Agitation in the Trauma Bay Is an Early Indicator of Hemorrhagic Shock

Published:November 25, 2022DOI:



      Agitation on arrival in trauma patients is known as a sign of impending demise. The aim of this study is to determine outcomes for trauma patients who present in an agitated state. We hypothesized that agitation in the trauma bay is an early indicator for hemorrhage in trauma patients.


      We performed a single-institution prospective observational study from September 2018 to December 2020 that included any trauma patient who arrived agitated, defined as a Richmond Agitation-Sedation Scale of +1 to +4. Variables collected included demographics, mechanism of injury, admission physiology, blood alcohol level, toxicity screen, and injury severity. The primary outcomes were need for massive transfusion (≥ 10 units) and need for emergent therapeutic intervention for hemorrhage control (laparotomy, preperitoneal pelvic packing, sternotomy, thoracotomy, or angioembolization).


      Of 4657 trauma admissions, 77 (2%) patients arrived agitated. Agitated patients were younger (40 versus 46, P = 0.03), predominantly male (94% versus 66%, P < 0.0001) sustained more penetrating trauma (31% versus 12%, P < 0.0001), had a lower systolic blood pressure (127 versus 137, P < 0.0001), and a higher Injury Severity Score (17 versus 9, P < 0.0001). On multivariable logistic regression, agitation was independently associated with massive transfusion (odds ratio: 2.63 [1.20-5.77], P = 0.02) and emergent therapeutic intervention for hemorrhage control (odds ratio: 2.60 [1.35-5.03], P = 0.005).


      Agitation in trauma patients may serve as an early indicator of hemorrhagic shock, as agitation is independently associated with a two-fold increase in the need for massive transfusion and emergent therapeutic intervention for hemorrhage control.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Surgical Research
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Centers for Disease Control and Prevention
        Ten leading causes of death and injury. Injury prevention & control: data & statistics web site.
        (Available at:)
        • Oyeniyi B.T.
        • Fox E.E.
        • Scerbo M.
        • Tomasek J.S.
        • Wade C.E.
        • Holcomb J.B.
        Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care.
        Injury. 2017; 48: 5-12
        • Demetriades D.
        • Kimbrell B.
        • Salim A.
        • et al.
        Trauma deaths in a mature urban trauma system: is "trimodal" distribution a valid concept?.
        J Am Coll Surg. 2005; 201: 343-348
        • Holcomb J.B.
        • Tilley B.C.
        • Baraniuk S.
        • et al.
        Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ratio and mortality in patients with severe trauma: the PROPPR randomized clinical trial.
        JAMA. 2015; 313: 471-482
        • American College of Surgeons Committee on Trauma
        ATLS, advanced trauma Life support-10th Ed.
        Am Coll Surgeons. 2018; : 48-51
        • Mutschler M.
        • Nienaber U.
        • Brockamp T.
        • et al.
        Renaissance of base deficit for the initial assessment of trauma patients: a base deficit-based classification for hypovolemic shock developed on data from 16,305 patients derived from the TraumaRegister DGU®.
        Crit Care. 2013; 17: R42
        • Mutschler M.
        • Paffrath T.
        • Wölfl C.
        • et al.
        The ATLS(®) classification of hypovolaemic shock: a well established teaching tool on the edge?.
        Injury. 2014; 45: S35-S38
        • Bankhead-Kendall B.
        • Teixeira P.
        • Roward S.
        • et al.
        Narrow pulse pressure is independently associated with massive transfusion and emergent surgery in hemodynamically stable trauma patients.
        Am J Surg. 2020; 220: 1319-1322
        • Zhu C.S.
        • Cobb D.
        • Jonas R.B.
        • et al.
        Shock index and pulse pressure as triggers for massive transfusion.
        J Trauma Acute Care Surg. 2019; 87: S159-S164
        • Priestley E.M.
        • Inaba K.
        • Byerly S.
        • et al.
        Pulse pressure as an early warning of hemorrhage in trauma patients.
        J Am Coll Surg. 2019; 229: 184-191
        • Warren J.
        • Moazzez A.
        • Chong V.
        • et al.
        Narrowed pulse pressure predicts massive transfusion and emergent operative intervention following penetrating trauma.
        Am J Surg. 2019; 218: 1185-1188
        • Schellenberg M.
        • Owattanapanich N.
        • Getrajdman J.
        • Matsushima K.
        • Inaba K.
        Prehospital narrow pulse pressure predicts need for resuscitative thoracotomy and emergent intervention after trauma [published correction appears in J Surg Res. 2021 Oct 6;270:1].
        J Surg Res. 2021; 268: 284-290
        • Sessler C.N.
        • Gosnell M.S.
        • Grap M.J.
        • et al.
        The Richmond Agitation-Sedation Scale: validity and reliability in adult intensive care unit patients.
        Am J Respir Crit Care Med. 2002; 166: 1338-1344
        • Ely E.W.
        • Truman B.
        • Shintani A.
        • et al.
        Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).
        JAMA. 2003; 289: 2983-2991
        • Iaccarino M.A.
        • Bhatnagar S.
        • Zafonte R.
        Rehabilitation after traumatic brain injury.
        Handb Clin Neurol. 2015; 127: 411-422
        • Ganau M.
        • Lavinio A.
        • Prisco L.
        Delirium and agitation in traumatic brain injury patients: an update on pathological hypotheses and treatment options.
        Minerva Anestesiol. 2018; 84: 632-640
        • Sessler C.N.
        • Grap M.J.
        • Brophy G.M.
        Multidisciplinary management of sedation and analgesia in critical care.
        Semin Respir Crit Care Med. 2001; 22: 211-226
        • Luauté J.
        • Plantier D.
        • Wiart L.
        • Tell L.
        • SOFMER group
        Care management of the agitation or aggressiveness crisis in patients with TBI. Systematic review of the literature and practice recommendations.
        Ann Phys Rehabil Med. 2016; 59: 58-67
        • Lin J.
        • Figuerado Y.
        • Montgomery A.
        • et al.
        Efficacy of ketamine for initial control of acute agitation in the emergency department: a randomized study.
        Am J Emerg Med. 2021; 44: 306-311
        • Kanich W.
        • Brady W.J.
        • Huff J.S.
        • et al.
        Altered mental status: evaluation and etiology in the ED.
        Am J Emerg Med. 2002; 20: 613-617
        • Cannon C.M.
        • Braxton C.C.
        • Kling-Smith M.
        • Mahnken J.D.
        • Carlton E.
        • Moncure M.
        Utility of the shock index in predicting mortality in traumatically injured patients.
        J Trauma. 2009; 67: 1426-1430
        • Cotton B.A.
        • Dossett L.A.
        • Haut E.R.
        • et al.
        Multicenter validation of a simplified score to predict massive transfusion in trauma.
        J Trauma. 2010; 69: S33-S39