SHOCK, Vol. 46, Supplement 1, pp.

5054, 2016

REVITALIZING VITAL SIGNS: THE ROLE OF DELTA SHOCK INDEX

Bellal Joseph, Ansab Haider, Kareem Ibraheem, Narong Kulvatunyou,
Andrew Tang, Asad Azim, Terence OKeeffe, Lynn Gries, Gary Vercruysse,
and Peter Rhee
Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery,
University of Arizona, Tucson, Arizona
Received 9 Feb 2016; first review completed 24 Feb 2016; accepted in final form 23 Mar 2016
ABSTRACTIntroduction: Although variability in vital parameters has been shown to predict outcomes, the role of change
in shock index (delta SI) as a predictive tool remains unknown. Methods: The National Trauma Data Bank (20112012) was
abstracted for all patients aged 18 to 85 years and Injury Severity Score more than 15 with complete data. Transferred
patients and patients dead on arrival were excluded. Patient demographics and injury parameters were recorded, and SI in
the field, SI in the emergency department (ED), and change in SI (delta SI ED SIfield SI) were calculated. Our outcome
measure was mortality. Cox regression and Kaplan-Meier analysis was performed. Results: A total of 95,088 patients were
included, and the overall mortality rate was 11.9%. Patients with a positive delta SI had a mortality rate of 13.3% compared
with 9.6% mortality rate in patients who had an unchanged or negative delta SI. After controlling for confounders, a delta SI
more than 0.1 was found to be associated with an increased hazard of death (hazard ratio [95% CI] 1.36 [1.291.45]) and
mortality (16.6% vs. 9.5%, P < 0.001). Even in hemodynamically stable patients, a delta SI more than 0.1 was associated
with increased hazard of death (hazard ratio [95% CI] 1.29 [1.201.39]). Conclusions: Delta SI from field to hospital
independently predicts higher mortality. It predicts higher mortality even in apparently hemodynamically stable patients with
normal traditional vital signs and normal SI. Delta SI may serve as an adjunct to existing traditional vital signs for the
identification of occult hypovolemic shock and higher risk of death in trauma patients.
KEYWORDSChange in shock index, delta shock index, hemorrhagic shock, occult hemorrhagic shock, shock index

INTRODUCTION

established that SI is better at predicting hemorrhagic shock

than either HR or the SBP alone. However, based on our
observation, there are two scenarios where SI may not be
elevated despite the hypovolemia: first, in those trauma patients
who present with pseudohypertension, and second, in trauma
patients who present with relative bradycardia (7). In these
patients, despite normal absolute values of SBP and SI, there
may still be a demonstrable increase in SI from the field to the
ED. For this reason, a change in SI may have more clinical
relevance to all subgroups of trauma patients.
The aim of our study was to assess if change in SI (delta SI)
from field to the trauma bay can predict mortality in trauma
patients. We hypothesized that a positive delta SI (increasing
SI) predicts higher mortality than unchanged or negative
(decreasing SI) delta SI.

Trauma is the leading cause of death in people aged 46 years

or younger, and more than 170,000 people die every year of
trauma in the United States (1). The classic description of
trauma deaths demonstrates that these deaths have a trimodal
distribution over time (2). The early trauma deaths, which occur
during the first 6 h, result from evolving and potentially preventable conditions. This includes hemorrhagic shock, which is
the most common cause of preventable deaths in trauma
patients (3). Early identification of shock, hemorrhage control,
and resuscitation can improve mortality and decrease hemorrhage associated with preventable deaths. Resuscitation in
trauma patients is traditionally guided by systolic blood pressure (SBP) and heart rate (HR). Despite normal vital signs,
several patients may have concealed deficiency in systemic
oxygenation that contributes to higher mortality in these
patients (4).
Shock index (SI) is a simple ratio of HR and SBP that can be
easily calculated in the field and the emergency department
(ED) (5). The normal value of SI is less than 0.7, and an SI
greater than 1.0 is generally considered as a predictor of
hemodynamic instability and mortality (6). It is well

