Usefulness of the Shock Index as a secondary triage tool.

INTRODUCTION: Secondary triage at a major incident allows for a more detailed assessment of the patient. In the UK, the Triage Sort (TSO) is the preferred method, combining GCS, systolic BP (SBP) and RR to categorise Priority 1 casualties. The Shock Index (SI) is calculated by dividing HR by SBP (HR/SBP). This study examines whether SI is better at predicting need for life-saving intervention (LSI) following trauma than TSO. METHODS: A prospective observational study was undertaken. Physiological data and interventions performed in the Emergency Department and operating theatre were prospectively collected for 482 consecutive adult trauma patients presenting to Camp Bastion, Afghanistan, over a 6-month period. A patient was deemed to have required LSI if they received any intervention from a set described previously. RESULTS: Complete data were available for 345 patients (71.6%). Of these, 203 (58.8%) were gold standard P1, and 142 (41.2%) were non-P1. The TSO predicted need for LSI with a sensitivity of 58.6% (95% CI 51.8% to 65.4%) and specificity of 88.7% (95% CI 83.5% to 93.9%). Using an SI cut-off >0.75 provided greater sensitivity of 70.0% (95% CI 63.6% to 76.3%) while maintaining an acceptably high (although lower than TSO) specificity of 74.7% (95% CI 67.5% to 81.8%). At this SI cut-off, there was evidence of a difference between TSO and SI in terms of the way in which patients were triaged (p<0.0001). DISCUSSION: Our study showed that a SI >0.75 more accurately predicted the need for LSI, while maintaining acceptable specificity. SI may be more useful than TSO for secondary triage in a mass-casualty situation; this relationship in civilian trauma should be examined to clarify whether these results can be more widely translated into civilian practice. PROJECT REGISTRATION NUMBER: RCDM/Res/Audit/1036/12/0050.

Reinforcer interactions under concurrent schedules of food, water, and intravenous cocaine.

Rats housed in three-lever, operant-conditioning chambers were trained under a concurrent, chained fixed-ratio 1, fixed-ratio 9 schedule (conc chain FR1 FR9) of food and water deliveries. After stable patterns of food and water intake were observed, the rats were prepared with intravenous catheters and a drug self-administration option was added to the schedule. Cocaine infusions (0.33 mg/infusion) were available for only 6 h (09.00 h-15.00 h), while access to food and water was available for 24 h. Addition of the cocaine option produced a minimal decrease in food and water intake and a considerable disruption ruption of food and water intake patterns. Changes in the cocaine dose (0.08-0.84 mg/infusion) did not alter responding on the levers resulting in either food or water deliveries. Cocaine self-administration, however, showed an inverted "U" shaped function as the dose of cocaine was increased. Drug extinction probes resulted in a significant increase in responding on the levers resulting in food and water deliveries and substantial decreases on the lever previously resulting in cocaine infusions. Twenty-four hour food extinction probes decreased responding on the levers resulting in food and water deliveries and produced a modest decrease in the self-administration of cocaine.