Physiologic Predictors of Severe Injury: Systematic Review [Entered Retrospectively]

Project Summary Title and Description

Physiologic Predictors of Severe Injury: Systematic Review [Entered Retrospectively]
Objectives. To systematically identify and summarize evaluations of measures of circulatory and respiratory compromise, focusing on measures that can be used in field assessment by emergency medical services to inform decisions about the level of trauma care needed. We identified research on the ability of different measures to predict whether a patient was seriously injured and thus required transport to the highest level of trauma care available. Data sources. We searched Ovid MEDLINE®, CINAHL®, and the Cochrane databases from 1996 through August 2017. Reference lists of included articles were reviewed for additional relevant citations. Review methods. We included studies of individual measures and measures that combined circulatory, respiratory, and level of consciousness assessment. Evaluations included diagnostic accuracy (sensitivity and specificity) and area under the receiver operating characteristic curve (AUROC). We used data provided to calculate values that were not reported and pooled estimates across studies when feasible. Results. We identified and included 138 articles reporting results of 134 studies. Circulatory compromise measures evaluated in these studies included systolic blood pressure, heart rate, shock index, lactate, base deficit, and heart rate variability or complexity. The respiratory measures evaluated included respiration rate, oxygen saturation, partial pressure of carbon dioxide, and need for airway support. Many different combination measures were identified, but most were evaluated in only one or two studies. Pooled AUROCs from out-of-hospital data were 0.67 for systolic blood pressure (moderate strength of evidence); 0.67 for heart rate, 0.72 for shock index, 0.77 for lactate, 0.70 for respiratory rate, and 0.89 for Revised Trauma Score combination measure (all low strength of evidence); and were considered poor to fair. The only AUROC that reached a level considered excellent was for the Glasgow Coma Scale, age, and arterial pressure (GAP) combination measure (AUROC, 0.96; estimate based on emergency department data). All of the measures had low sensitivities and comparatively high specificities (e.g., sensitivities ranging from 13% to 74% and specificities ranging from 62% to 96% for out-of-hospital pooled estimates). Conclusions. Physiologic measures usable in triaging trauma patients have been evaluated in multiple studies; however, their predictive utilities are moderate and far from ideal. Overall, the measures have low sensitivities, high specificities, and AUROCs in the poor-to-fair range. Combination measures that include assessments of consciousness seem to perform better, but whether they are feasible and valuable for out-of-hospital use needs to be determined. Modification of triage measures for children or older adults is needed, given that the measures perform worse in these age groups; however, research has not yet conclusively identified modifications that result in better performance.
Authors of Report
Methodology description
Review methods. We included studies of individual measures and measures that combined circulatory, respiratory, and level of consciousness assessment. Evaluations included diagnostic accuracy (sensitivity and specificity) and area under the receiver operating characteristic curve (AUROC). We used data provided to calculate values that were not reported and pooled estimates across studies when feasible.
This project was entered retrospectively by uploading data to the project. Tables uploaded to this project: Evidence Tables and Risk of Bias Assessment Table The DOI for this report is
Funding Source
Agency for Healthcare Research and Quality (AHRQ)

Key Questions

1. Key Question 1: For patients with known or suspected trauma who are treated out-of-hospital by EMS personnel, what is the predictive utility of measures of circulatory compromise or derivative measures (e.g., the shock index) for predicting serious injury requiring transport to the highest level trauma center available? 1a: How does the predictive utility of the studied measures of circulatory compromise vary across age groups (e.g., children or the elderly)? Specifically, what values for the different age ranges are supported by the evidence?
2. Key Question 2: For patients with known or suspected trauma who are treated out-of-hospital by EMS personnel, what is the predictive utility of measures of respiratory compromise for predicting serious injury requiring transport to the highest level trauma center available? 2a: How does the predictive utility of the studied measures of respiratory compromise vary across age groups (e.g., children or the elderly)? Specifically, what values for the different age ranges are supported by the evidence?
3. Key Question 3: For patients with known or suspected trauma who are treated out-of-hospital by EMS personnel, what is the evidence that scales combining (a) measures of respiratory and circulatory compromise or (b) measures of respiratory and/or circulatory compromise together with measurement of altered levels of consciousness (as defined by Glasgow Coma Scale or its components) can predict the need for transport to a trauma center? 3a. How does the predictive utility of combinations of measures vary across age groups (e.g., children or the elderly)? Specifically, what values for the different age ranges are supported by the evidence?

