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Physiologic Predictors of Severe Injury: Systematic Review
Comparative Effectiveness Review, No. 205
Investigators: Annette M. Totten, Ph.D., Tamara P. Cheney, M.D., Maya E. O’Neil, Ph.D., Craig D. Newgard, M.D., M.P.H., Mohamud Daya, M.D., M.S., Rongwei Fu, Ph.D., Ngoc Wasson, M.P.H., Erica L. Hart, M.S.T., and Roger Chou, M.D.
Structured Abstract
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.
Contents
- Key Messages
- Preface
- Acknowledgments
- Technical Expert Panel
- Peer Reviewers
- Evidence Summary
- Introduction
- Methods
- Search Strategy
- Criteria for Inclusion/Exclusion of Studies in the Review
- Study Selection
- Data Abstraction and Data Management
- Assessment of Methodological Risk of Bias of Individual Studies
- Data Analysis and Synthesis
- Grading the Strength of Evidence for Major Comparisons and Outcomes
- Assessing Applicability
- Managing Bias and the Appearance of Bias
- Peer Review and Public Commentary
- Results
- Discussion
- References
- Abbreviations and Acronyms
- Appendixes
- Appendix A. Search Strategies
- Appendix B. List of Included Studies
- Appendix C. List of Excluded Studies
- Appendix D. Evidence Tables
- Appendix E. Risk of Bias Criteria
- Appendix F. Risk of Bias Assessment
- Appendix G. Multivariate Results Summaries
- Appendix H. Strength of Evidence
- Appendix I. Meta-Analysis Results for Studies of Predictive Utility in the Emergency Department Setting
Suggested citation:
Totten AM, Cheney TP, O’Neil ME, Newgard CD, Daya M, Fu R, Wasson N, Hart EL, Chou R. Physiologic Predictors of Severe Injury: Systematic Review. Comparative Effectiveness Review No. 205. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2015-00009-I.) AHRQ Publication No. 18-EHC008-EF. Rockville, MD: Agency for Healthcare Research and Quality; April 2018. Posted final reports are located on the Effective Health Care Program search page. DOI: https://doi.org/10.23970/AHRQEPCCER205.
This report is based on research conducted by the Pacific Northwest Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2015-00009-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report is made available to the public under the terms of a licensing agreement between the author and the Agency for Healthcare Research and Quality. This report may be used and reprinted without permission except those copyrighted materials that are clearly noted in the report. Further reproduction of those copyrighted materials is prohibited without the express permission of copyright holders.
AHRQ or U.S. Department of Health and Human Services endorsement of any derivative products that may be developed from this report, such as clinical practice guidelines, other quality enhancement tools, or reimbursement or coverage policies, may not be stated or implied.
This report may periodically be assessed for the currency of conclusions. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at www.effectivehealthcare.ahrq.gov. Search on the title of the report.
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