Real-time heart rate entropy predicts the need for lifesaving interventions in trauma activation patients

J Trauma Acute Care Surg. 2013 Oct;75(4):607-12. doi: 10.1097/TA.0b013e31829bb991.


Background: Heart rate complexity (HRC), commonly described as a "new vital sign," has shown promise in predicting injury severity, but its use in clinical practice has been precluded by the absence of real-time data. This study was conducted to evaluate the utility of real-time, automated, instantaneous, hand-held heart rate entropy analysis in predicting the need for lifesaving interventions (LSIs). We hypothesized that real-time HRC would predict LSIs.

Methods: Prospective enrollment of patients who met criteria for trauma team activation was conducted at a Level I trauma center (September 2011 to February 2012). A novel, hand-held, portable device was used to measure HRC (by sample entropy) and time-domain heart rate variability continuously in real time for 2 hours after the moment of presentation. Electric impedance cardiography was used to determine cardiac output. Patients who received an LSI were compared with patients without any intervention (non-LSI). Multivariable analysis was performed to control for differences between the groups.

Results: Of 82 patients enrolled, 21 (26%) received 67 LSIs within 24 hours of hospital arrival. Initial systolic blood pressure was similar in both groups. LSI patients had a lower Glasgow Coma Scale (GCS) score (9.2 [5.1] vs. 14.9 [0.2], p < 0.0001). The mean (SD) HRC value on presentation was 0.8 (0.6) in the LSI group compared with 1.5 (0.6) in the non-LSI group (p < 0.0001). With the use of logistic regression, initial HRC was the only significant predictor of LSI. A cutoff value for HRC of 1.1 yields sensitivity, specificity, negative predictive value, and positive predictive value of 86%, 74%, 94%, and 53%, respectively, with an accuracy of 77% for predicting an LSI.

Conclusion: Decreased HRC on hospital arrival is an independent predictor of the need for LSI in trauma activation patients. Real-time HRC may be a useful adjunct to standard vital signs monitoring and predicts LSIs.

Level of evidence: Prognostic and diagnostic study, level III.

MeSH terms

  • Adult
  • Advanced Cardiac Life Support*
  • Cardiac Output / physiology
  • Female
  • Glasgow Coma Scale
  • Heart Rate* / physiology
  • Humans
  • Injury Severity Score
  • Logistic Models
  • Male
  • Multivariate Analysis
  • Prospective Studies
  • Sensitivity and Specificity
  • Wounds and Injuries / physiopathology*
  • Wounds and Injuries / therapy