Shock index (SI) is defined as the heart rate (HR) divided by systolic blood pressure (SBP). It has been studied in patients either at risk of or experiencing shock from a variety of causes: trauma, hemorrhage, myocardial infarction, pulmonary embolism, sepsis, and ruptured ectopic pregnancy. While HR and SBP have traditionally been used to characterize shock in these patients, they often appear normal in the compensatory phase of shock and can be confounded by factors such as medications (eg, antihypertensives, beta-agonists). SI >1.0 has been widely found to predict increased risk of mortality and other markers of morbidity, such as need for massive transfusion protocol activation and admission to intensive care units. Recent research has aimed to study the use of SI in patients immediately on arrival to the emergency department (ED). In this review, we summarize the literature pertaining to use of SI across a variety of settings in the management of ED patients, in order to provide context for use of this measure in the triage and management of critically ill patients.

Determining triage activation levels in geriatric patients who fall (GF), and patients with penetrating wounds can be difficult and inaccurate, resulting in excessive overtriage (OT) and undertriage (UT) rates. We developed trauma activation prediction models using field data to predict with greater accuracy trauma activation level and triage rates consistent with the ACS recommendations. Using data from the 2014 National Trauma Data Bank, we created binary regression equations for each type of injury (GF and penetrating wounds). The 2014 data were randomized and divided into two halves. The first half for each injury type was used to generate prediction models, whereas the second half of the 2014 data were combined with 2013 and 2015 National Trauma Data Bank data for model verification. Binary regression equations were generated from vital signs collected by EMS. A Cribari grid with ISS ≥ 15 was used to determine the appropriateness of activation level. Chi-square analysis was used to determine significant differences between OT, UT, and accuracy predictions. Using our triage models, we were able to obtain UTrates of less than 4 per cent for GF with OT rates of less than 40 per cent, UT rates less than 4.1 per cent and OT of less than 50 per cent for patients with gunshot wounds, and UTrates less than 4 per cent and OT rates less than 25 per cent for patients who had stab wounds. Our developed trauma level prediction models enable health providers to predict trauma activation levels that can result in OT and UT rates in the recommended ranges by the ACS.

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Conclusion: Overall, a single dose administration of fentanyl sublingual spray at doses ranging from 100 mcg to 800 mcg was generally well tolerated in healthy opiodnaive subjects. A single dose up to 400 mcg may be safely administered without the need for supplemental oxygenation in a healthy opioid-naive population in an appropriately monitored and equipped setting.