Detection of haemorrhagic shock: Are vital signs obsolete? A commentary by Dr M. Luginbühl

The ATLS program by the American college of surgeons is probably the most important globally active training organization dedicated to improve trauma management. Detection of acute haemorrhagic shock belongs to the key issues in clinical practice and thus also in medical teaching. (In this issue of the journal William Schulz and Ian McConachrie critically review the ATLS shock classification Table 1), which has been criticized after several attempts of validation have failed [1]. The main problem is that distinct ranges of heart rate are related to ranges of uncompensated blood loss and that the heart rate decrease observed in severe haemorrhagic shock is ignored [2]. Table 1. Estimated blood loos based on patient's initial presentation (ATLS Students Course Manual, 9th Edition, American College of Surgeons 2012). Class I Class II Class III Class IV Blood loss ml Up to 750 750–1500 1500–2000 >2000 Blood loss (% blood volume) Up to 15% 15–30% 30–40% >40% Pulse rate (BPM) <100 100–120 120–140 >140 Systolic blood pressure Normal Normal Decreased Decreased Pulse pressure Normal or ↑ Decreased Decreased Decreased Respiratory rate 14–20 20–30 30–40 >35 Urine output (ml/h) >30 20–30 5–15 negligible CNS/mental status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Initial fluid replacement Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Table options In a retrospective evaluation of the Trauma Audit and Research Network (TARN) database blood loss was estimated according to the injuries in nearly 165,000 adult trauma patients and each patient was allocated to one of the four ATLS shock classes [3]. Although heart rate increased and systolic blood pressure decreased from class I to class IV, respiratory rate and GCS were similar. The median heart rate in class IV patients was substantially lower than the value of 140 min−1 postulated by ATLS. Moreover deterioration of the different parameters does not necessarily go parallel as suggested in the ATLS shock classification [4] and [5]. In all these studies injury severity score (ISS) and mortality increased with in increasing shock class [3] and with increasing heart rate and decreasing blood pressure [4] and [5]. This supports the general concept that the higher heart rate and the lower blood pressure, the sicker is the patient. A prospective study attempted to validate a shock classification derived from the ATLS shock classes [6]. The authors used a combination of heart rate, blood pressure, clinically estimated blood loss and response to fluid resuscitation to classify trauma patients (Table 2) [6]. In their initial assessment of 715 predominantly blunt trauma patients 78% were classified as normal (Class 0), 14% as Class I, 6% as Class II and only 1% as Class III and Class IV respectively. This corresponds to the results from the previous retrospective studies [4] and [5]. The main endpoint used in the prospective study was therefore presence or absence of significant haemorrhage, defined as chest tube drainage >500 ml, evidence of >500 ml of blood loss in peritoneum, retroperitoneum or pelvic cavity on CT scan or requirement of any blood transfusion >2000 ml of crystalloid. Because of the low prevalence of class II or higher grades statistical evaluation was limited to a comparison between Class 0 and Class I–IV combined. As in the retrospective studies, Lawton did not find a statistical difference of heart rate and blood pressure among the five groups either, although there was a tendency to a higher heart rate in Class II patients. Apparently classification during primary survey did not rely on vital signs but considered the rather soft criterion of “clinical estimation of blood loss” and requirement of fluid substitution. This suggests that allocation of an individual patient to a shock classification was probably more an intuitive decision than an objective calculation the shock classification. Nevertheless it was a significant predictor of ISS [6]. Table 2. Shock grade categories in prospective validation study (Lawton, 2014) [6]. Normal No haemorrhage Class I Mild Class II Moderate Class III Severe Class IV Moribund Vitals Normal Normal HR > 100 with SBP >90 mmHg SBP < 90 mmHg SBP < 90 mmHg or imminent arrest Response to fluid bolus (1000 ml) NA Yes, no further fluid required Yes, no further fluid required Requires repeated fluid boluses Declining SBP despite fluid boluses Estimated blood loss (ml) None Up to 750 750–1500 1500–2000 >2000 Table options What does this mean for clinical practice and medical teaching? All these studies illustrate the difficulty to validate a useful and accepted physiologic general concept of the response of the organism to fluid loss: Decrease of cardiac output, increase of heart rate, decrease of pulse pressure occurring first and hypotension and bradycardia occurring only later. Increasing heart rate, increasing diastolic blood pressure or decreasing systolic blood pressure should make any clinician consider hypovolaemia first, because it is treatable and deterioration of the patient is preventable. This is true for the patient on the ward, the sedated patient in the intensive care unit or the anesthetized patients in the OR. We will therefore continue to teach this typical pattern but will continue to mention the exceptions and pitfalls on a second stage. The shock classification of ATLS is primarily used to illustrate the typical pattern of acute haemorrhagic shock (tachycardia and hypotension) as opposed to the Cushing reflex (bradycardia and hypertension) in severe head injury and intracranial hypertension or to the neurogenic shock in acute tetraplegia or high paraplegia (relative bradycardia and hypotension). Schulz and McConachrie nicely summarize the various confounders and exceptions from the general pattern and explain why in clinical reality patients often do not present with the “typical” pictures of our textbooks [1]. ATLS refers to the pitfalls in the signs of acute haemorrhage as well: Advanced age, athletes, pregnancy, medications and pace makers and explicitly state that individual subjects may not follow the general pattern. Obviously the ATLS shock classification which is the basis for a number of questions in the written test of the ATLS students course and which has been used for decades probably needs modification and cannot be literally applied in clinical practice. The European Trauma Course, another important Trauma training program uses the same parameters to estimate blood loss together with clinical exam and laboratory findings (e.g. base deficit and lactate) but does not use a shock classification related to absolute values. In conclusion the typical physiologic response to haemorrhage as illustrated by the ATLS shock classes remains an important issue in clinical practice and in teaching. The estimation of the severity haemorrhage in the initial assessment trauma patients is (and was never) solely based on vital signs only but includes the pattern of injuries, the requirement of fluid substitution and potential confounders. Vital signs are not obsolete especially in the course of treatment but must be interpreted in view of the clinical context. Conflict of interest None declared. Member of Swiss national ATLS core faculty.

