Clinical outcomes in a controlled trial of early identification and rapid systematic treatment of shock, modeled after the trauma system

Hypothesis

Early identification and rapid systematic treatment of shock will improve outcomes.

Inclusion criteria

Sustained inadequate tissue perfusion not responsive to initial volume resuscitation.

Hypotension. SBP <90, MAP ≤ 60, not corrected with one liter rapidly infused crystalloid and one or more of the following: or

Normotension. With three of the following: Temperature ≤ 36; Cool extremities or skin mottling; Altered mental status; RR ≥ 20; Oliguria; Lactic acidosis or BE ≤ -5.

Identified to be in shock by the caregiver (i.e. septic, cardiogenic, hypovolemic).

Exclusion criteria

Trauma, acute MI, patients already receiving mechanical ventilation/pressors, and patients who are not candidates for ACLS.

Methods

Patients at Redding Medical Center between 1998 and 1 June 2000 in shock (control group) were treated in the standard fashion. The outcomes of those patients were compared to the outcome of patients at Redding Medical Center in shock after 1 July 2000 (treatment group). Both groups had the same inclusion and exclusion criteria and assessed for severity of illness using APACHE III. During the month of June 2000 intensive education to all nursing personnel, Emergency Department physicians, intensivists, surgeons, interventional radiologists, and medical staff at large was undertaken for the purpose of improving earlier identification and treatment of shock. Beginning 1 July 2000 standardized treatment protocols utilizing best practice were implemented for the EMS, Emergency Department, critical care units and general nursing units and a 'shock bed' in ICU became available at all times. Activated by a shock alert a shock team comprised of intensivists, Emergency Department physicians, critical care nurse, nursing supervisor, respiratory therapy, radiology, clinical laboratory, electrocardiography, social and pastoral services rapidly responds to the patient's bedside and implements the treatment protocols. The primary care physician is notified.

Discussion

No significant changes in types of therapy or in the physician mix in the treatment of shock were made from the time intervals of the historical control group compared to the treatment group. The severity of illness between the two groups is equivalent. Therefore, it is likely that the observed changes in the time intervals for treatment and the mortality outcome are due to the initiation of the Shock Program at Redding Medical Center.

Conclusion

Early identification of shock and rapid initiation of treatment reduces the time to the initiation of therapy and mortality.

Table

Table 2 Table 1