PATIENTS AND METHODS

We performed a 2-year (20112012) retrospective study of the National
Trauma Data Bank (NTDB). The NTDB is maintained by the American College
of Surgeons (Chicago, IL) and is the largest collection of trauma cases with
more than 1.8 million patients, which are contributed by over 900 trauma
centers across United States.
We included all trauma patients aged 18 to 85 years, an Injury Severity Score
(ISS) of 16 or above, and complete variables were included. Transferred patients
and patients who arrived with no signs of life were excluded.
The following data points were abstracted for each patient from the NTDB:
demographics (age, sex, race, and insurance status), ISS, ED HR, ED SBP, ED
respiratory rate, ED Glasgow Coma Scale (GCS) score, emergency medical
services (EMS) HR, EMS SBP, EMS respiratory rate, mechanism of injury
(blunt and penetrating), trauma center designation (level I, II, and others), mode
of transport (air transport vs. others), and mortality. We calculated shock indices
both in the field and in the ED. Field SI was calculated by dividing the EMS HR
by EMS SBP. ED SI was calculated by dividing the ED HR by ED SBP. Delta SI
was defined as the difference between field SI and ED SI. It was calculated by
subtracting the field SI from ED SI.

Address reprint requests to Bellal Joseph, MD, FACS, Division of Trauma,

Critical Care, Emergency Surgery, and Burns, Department of Surgery, University of
Arizona, 1501 N. Campbell Ave., Room 5411, P.O. Box 245063, Tucson, AZ 85724.
E-mail: bjoseph@surgery.arizona.edu
Poster presentation at the Military Science and Health Research Symposium, Ft.
Lauderdale, FL, 2015.
The authors have no financial or proprietary interest in the subject matter or
materials discussed in the manuscript.
The authors report no conflicts of interest.
DOI: 10.1097/SHK.0000000000000618
Copyright 2016 by the Shock Society

50

Copyright 2016 by the Shock Society. Unauthorized reproduction of this article is prohibited.

SHOCK SEPTEMBER 2016

DELTA SHOCK INDEX PREDICTS MORTALITY

51

TABLE 1. Demographics
Variable
Age, mean (SD), years
Male, % (n)
Whites, % (n)
Uninsured, % (n)
Blunt trauma, % (n)
EMS SBP, mean (SD)
Hypotension, % (n)
EMS HR, mean (SD)
Tachycardia, % (n)
ED SBP, mean (SD)
Hypotension, % (n)
ED HR, mean (SD)
Tachycardia, mean (SD)
EMS shock index, mean (SD)
ED shock index, mean (SD)
ED GCS, median [IQR]
GCS score 8, % (n)
ISS, median [IQR]

Positive delta SI (n 41,475)

Unchanged or negative delta SI (n 53,613)

46.7 (19.1)
71.8 (29,787)
68.6 (36,753)
17.6 (7,306)
93.7 (38,866)
140.8 (30.1)
6.6 (2,731)
90.2 (23.1)
28.1 (11,640)
124.4 (30.5)
19.0 (7,876)
99.2 (23.5)
43.0 (17,828)
0.67 (0.2)
0.87 (0.6)
14 [715]
27.0 (11,179)
22 [1729]

45.7 (19.2)
73.3 (39,287)
69.9 (28,981)
18.4 (9,880)
92.8 (49,768)
118.7 (37.6)
22.1 (11,828)
94.3 (26.9)
36.7 (19,687)
136.1 (38.4)
9.4 (5,035)
86.6 (27.0)
26.6 (14,253)
0.85 (1.1)
0.66 (0.2)
15 [1115]
25.4 (13,609)
22 [1727]

<0.001
<0.001
<0.001
0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Bold cells indicate statistically significant P values.

AIS, Abbreviated Injury Scale; ED, emergency department; EMS, emergency medical services; GCS, Glasgow Coma Scale; HR, heart rate; IQR,
interquartile range; ISS, Injury Severity Score; SBP, systolic blood pressure; SI, shock index; SD, standard deviation.
Patients were then divided into two groups: patients with an unchanged or
negative delta SI and patients with a positive delta SI. Our outcome measure was
mortality. A subgroup analysis was performed for hemodynamically stable
patients defined by both EMS and ED SBPs greater than 100 mmHg or SI less
than 1.0. We also performed a subanalysis of patients with both EMS and ED
SBPs greater than 100 mmHg and SI less than 1.0 and with a preexisting cardiac
comorbidity (hypertension, angina, myocardial infarction).