First Signs of Emerging Psychosis

The majority of first-episode psychoses are preceded by a prodromal phase that is several years on average, frequently leads to some decline in psychosocial functioning and offers the opportunity for early detection within the framework of an indicated prevention. To this, two approaches are currently mainly followed. The ultra-high-risk (UHR) criteria were explicitly developed to predict first-episode psychosis within 12 months, and indeed the majority of conversions in clinical UHR samples seem to occur within the first 12 months of initial assessment. Their main criterion, the attenuated psychotic symptoms criterion, captures symptoms that resemble positive symptoms of psychosis (i.e. delusions, hallucinations and formal thought disorders) with the exception that some level of insight is still maintained, and these frequently compromise functioning already. In contrast, the basic symptom criteria try to catch patients at increased risk of psychoses at the earliest possible time, i.e. ideally when only the first subtle disturbances in information processing have developed that are experienced with full insight and do not yet overload the person's coping abilities, and thus have not yet resulted in any functional decline. First results from prospective studies not only support this view, but indicate that the combination of both approaches might be a more favorable way to increase sensitivity and detect risk earlier, as well as to establish a change-sensitive risk stratification approach.

Are there signs of change in gendered language use in children's early reading material?

In this study we investigate the relative frequencies of female and male terms in early reading material for children using the Children’s Printed Word Database as a resource. As roles of females and males have changed over time it is of interest to see if there has been a corresponding change in representations of females and males in children’s books. We carried out analyses regarding different words related to gender. Except for nouns referring to relatives, we found in all word groups a preponderance of male terms. The imbalance of male and female pronouns is equivalent to that reported by Carroll, Davies, and Richman (1971) in a frequency count of printed words in children’s book in the USA conducted some 40 years ago. The results are discussed in terms of gender inequality in reading materials and the development of social mores and stereotypical ideas.

Street-Ball: The Myth of the Ghetto Basketball Star

In recent decades, countless scholars have examined the developing trend of African American dominance in United States’ professional sports. Many have hypothesized that this over-representation is caused by the presumed reliance on sports as an avenue out of poverty for the African American youths. This trend, it is believed, has a highly detrimental effect the African American community. In actuality, this argument is flawed because it works under the stereotypical assumption that the overwhelming majority of African Americans come from abject poverty. To dispel this fallacy, the author has analyzed the upbringings of each All-National Basketball League First Team player over the past thirty years. The author discovered that while the majority of the players selected were African American, only a small percentage of these athletes were raised in a poverty-stricken environment. Logically, this would not be the case if poor African Americans relied more heavily on sports than middle-class African Americans. This data proves that stereotypes, not empirical evidence, are the substance of nearly every previous study conducted on the topic.

Pike Street [Illustration] : (Radierung)

Elias M. Großmann

Georges Street, Kniestück

Signatur des Originals: S 36/F10012

An analysis of the effects of a peer mentor program and other factors on HIV patients' retention in care and clinical outcomes at Thomas Street Health Clinic, Houston Texas

