Predicting in-hospital mortality in pulmonary embolism patients: development and external validation of the PATHOS score. Clinical and Experimental Emergency Medicine. 2023; 10: 26–36.

[11] Kim DS, Park JE, Hwang SY, Jeong D, Lee GT, Kim T, et al. Prediction of vasopressor requirement among hypotensive patients with suspected infection: usefulness of diastolic shock index and lactate. Clinical and Experimental Emergency Medicine. 2022; 9: 176–186.

[12] Daeppen JB, Gaume J, Bady P, Yersin B, Calmes JM, Givel J, et al. Brief alcohol intervention and alcohol assessment do not influence alcohol use in injured patients treated in the emergency department: a randomized controlled clinical trial. Addiction. 2007; 102: 1224–1233.

[13] Taylor B, Rehm J. The relationship between alcohol consumption and fatal motor vehicle injury: high risk at low alcohol levels. Alcohol: Clinical and Experimental Research. 2012; 36: 1827–1834.

[14] Tian Y, Liu J, Zhao Y, Jiang N, Liu X, Zhao G, et al. Alcohol consumption and all-cause and cause-specific mortality among US adults: prospective cohort study. BMC Medicine. 2023; 21(1): 208.

[15] Yun KS, Cho JS, Lim YS, Jang JH, Yang HJ, Choi WS. Effect of alcohol intake on the severity of injuries caused by slipping down. Clinical and Experimental Emergency Medicine. 2020; 7: 170–175.

[16] Park JH, Park JO, Ro YS, Shin SD. Effect of alcohol use on emergency department length of stay among minimally injured patients based on mechanism of injury: multicenter observational study. Clinical and Experimental Emergency Medicine. 2018; 5: 7–13.

[17] Gitajn IL, Reider L, Scharfstein DO, O’Toole RV, Bosse MJ, Castillo RC, et al. Variability in discharge disposition across US trauma centers after treatment for high-energy lower extremity injuries. Journal of Orthopaedic Trauma. 2020; 34: e78–e85.

[18] Biberthaler P, Mussack T, Wiedemann E, Gilg T, Soyka M, Koller G, et al. Elevated serum levels of S-100B reflect the extent of brain injury in alcohol intoxicated patients after mild head trauma. Shock. 2001; 16: 97–101.

[19] Saar S, Lipping E, Bahhir A, Talviste M, Lepp J, Väli M, et al. Outcomes of resuscitative and emergent thoracotomies following injury at the largest trauma center in Estonia. To be published in European Journal of Trauma and Emergency Surgery. 2023. [Preprint].

[20] Curran MWT, Wieschollek S, Strauss R, Manzanero S, Hope B, Couzens G, et al. Clinical outcomes of arthroscopic ligament-sparing dorsal capsulodesis for partial scapholunate ligament tear. Journal of Wrist Surgery. 2023; 12: 218–224.

[21] Zarzaur BL, Croce MA, Fischer PE, Magnotti LJ, Fabian TC. New vitals after injury: shock index for the young and age × shock index for the old. Journal of Surgical Research. 2008; 147: 229–236.

[22] Shibahashi K, Kato T, Hikone M, Sugiyama K. The edemiological state of blunt diaphragmatic injury: an analysis of a nationwide trauma registry in Japan. Injury. 2023; 54: 110790.

[23] Nguyen P, Pokrzywa C, Figueroa J, Jocoy KA, Brandolino A, Karam BS, et al. Predictive factors for the application of pelvic binders in the prehospital setting. To be published in Prehospital Emergency Care Journal. 2023. [Preprint].

[24] Quinn TJ, Dawson J, Walters MR, Lees KR. Reliability of the modified Rankin Scale. Stroke. 2009; 40: 3393–3395.

[25] Pandit V, Rhee P, Hashmi A, Kulvatunyou N, Tang A, Khalil M, et al. Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank. Journal of Trauma and Acute Care Surgery. 2014; 76: 1111–1115.

[26] Bruijns SR, Guly HR, Bouamra O, Lecky F, Lee WA. The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality. Journal of Trauma and Acute Care Surgery. 2013; 74: 1432–1437.

[27] Vang M, Østberg M, Steinmetz J, Rasmussen LS. Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis. European Journal of Trauma and Emergency Surgery. 2022; 48: 2559–2566.

[28] Syed SA, Sinha R, Milivojevic V, MacDougall A, LaValle H, Angarita GA, et al. Hypothalamic‐pituitary‐adrenal and autonomic response to psychological stress in abstinent alcohol use disorder individuals with and without depressive symptomatology. Human Psychopharmacology: Clinical and Experimental. 2023; 38: e2867.

[29] Chudzińska M, Wołowiec Ł, Banach J, Rogowicz D, Grześk G. Alcohol and cardiovascular diseases—do the consumption pattern and dose make the difference? Journal of Cardiovascular Development and Disease. 2022; 9: 317.

[30] Oyetunji TA, Chang DC, Crompton JG, Greene WR, Efron DT, Haut ER, et al. Redefining Hypotension in the elderly: normotension is not reassuring. The Archives of Surgery. 2011; 146: 865–869.

[31] Wright JD, Hughes JP, Ostchega Y, Yoon SS, Nwankwo T. Mean systolic and diastolic blood pressure in adults aged 18 and over in the United States, 2001–2008. National Health Statistics Reports. 2011; 25: 1–22.

[32] Laurent S, Boutouyrie P. Arterial stiffness and hypertension in the elderly. Frontiers in Cardiovascular Medicine. 2020; 7: 544302.

[33] Tasnim S, Tang C, Musini VM, Wright JM. Effect of alcohol on blood pressure. Cochrane Database of Systematic Reviews. 2020; 7: CD012787.