Statistical analysis
Data are presented as the mean  standard deviation (SD) for continuous
variables, proportions for nominal variable, and median (interquartile range) for
ordinal variables. We performed the Student t test to assess the difference
between the two groups for parametric variables and Mann-Whitney U test for
nonparametric variables. Pearson chi-square test was performed to compare
differences between the two groups for nominal variables.
Cox regression analysis was performed to generate hazard ratio of positive
delta SI for the outcome of mortality using hospital length of stay in day as the
time variable. To determine the impact of different cutoff points of delta SI for
the outcome of mortality, a total of 10 Cox regressions were performed. With
each regression, the threshold value for delta SI was changed sequentially
(starting with delta SI >0.1 and finishing with delta SI >1.0). All models were
adjusted for age, sex, race, insurance status, ISS, ED GCS, trauma center
designation (level I, II, and others), and mode of transport (air transport vs.
others). Kaplan-Meier hazard curve was then generated for patients with
positive delta SI compared with patients with unchanged or negative delta
SI. The curves were compared with each other using Breslow, Tarone-Ware, and
log-rank tests.
To compare the predictive value of delta SI with other changing vital signs,
we calculated the predicted probabilities of delta SI, change in SBP from the
field to the ED, and change in HR from the field to the ED for mortality using
logistic regression models. The predicted probabilities of these three variables
were then compared with each other using receiver-operating curves (ROC).

For data analysis, we used statistical package for social sciences software
(SPSS, V20.0; IBM Inc, Armonk, NY). A P < 0.05 was considered
statistically significant.

RESULTS
A total of 95,088 patients were included with a mean age
(SD) of 46.2 (19.2) years, 72.6% (n 69,074) were male, and
median ISS was 22 [1727]. Overall, 43.6% (n 41,475) had a
positive delta SI, and 13.6% (n 12,911) of the patients were
hemodynamically unstable at the time of arrival in the ED.
Compared with patients with negative or unchanged delta SI,
patients with positive delta SI were more likely to be hypotensive
(P < 0.001) and tachycardic (P < 0.001) in the ED and less likely
to be hypotensive (P < 0.001) and tachycardic in the field
(P < 0.001). Patients with positive delta SI had higher ED SI
(P < 0.001) and lower field SI (P < 0.001) than patients with
negative or unchanged delta SI. Table 1 shows the comparison of
demographics and the injury severity between the patients with
positive delta SI and patients with unchanged or negative delta SI.
Patients with positive delta SI were more likely to require an
exploratory laparotomy (P < 0.001) and develop inhospital
complications (P < 0.001). The overall mortality rate was
11.9% (n 11,335). Patients with positive delta SI had a higher
mortality rate (P < 0.001) than patients with negative or
unchanged delta SI. Table 2 shows the outcomes between

TABLE 2. Outcomes
Variable
Mortality, % (n)
Length of stay, mean (SD)
Hospital length of stay
ICU length of stay
Ventilator days
Exploratory laparotomy, % (n)
Inhospital complications, % (n)

Positive delta SI (n 41,475)

Unchanged or negative delta SI (n 53,613)

13.3 (5,512)

9.6 (5,147)

<0.001

12.1
5.6
3.0
9.0
47.7

(15.5)
(9.4)
(8.4)
(3,711)
(19,775)

10.6
4.6
2.2
7.8
43.6

(14.2)
(9.1)
(7.5)
(4,161)
(23,364)

Bold cells indicate clinically significant P values.

ICU, intensive care unit; SI, shock index; SD, standard deviation.

Copyright 2016 by the Shock Society. Unauthorized reproduction of this article is prohibited.

<0.001
<0.001
<0.001
<0.001
<0.001

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SHOCK VOL. 46, SUPPLEMENT 1

JOSEPH

ET AL.

TABLE 3. Cox regression analysis

Variable
Delta
Delta
Delta
Delta
Delta
Delta
Delta
Delta
Delta
Delta

shock index >0.1

shock index >0.2
shock index >0.3
shock index >0.4
shock index >0.5
shock index >0.6
shock index >0.7
shock index >0.8
shock index >0.9
Shock Index >1.0

Hazard ratio

95% CI

1.36
1.57
1.70
1.82
1.89
1.91
2.07
2.16
2.12
2.14

1.291.43
1.491.66
1.611.82
1.701.96
1.742.06
1.742.09
1.862.31
1.912.44
1.852.43
1.832.48

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001

Each row in the table represents the hazard ratio for delta shock index
using the respective cutoff. All cox regression models were controlled for
age, sex, race, mechanism of trauma, insurance status, ISS, head AIS,
level of designation, and mode of transport. Bold cells indicate statistically
significant P values.
CI, confidence interval.

