In a recent Emergency Medicine Cases podcast, the speaker referenced the shock index. And so I decided I would quickly review some of my posts related to the shock index.
I simply typed “shock index” into to the search box which is on every page of my blog and linked to and reviewed the resulting posts:
The Shock Index In Pediatrics – Help From Dr. Sean Fox
Posted on April 16, 2016 by Tom Wade MD
Here are some excerpts from Dr. Fox’s post, Pediatric Shock Index:
- The Shock Index (Heart Rate / Systolic BP) has been shown to be useful in detecting adult patients with shock.
- There is evidence that the Shock Index can be useful in pediatric patients also. (Yasaka, 2013; Rousseaux, 2013)
- Since, pediatric vital signs alter with age, it would make sense to have a “adjusted” tool. (Acker, 2015)
- Using standard heart rate and systolic BP values for age ranges, Maximum Normal Shock Index values were calculated.
- Shock Index, Pediatric Adjusted (SIPA)
- 4-6 years = 1.2
- 6-12 years = 1
- > 12 years = 0.9
- Comparing the patient’s actual HR / Systolic BP to the SIPA was shown to perform better and identify those most severely injured following blunt trauma. (Acker, 2015)
Shock Index – Another Way To Avoid Missing Shock
Posted on April 16, 2016 by Tom Wade MD
The gist: Don’t rely on a trauma patient’s normal vital signs to assume they’re hemodynamically stable. Rather, use the shock index (HR/SBP) to predict a patient’s need for massive transfusion.Normal SI = 0.5-0.7
- SI > 0.9 then approach the patient as though they are actively bleeding
- SI increases more than 0.3 at any point in care (prehospital to ED), then treat this as though the patient is actively exsanguinating
- Don’t rule out bleeding if SI is within normal limits
- Elderly patient multiply their age by the SI (Age x SI)
The Vandromme, et al paper* in the Journal of Trauma in 2011 posited that the following holds true…
- SI > 0.9 predicts twice the risk of massive transfusion
- SI > 1.1 predicts four times the risk of massive transfusion
- SI > 1.3 predicts nine times the risk of massive transfusion!
So, in trauma patients who come in with normal appearing vital signs, calculate the SI (and hopefully get a lactate and base deficit) before determining the patient is stable.
Ep 122 Sepsis and Septic Shock From Emergency Medicine Cases
Posted on April 1, 2019 by Tom Wade MD
Note to myself: The above post is a very brief review. Go again and read it.
“Early suspicion of toxic shock syndrome” – Help From Dr. Farkas Of PulmCrit
Posted on June 25, 2018 by Tom Wade MD. What follows are quotes from Dr. Farkas:
It is essential to treat TSS as early as possible. Thus, in situations of diagnostic uncertainty, empiric treatment for TSS should be started while continuing to evaluate for alternative diagnoses. Rather than conceptualizing the diagnostic process as an all-or-none phenomena, it may be more useful to imagine varying levels of suspicion leading to different empiric treatments. If there is any suspicion of TSS, it is reasonable to initiate toxin-suppressive antibiotics [clindamycin and linezolid – discussed in Dr. Farkas’ post Toxic Shock Syndrome Management: A tale of two patients]. Since intravenous immunoglobulin is expensive, a higher level of suspicion is required to initiate this treatment as well.
Conclusion: Red Flags For TSSUnfortunately, TSS may manifest differently in different patients. TSS should be considered in many situations, especially the following:
- Systemic illness plus a diffuse blanchable erythematous rash.
- Younger person initially develops a gastroenteritis-like illness and subsequently progresses to septic shock without alternative explanation.
- Severe focal soft tissue pain out of proportion to examination plus systemic toxicity (e.g., high fever or elevated shock index).
- Peripartum septic shock.
- Septic shock due to proven or probable Group A streptococcal infection (e.g., cellulitis, necrotizing fasciitis), with sepsis severity out of proportion to the infectious source.
What follows is from Dr. Fox’s post, Capillary Refill & Shock:
The critically ill infant and child can be “tricky” to spot sometimes. Often the phrase “That kid just doesn’t look right,” is heard around the room of critically ill children. So we recognize that “something isn’t right,” but have a hard time putting our finger on what is wrong. Often the problem stems from the fact that the blood pressure “reassures” us. We have discussed several topics related to shock previously (ex, Epi vs Dopa, Pediatric Shock Index, and Damage Control Resuscitation), but now let us focus on recognizing SHOCK and one important aspect – Capillary Refill.
[Dr. Fox’s post is a great brief review of pediatric sepsis and an important part of today’s review. So review it now – note to myself.]