Research examining programs designed to retain patients in health care focus on repeated interactions between outreach workers and patients (Bradford et al. 2007; Cheever 2007). The purpose of this study was to determine if patients who are peer-mentored at their intake exam remain in care longer and attend more physicians' visits than those who were not mentored. Using patients' medical records and a previously created mentor database, the study determined how many patients attended their intake visit but subsequently failed to establish regular care. The cohort study examined risk factors for establishing care, determined if patients lacking a peer mentor failed to establish care more than peer mentor assisted patients, and subsequently if peer mentored patients had better health outcomes. The sample consists of 1639 patients who were entered into the Thomas Street Patient Mentor Database between May 2005 and June 2007. The assignment to the mentored group was haphazardly conducted based on mentor availability. The data from the Mentor Database was then analyzed using descriptive statistical software (SPSS version 15; SPSS Inc., Chicago, Illinois, USA). Results indicated that patients who had a mentor at intake were more likely to return for primary care HIV visits at 90 and 180 days. Mentored patients also were more likely to be prescribed ART within 180 days from intake. Other risk factors that impacted remaining in care included gender, previous care status, time from diagnosis to intake visit, and intravenous drug use. Clinical health outcomes did not differ significantly between groups. This supports that mentoring did improve outcomes. Continuing to use peer-mentoring programs for HIV care may help in increasing retention of patients in care and improving patients' health in a cost effective manner. Future research on the effects of peer mentoring on mentors, and effects of concordance of mentor and patient demographics may help to further improve peer-mentoring programs. ^

Sickle cell disease: Its signs, symptoms and varied manifestations

Seventy-five sickle cell patients, age 3-36 years from Houston, Texas, participated in the research study to investigate sickle cell manifestations, conducted between November 1989 and August 1990. All the participants were blacks. There were 35 females and 39 males among the participants in this research study. One of the participants did not document the gender.^ The sickle cell history questionnaire was administered to the participants. Data collected from this study were statistically analyzed using frequencies, percentages, crosstabulations and chi-squares.^ Regular source of health care influences the time of diagnosis of sickle cell disease. Early diagnosis of sickle cell disease with proper care and management will reduce the morbidity and mortality rate of the disease.^ Fevers, bacterial infection, pneumoniae, anemiae, pains, ulcers and cardiovascular problems are common causes of hospitalizations. The average length of stay in the hospital on admission were higher among the sickle cell patients than their family members who themselves did not have sickle cell disease. ^

Point of decision signs and stair use in a university worksite setting: General versus specific messages

Point-of-decision signs to promote stair use have been found to be effective in various environments. However, these signs have been more consistently successful in public access settings that use escalators, such as shopping centers and transportation stations, compared to worksite settings, which are more likely to contain elevators that are not directly adjacent to the stairs. Therefore, this study tested the effectiveness of two point-of-decision sign prompts to increase stair use in a university worksite setting. Also, this study investigated the importance of the message content of the signs. One sign displayed a general health promotion message, while the other sign presented more specific information. Overall, this project examined whether the presence of the point-of-decision signs increases stair use. In addition, this research determined whether the general or specific sign promotes greater stair use. ^ Inconspicuous observers measured stair use both before the signs were present and while they were posted. The study setting was the University of Texas School of Nursing, and the target population was anyone who entered the building, including employees, students, and visitors. The study was conducted over six weeks and included two weeks of baseline measurement, two weeks with the general sign posted, and two weeks with the specific sign posted. Each sign was displayed on a stand in the decision point area near the stairs and the elevator. Logistic regression was used to analyze the data. ^ After adjustment for covariates, the odds of stair use were significantly greater during the intervention period than the baseline period. Furthermore, the specific sign period showed significantly greater odds of stair use than the general sign period. These results indicate that a point-of-decision sign intervention can be effective at promoting stair use in a university worksite setting and that a sign with a specific health information message may be more effective at promoting stair use than a sign with a general health promotion message. These findings can be considered when planning future worksite and university based stair promotion interventions.^

Metropolitan Observatory for Street Children and Youngsters: A Chilean Experience of an Innovative Model

In Chile, street children and youngsters' situations have changed significantly over the last decades. The Metropolitan Observatory is an innovative organization that makes it possible to follow this velnerable group. The Observatory is becoming a pioneering actor in the subject, thanks to the participative work and agreed consensus of different institutions involved. The aim of this paper is to introduce the innovative cross-sectoral work done by the Metropolitan Observatory for street children and youth.

Indian street drama

Ipas India worked with Contact Base, a local organization, to develop street drama that highlights where and how safe abortion services, including medical abortion, can be obtained. Ipas works globally to increase women's ability to exercise their sexual and reproductive rights, and to reduce abortion-related deaths and injuries

Oxygen isotope composition of benthic foraminifera ofthe Florida Street

We present a new method for the quantitative reconstruction of upper ocean flows for during times in the past. For the warm (T>5°C) surface ocean, density can be accurately reconstructed from calcite precipitated in equilibrium with seawater, as both of these properties increase with decreasing temperature and increasing salinity. Vertical density profiles can be reconstructed from the oxygen isotopic composition of benthic foraminifera. The net volume transport between two vertical density profiles can be calculated using the geostrophic method. Using benthic foraminifera from surface sediment samples from either side of the Florida Straits (Florida Keys and Little Bahama Bank), we reconstruct two vertical density profiles and calculate a volume transport of 32 Sv using this method. This agrees well with estimates from physical oceanographic methods of 30-32 Sv for the mean annual volume transport. We explore the sensitivity of this technique to various changes in the relationship between temperature and salinity as well as salinity and the oxygen isotopic composition of seawater.