the patients with positive delta SI and patients with negative or

unchanged delta SI. Cox regression analysis revealed a hazard
ratio [95% CI] of 1.13 [1.081.18] for mortality in patients with
positive delta SI.
Table 3 shows the hazard ratios of mortality using different
cutoff points for positive delta SI. There was an increase in
hazard ratio [95% CI] for mortality from 1.36 [1.291.43] in
patients with delta SI more than 0.1 to 2.16 [1.912.44] in
patients with a delta SI more than 0.8 (Fig. 1). Patients with
delta SI more than 0.1 had a mortality rate of 16.6% versus
9.5% in patients without a delta SI at most 0.1 (P < 0.001)
(Fig. 2). Kaplan-Meier hazard curve comparing the hazard rates
for these two groups using log-rank (P < 0.001), Breslow
(P < 0.001), and Tarone-Ware (P < 0.001) tests revealed
increased hazard of death in patients with a delta SI more
than 0.1.
On subanalysis of patients with ED SBP and EMS SBP more
than 100 mmHg, patients with a delta SI more than 0.1 had a
higher mortality rate of 15.3% compared with 8.9% (P < 0.001)
and a hazard ratio [95% CI] of 1.29 [1.201.39] compared with
patients with negative/unchanged delta SI. Similarly, on subanalysis of patients with ED SI and EMS SI less than 1.0,
patients with a delta SI more than 0.1 had a higher mortality rate
of 10.9% compared with 8.0% (P < 0.001) and a hazard ratio

FIG. 2. Mortality comparison between patients with delta SI more

than 1 and delta SI at most 1. SI, shock index.

[95% CI] of 1.14 [1.091.20] compared with patients with

negative/unchanged delta SI. On subanalysis of patients with
ED and EMS SBP more than 100 mmHg, SI more than 1.0, the
presence of cardiac comorbidities patients with a positive delta
SI had a significantly higher hazard of death [95% CI] of 1.13
[1.031.24] than patients with negative/unchanged delta SI.
On stratifying of patients based on blunt and penetrating
injury, delta SI more than 0.1 was independently associated
with increased hazard ratio [95% CI] of death in patients with
blunt injury 1.33 [1.271.41] and patients with penetrating
injury 1.16 [1.011.33]. After stratifying patients into groups
based on age (1864 years and >65 years), sex, ISS (ISS 25
and ISS <25), and GCS (score 8 and score 915), delta SI
more than 0.1 still remained independently associated with
increased hazard of death (Table 4).
On comparing the predictive values for mortality using area
under the receiver-operating curve (AUROC), delta SI had
higher AUROC [95% CI]: 0.556 [0.5500.563] compared with
change in SBP (AUROC [95% CI]: 0.520 [0.5130.526]) and
change in HR (AUROC [95% CI]: 0.546 [0.5400.553]).
DISCUSSION

FIG. 1.
index.

Hazard ratios for mortality with increasing delta SI. SI, shock

Guidelines for resuscitation of trauma patients are based on

measurement of traditional vital signs. This study demonstrates
that delta SI may be a vital tool for the identification of subtle
hemodynamic instability that may be missed using traditional

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SHOCK SEPTEMBER 2016

DELTA SHOCK INDEX PREDICTS MORTALITY

TABLE 4. Stratified analysis: hazard ratios of mortality for delta SI

more than 0.1
Variable
Mechanism of trauma
Blunt
Penetrating
ED SBP >100
EMS SBP >100
Age
1864
65
Male
ISS
ISS < 25
ISS  25
GCS score
915
8

Hazard ratio

95% CI

1.33
1.16
1.26
1.42

1.271.41
1.011.33
1.191.33
1.341.49

<0.001
0.03
<0.001
<0.001

1.37
1.38
1.36

1.291.45
1.271.51
1.281.43

<0.001
<0.001
<0.001

1.64
1.28

1.461.85
1.211.35

<0.001
<0.001

1.36
1.14

1.231.51
1.081.20

<0.001
<0.001

Each row in the table represents a subanalysis of the hazard ratio of delta
shock more than 0.1 for mortality. All Cox regression models were
controlled for age, sex, race, mechanism of trauma, insurance status,
ISS, head AIS, level of designation, and mode of transport. Bold cells
indicate statistically significant P values.
CI, confidence interval; ED, emergency department; EMS, emergency
medical services; GCS, Glasgow Coma Scale; ISS, Injury Severity Score;
SBP, systolic blood pressure; SI, shock index.

