title: Using the Reverse Shock Index at the Injury Scene and in the Emergency Department to Identify High-Risk Patients: A Cross-Sectional Retrospective Study.
abstract: BACKGROUND
  The ratio of systolic blood pressure (SBP) to heart rate (HR), called the reverse shock index (RSI), is used to evaluate the hemodynamic stability of trauma patients. A SBP lower than the HR (RSI < 1) indicates the probability of hemodynamic shock. The objective of this study was to evaluate whether the RSI as evaluated by emergency medical services (EMS) personnel at the injury scene (EMS RSI) and the physician in the emergency department (ED RSI) could be used as an additional variable to identify patients who are at high risk of more severe injury.
  
  
  METHODS
  Data obtained from all 16,548 patients added to the trauma registry system at a Level I trauma center between January 2009 and December 2013 were retrospectively reviewed. Only patients transferred by EMS were included in this study. A total of 3715 trauma patients were enrolled and subsequently divided into four groups: group I patients had an EMS RSI ≥1 and an ED RSI ≥1 (n = 3485); group II an EMS RSI ≥ 1 and an ED RSI < 1 (n = 85); group III an EMS RSI < 1 and an ED RSI ≥ 1 (n = 98); and group IV an EMS RSI < 1 and a ED RSI < 1 (n = 47). A Pearson's χ² test, Fisher's exact test, or independent Student's t-test was conducted to compare trauma patients in groups II, III, and IV with those in group I.
  
  
  RESULTS
  Group II and IV patients had a higher injury severity score, a higher incidence of commonly associated injuries, and underwent more procedures (including intubation, chest tube insertion, and blood transfusion in the ED) than patients in group I. Group II and IV patients were also more likely to receive a severe injury to the thoracoabdominal area. These patients also had worse outcomes regarding the length of stay in hospital and intensive care unit (ICU), the proportion of patients admitted to ICU, and in-hospital mortality. Group II patients had a higher adjusted odds ratio for mortality (5.8-times greater) than group I patients.
  
  
  CONCLUSIONS
  Using an RSI < 1 as a threshold to evaluate the hemodynamic condition of the patients at the injury scene and upon arrival to the ED provides valid information regarding deteriorating outcomes for certain subgroups of patients in the ED setting. Particular attention and additional resources should be provided to patients with an EMS RSI ≥ 1 that deteriorates to an RSI < 1 upon arrival to the ED since a higher odds of mortality was found in these patients.
authors.affiliation: Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. abdiel@cgmh.org.tw.
authors.forename: Wei-Hung
authors.initials: WH
authors.lastname: Lai
authors.affiliation: Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. ersh2127@cloud.cgmh.org.tw.
authors.forename: Cheng-Shyuan
authors.initials: CS
authors.lastname: Rau
authors.affiliation: Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. ah.lucy@hotmail.com.
authors.forename: Shiun-Yuan
authors.initials: SY
authors.lastname: Hsu
authors.affiliation: Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. shaochunwu@gmail.com.
authors.forename: Shao-Chun
authors.initials: SC
authors.lastname: Wu
authors.affiliation: Department of Plastic and Reconstructive Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. bow110470@gmail.com.
authors.forename: Pao-Jen
authors.initials: PJ
authors.lastname: Kuo
authors.affiliation: Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. sylvia19870714@hotmail.com.
authors.forename: Hsiao-Yun
authors.initials: HY
authors.lastname: Hsieh
authors.affiliation: Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. libe320@yahoo.com.tw.
authors.forename: Yi-Chun
authors.initials: YC
authors.lastname: Chen
authors.affiliation: Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung 833, Taiwan. m93chinghua@gmail.com.
authors.forename: Ching-Hua
authors.initials: CH
authors.lastname: Hsieh
mesh_terms: D000328:Adult; D001794:Blood Pressure; D003430:Cross-Sectional Studies; D004632:Emergency Medical Services / Q000379:methods / Q000706:statistics & numerical data; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data; D005260:Female; D006339:Heart Rate; D017052:Hospital Mortality; D006801:Humans; D015601:Injury Severity Score; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D012042:Registries; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods; D012769:Shock / Q000175:diagnosis* / Q000209:etiology; D014947:Wounds and Injuries / Q000150:complications*; D055815:Young Adult
keywords: emergency medical services (EMS); injury severity score (ISS); length of stay (LOS); mortality; reverse shock index (RSI); shock index (SI)