Associated Extraction Forms

Associated Studies (each link opens a new tab)

Initial hematocrit predicts the use of blood transfusion in the pediatric trauma patient.2014
A comparison of prehospital and hospital data in trauma patients.2004
Rapid prediction of trauma patient survival by analysis of heart rate complexity: impact of reducing data set size.2009
Capillary lactate concentration on admission of normotensive trauma patients: a prospective study.
Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level.2016
Serum lactate and base deficit as predictors of mortality in normotensive elderly blunt trauma patients.2009
Utility of the shock index in predicting mortality in traumatically injured patients.2009
Comparing biomarkers of traumatic shock: the utility of anion gap, base excess, and serum lactate in the ED.2015
The significance of out-of-hospital hypotension in blunt trauma patients.1997
Is respiration-induced variation in the photoplethysmogram associated with major hypovolemia in patients with acute traumatic injuries?2010
Diagnosis of hemorrhage in a prehospital trauma population using linear and nonlinear multiparameter analysis of vital signs.2007
Trauma team activation and the impact on mortality.
Admission base deficit predicts transfusion requirements and risk of complications.1996
Application of the Shock Index to the prediction of need for hemostasis intervention.2013
A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting.
Lactate and base deficit in trauma: does alcohol or drug use impair their predictive accuracy?
Hypotension begins at 110 mm Hg: redefining "hypotension" with data.
Initial venous lactate levels in patients with isolated penetrating extremity trauma: a retrospective cohort study.2015
Prehospital hypotension as a valid indicator of trauma team activation.2000
A comparison of prehospital lactate and systolic blood pressure for predicting the need for resuscitative care in trauma transported by ground.
Validation of the Shock Index, Modified Shock Index, and Age Shock Index for Predicting Mortality of Geriatric Trauma Patients in Emergency Departments.2016
Heart rate variability as a triage tool in patients with trauma during prehospital helicopter transport.2009
Shock index as a marker for significant injury in trauma patients.
The use of the reverse shock index to identify high-risk trauma patients in addition to the criteria for trauma team activation: a cross-sectional study based on a trauma registry system.2016
Using the Reverse Shock Index at the Injury Scene and in the Emergency Department to Identify High-Risk Patients: A Cross-Sectional Retrospective Study.2016
Evaluation of prehospital and emergency department systolic blood pressure as a predictor of in-hospital mortality.2009
Trauma team activation: simplified criteria safely reduces overtriage.2007
Prehospital hypotension is a predictor of the need for an emergent, therapeutic operation in trauma patients with normal systolic blood pressure in the emergency department.2006
Comparison of Decision-Assist and Clinical Judgment of Experts for Prediction of Lifesaving Interventions.2015
Automated prediction of early blood transfusion and mortality in trauma patients.
Should we still use motor vehicle intrusion as a sole triage criterion for the use of trauma center resources?
Radial pulse character relationships to systolic blood pressure and trauma outcomes.-- Not Found --
An analysis of shock index as a correlate for outcomes in trauma by age group.2013
Discrepancy between heart rate and makers of hypoperfusion is a predictor of mortality in trauma patients.2011
The Shock Index revisited - a fast guide to transfusion requirement? A retrospective analysis on 21,853 patients derived from the TraumaRegister DGU.2013
Admission serum lactate levels do not predict mortality in the acutely injured patient.2006
Leukocytosis as prognostic indicator of major injury.2010
Shock index predicts mortality in geriatric trauma patients: an analysis of the National Trauma Data Bank.2014
Automated continuous vital signs predict use of uncrossed matched blood and massive transfusion following trauma.2016
The predictive value of initial serum lactate in trauma patients.2014
Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma: Retrospective analysis of a large regional trauma database.2016
Comparison of the Prognostic Significance of Initial Blood Lactate and Base Deficit in Trauma Patients.2017
Prognostic significance of blood lactate and lactate clearance in trauma patients.2012
Is heart period variability associated with the administration of lifesaving interventions in individual prehospital trauma patients with normal standard vital signs?2010
Venous glucose and arterial lactate as biochemical predictors of mortality in clinically severely injured trauma patients--a comparison with ISS and TRISS.2009
Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf?-- Not Found --
Predicting blood transfusion using automated analysis of pulse oximetry signals and laboratory values.2015
Diagnostic accuracy of a single point-of-care prehospital serum lactate for predicting outcomes in pediatric trauma patients.2013
Mathematical program for outcome prediction and therapeutic support for trauma beginning within 1 hr of admission: a preliminary report.2005
Role of trauma team activation in poor outcomes of elderly patients.2016
Reappraising the concept of massive transfusion in trauma.2010
Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index.2011
Prospective identification of patients at risk for massive transfusion: an imprecise endeavor.2011
Lactate is a better predictor than systolic blood pressure for determining blood requirement and mortality: could prehospital measures improve trauma triage?2010
Predicting haemorrhage in pre-hospital traumatic patients: evaluation of the novel heart-to-arm time index.2013
Trends of Hemoglobin Oximetry: Do They Help Predict Blood Transfusion During Trauma Patient Resuscitation?2016
New vitals after injury: shock index for the young and age x shock index for the old.2008
Predicting the need to perform life-saving interventions in trauma patients by using new vital signs and artificial neural networks2009
Changes in vital signs of trauma victims from prehospital to hospital settings2011
Shock index as a mortality predictor in patients with acute polytrauma2015
Prehospital dynamic tissue oxygen saturation response predicts in-hospital lifesaving interventions in trauma patients.
Low tissue oxygen saturation is associated with requirements for transfusion in the rural trauma population.2014
Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients.2006
End-tidal carbon dioxide and occult injury in trauma patients: ETCO2016
Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department.2014
Field trauma triage: combining mechanism of injury with the prehospital index for an improved trauma triage tool.1997
Prediction of mortality and of the need for massive transfusion in casualties arriving at combat support hospitals in Iraq.2008
Prehospital factors associated with mortality in injured air medical patients.-- Not Found --
START triage: does it work?-- Not Found --
Trauma triage: a comparison of CRAMS and TRTS in a UK population.1997
Manual vital signs reliably predict need for life-saving interventions in trauma patients.2005
UK triage--an improved tool for an evolving threat.2013
Geriatric-specific triage criteria are more sensitive than standard adult criteria in identifying need for trauma center care in injured older adults.2015
Rapid Emergency Medicine Score (REMS) in the trauma population: a retrospective study.2014
Comparison of the trauma and injury severity score and modified early warning score with rapid lactate level (the ViEWS-L score) in blunt trauma patients.2014
External validation of the Emergency Trauma Score for early prediction of mortality in trauma patients.2014
Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score.2011
Improving the prediction of mortality and the need for life-saving interventions in trauma patients using standard vital signs with heart-rate variability and complexity.2015
Helicopter transport of injured children: system effectiveness and triage criteria.1996
Improving early identification of the high-risk elderly trauma patient by emergency medical services.2016
Predicting early death in patients with traumatic bleeding: development and validation of prognostic model.
Development and validation of a prognostic model to predict death in patients with traumatic bleeding, and evaluation of the effect of tranexamic acid on mortality according to baseline risk: a secondary analysis of a randomised controlled trial.2013
Development of a novel age-specific pediatric trauma score.2001
Field triage of trauma patients: improving on the Prehospital Index.2002
Major incident triage: Derivation and comparative analysis of the Modified Physiological Triage Tool (MPTT).2017
A simplified emergency trauma score for predicting mortality in emergency setting.2016
Evaluation of MGAP and GAP trauma scores to predict prognosis of multiple-trauma patients2017
Sublingual capnometry for rapid determination of the severity of hemorrhagic shock.2007
Diagnostic utility of sublingual PCO2 for detecting hemorrhage in penetrating trauma patients.2004
Continuous noninvasive tissue oximetry in the early evaluation of the combat casualty: a prospective study.2010
The value of traditional vital signs, shock index, and age-based markers in predicting trauma mortality.2013
The value of the difference between ED and prehospital vital signs in predicting outcome in trauma.2014
Nasal cannula end-tidal CO2 correlates with serum lactate levels and odds of operative intervention in penetrating trauma patients: a prospective cohort study.2012