vital signs in trauma patients. Patients with a positive delta SI

have higher rate of exploratory laparotomy, mortality, and
complications than patients with unchanged or negative delta
SI. Compared with other changing vital signs (SBP and HR),
delta SI had significantly higher discrimination for predicting
mortality. We further performed subanalysis on several groups
based on age, sex, mechanism of injury, and ISS, and found that
positive delta SI is consistently associated with higher hazards
of death. Moreover, even in patients with an apparently normal
hemodynamic status based on traditional vital signs, a positive
delta SI is predictive of higher mortality. As guidelines for the
management of trauma patients with hemorrhagic shock continue to be redefined, delta SI can be a useful tool to predict the
risk of mortality and identify patients with occult hypoperfusion who are at higher risk for mortality.
Several studies have looked at factors on arrival at the
hospital that predict mortality in trauma patients. These factors
include lactate, hemoglobin, base deficit, and injury severity
(812). However, most of these factors are not immediately
available and require more invasive means to measure them.
Therefore, trauma surgeons rely on vital signs such as SBP and
HR to determine the hemodynamic status and ongoing shock in
trauma patients. Studies have shown that HR or SBP alone is
not reliable and accurate in predicting outcomes in trauma
patients (13, 14).
More recently, SI that is derived from SBP and HR has shown
to be an accurate predictor of mortality in trauma patients (5). It
is intuitive to believe that a combination of two vital signs
provide more accurate information in predicting mortality for
critically injured trauma patients. In our study, we measured the
SI in the field and the ED to calculate a new variable that we
defined as the delta SI. A positive delta SI signifies increasing
shock, hypovolemia, and ongoing hemorrhage. This is evident
with higher hazard of death, complications, and need for

53

exploratory laparotomy in patients with a positive delta SI.

We looked at several different cutoffs of delta SI, and found that
there is a progressive increase in the hazard of death with each
degree rises in the delta SI. This is in congruence with the
findings of Cannon et al. (15), who demonstrated higher
mortality rate in patients with an increase in SI.
Traditionally, SI more than 1.0 is considered as the cutoff and
is well established to be associated with higher mortality, blood
transfusions, and lactic acidosis (16, 17). This cutoff is
extremely simple and convenient to use in a stressful trauma
setting. Any patient with an HR higher than the SBP would
have an SI greater than 1.0, which indicates a state of shock.
This approach, however, comes with a potential caveat. Some
trauma patients despite the ongoing hemorrhage and hypovolemia do not exhibit a sufficient tachycardic response that
would allow the absolute value of SI to exceed 1.0 (7).
Similarly, some trauma patients present with a pseudohypertensive state in the face of hypovolemia. Despite a tachycardic
response, the SI in such patients does not exceed 1.0 and may
thus be falsely reassuring. We used the delta SI to predict
mortality in patients who would be considered hemodynamically stable based on normal SBP and SI. Interestingly even in
this subgroup, patients with a positive delta SI had higher
hazard of death.
Delta SI has several implications. A positive delta SI
indicates ongoing hemorrhage, and signifies critically ill
trauma patients who are significantly increased risk for death.
Some patients do not manifest the physiologic response to
injury and hemorrhage resulting in falsely reassuring vital
signs. The physiologic response is particularly blunted in the
older patients with coexisting comorbidities such as hypertension and those using medications such as beta-blockers. As
the elderly population in the United States increases, an
increasing number of older trauma patients with comorbidities and using antihypertensive medications are likely to visit
trauma centers. Therefore, the use of delta SI in these patients
may be particularly valuable for identifying apparently stable
patients who are at higher risk for mortality. Although the
NTDB does not provide information regarding prehospital
use of medications, we assessed the performance of delta SI in
hemodynamically stable patients with history of cardiac illness (hypertension, myocardial infarction, or angina) as
patients with these comorbidities are the group most likely
using antihypertensive or cardiac rate limiting medications.
Even in this group, delta SI reliably predicted mortality. SI is a
simple variable that can easily be calculated and displayed on
monitors in trauma bay as a part of daily practice. Delta SI
may also be used to triage trauma patients with patients who
have a positive delta SI undergoing highest level of trauma
activation. We used two time points, field and ED, to calculate
the delta SI for these patients. The same concept, however,
may be applied in the ED to monitor trauma patients
response to resuscitation by trending the SI over time.
Our study should be interpreted in context of its inherited
limitations, foremost being a retrospective design. Despite a
large sample size, NTDB has a significant amount of missing
data. The prehospital data vital signs that include SBP and HR
were the most common missing variables. We elected to

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54

SHOCK VOL. 46, SUPPLEMENT 1

choose only patients with missing complete data points that

introduce the potential for selection bias. Owing to the very
large sample size, even subtle differences in some clinical
outcomes were statistically significant and the true clinical
significance of these differences is unclear. The use of
prehospital medication such as beta-blockers can affect the
HR. Owing to lack of this information, we could not control
for this factor in the analysis directly; however, we utilized the
use of cardiac illnesses as a surrogate marker for this in the
subgroup analysis mentioned before. Despite these limitations, we present a novel index that can be easily calculated
and used in day-to-day trauma practice to identify high-risk
trauma patients and guide management.
CONCLUSIONS
Delta SI from field to hospital independently predicts
higher mortality. It predicts higher mortality even in apparently hemodynamically stable patients with normal
traditional vital signs and normal SI. Delta SI may serve as
an adjunct to existing traditional vital signs for the identification of occult hypovolemic shock and higher risk of death in
trauma patients.
REFERENCES
1. Rhee P, Joseph B, Pandit V, Aziz H, Vercruysse G, Kulvatunyou N, Friese RS:
Increasing trauma deaths in the United States. Ann Surg 260(1):1321, 2014.
2. Cales RH, Trunkey DD: Preventable trauma deaths. A review of trauma care
systems development. JAMA 254(8):10591063, 1985.
3. Teixeira PG, Inaba K, Hadjizacharia P, Brown C, Salim A, Rhee P, Browder T,
Noguchi TT, Demetriades D: Preventable or potentially preventable mortality at
a mature trauma center. J Trauma 63(6):13381346, 2007.

JOSEPH

ET AL.

4. Bland RD, Shoemaker WC, Abraham E, Cobo JC: Hemodynamic and oxygen
transport patterns in surviving and nonsurviving postoperative patients. Crit
Care Med 13(2):8590, 1985.
5. Pandit V, Rhee P, Hashmi A, Kulvatunyou N, Tang A, Khalil M, OKeeffe T,
Green D, Friese RS, Joseph B: Shock index predicts mortality in geriatric trauma
patients: an analysis of the National Trauma Data Bank. J Trauma Acute Care
Surg 76(4):11111115, 2014.
6. Rady MY, Nightingale P, Little RA, Edwards JD: Shock index: a re-evaluation in
acute circulatory failure. Resuscitation 23(3):227234, 1992.
7. Demetriades D, Chan LS, Bhasin P, Berne TV, Ramicone E, Huicochea F,
Velmahos G, Cornwell EE, Belzberg H, Murray J: Relative bradycardia in
patients with traumatic hypotension. J Trauma Acute Care Surg 45(3):534539,
1998.
8. Callaway DW, Shapiro NI, Donnino MW, Baker C, Rosen CL: Serum lactate and
base deficit as predictors of mortality in normotensive elderly blunt trauma
patients. J Trauma Acute Care Surg 66(4):10401044, 2009.
9. Kaplan LJ, Kellum JA: Initial pH, base deficit, lactate, anion gap, strong ion
difference, and strong ion gap predict outcome from major vascular injury. Crit
Care Med 32(5):11201124, 2004.
10. MacLeod JB, Lynn M, McKenney MG, Jeroukhimov I, Cohn SM: Predictors of
mortality in trauma patients. Am Surg 70(9):805810, 2004.
11. Manikis P, Jankowski S, Zhang H, Kahn RJ, Vincent J-L: Correlation of serial
blood lactate levels to organ failure and mortality after trauma. Am J Emerg Med
13(6):619622, 1995.
12. Morris JA, MacKenzie EJ, Damiano AM, Bass SM: Mortality in trauma
patients: the interaction between host factors and severity. J Trauma Acute
Care Surg 30(12):14761482, 1990.
13. 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. Ann Emerg Med 24(4):685690, 1994.
14. Victorino GP, Battistella FD, Wisner DH: Does tachycardia correlate with
hypotension after trauma? J Am Coll Surg 196(5):679684, 2003.
15. 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. J Trauma Acute Care Surg 67(6):14261430, 2009.
16. Allgower M, Burri C: [ Shock index]. Dtsch Med Wochenschr 92(43):1947
1950, 1967.
17. Oestern H-J, Trentz O, Hempelmann G, Trentz O, Sturm J: Cardiorespiratory
and metabolic patterns in multiple trauma patients. Resuscitation 7(3):169183,
1979.

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