Heart rate variability and its association with mortality in prehospital trauma patients.
Refining the trauma triage algorithm at an Australian major trauma centre: derivation and internal validation of a triage risk score.2014
Is heart rate variability better than routine vital signs for prehospital identification of major hemorrhage?2015
Prehospital triage in the injured pediatric patient.2000
Evaluation of the performance of French physician-staffed emergency medical service in the triage of major trauma patients.2014
Ability of the Physiologic Criteria of the Field Triage Guidelines to Identify Children Who Need the Resources of a Trauma Center.-- Not Found --
Development and validation of a machine learning algorithm and hybrid system to predict the need for life-saving interventions in trauma patients.2014
Do prehospital criteria optimally assign injured children to the appropriate level of trauma team activation and emergency department disposition at a level I pediatric trauma center?2014
The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort.-- Not Found --
Early risk stratification of patients with major trauma requiring massive blood transfusion.2011
Utility of admission serum lactate in pediatric trauma.2015
Heart rate variability is an independent predictor of morbidity and mortality in hemodynamically stable trauma patients.2011
Initial emergency department trauma scores from the OPALS study: the case for the motor score in blunt trauma.2004
Admission lactate level and the APACHE II score are the most useful predictors of prognosis following torso trauma.2004
Mechanism of injury and special consideration criteria still matter: an evaluation of the National Trauma Triage Protocol.2011
Can we improve the clinical utility of respiratory rate as a monitored vital sign?2009
Comparative analysis of multiple-casualty incident triage algorithms.2001
Prehospital physiologic data and lifesaving interventions in trauma patients.2005
Norwegian survival prediction model in trauma: modelling effects of anatomic injury, acute physiology, age, and co-morbidity.2014
Evaluation of standard versus nonstandard vital signs monitors in the prehospital and emergency departments: results and lessons learned from a trauma patient care protocol.2014
Statistical validation of the Revised Trauma Score.2006
Physiologic field triage criteria for identifying seriously injured older adults.-- Not Found --
Prehospital identification of major trauma patients.2009
Novel prehospital monitor with injury acuity alarm to identify trauma patients who require lifesaving intervention.2014
Continuously recorded oxygen saturation and heart rate during prehospital transport outperform initial measurement in prediction of mortality after trauma.2012
Calculation of different triage scores based on the German Trauma Registry: value of the shock index2005
Prehospital loss of R-to-R interval complexity is associated with mortality in trauma patients.2007
Systolic blood pressure criteria in the National Trauma Triage Protocol for geriatric trauma: 110 is the new 90.2015
Heart-rate complexity for prediction of prehospital lifesaving interventions in trauma patients.2008
Decision tool for the early diagnosis of trauma patient hypovolemia.2008
Prehospital serum lactate as a predictor of outcomes in trauma patients: a retrospective observational study.2011
Substituting systolic blood pressure with shock index in the National Trauma Triage Protocol.2016
Incremental benefit of individual American College of Surgeons trauma triage criteria.1996
The modified rapid emergency medicine score: A novel trauma triage tool to predict in-hospital mortality.2017
The utility of base deficit and arterial lactate in differentiating major from minor injury in trauma patients with normal vital signs.2008
Triage hyperglycemia as a prognostic indicator of major trauma.2010
The utility of shock index in differentiating major from minor injury.2011
Usefulness of the Shock Index as a secondary triage tool.2015
Early prediction of posttraumatic in-hospital mortality in pediatric patients.-- Not Found --
Pediatric trauma team activation: are we making the right call?2014
Utility of vital signs, heart rate variability and complexity, and machine learning for identifying the need for lifesaving interventions in trauma patients.2014
Data quality of a wearable vital signs monitor in the pre-hospital and emergency departments for enhancing prediction of needs for life-saving interventions in trauma patients.2015
What do prehospital trauma scores predict besides mortality?2011
Muscle Oxygen Saturation Improves Diagnostic Association Between Initial Vital Signs and Major Hemorrhage: A Prospective Observational Study.2016
Mechanism, glasgow coma scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients.2010

Downloadable Data Content

  • XLSX Project Data