Shock index and early warning score in liver cancer rupture shock

Abstract

BACKGROUND

Primary liver cancer is a globally prevalent malignancy, with China accounting for approximately 55% of new cases, and is linked to hepatitis B, aflatoxin, and cirrhosis. Its rupture with hemorrhagic shock is a lethal complication with high mortality, and traditional triage struggles with timely risk stratification, necessitating better tools, such as the integrated shock index (SI)-early warning score (EWS).

AIM

To study and analyze the combined effect of the SI and EWS in primary liver cancer patients with ruptured hemorrhage and shock.

METHODS

In total, 118 patients who visited the Emergency Department of Nantong Third People's Hospital from January 2023 to December 2024 were selected and randomly divided into a control group (59 patients who received routine emergency treatment) and an observation group (59 patients who received condition assessment and intervention by combining the SI and EWS based on routine emergency treatment). The clinical treatment outcomes, respiratory function indicators, serological indicators, complications, and satisfaction with emergency intervention before and after the emergency intervention were compared between the two groups.

RESULTS

The emergency, triage, waiting, and hemostasis times, as well as hospital stay were shorter in the observation group than in the control group (P < 0.05). After 48 hours of emergency intervention, blood oxygen saturation and partial pressure of oxygen in the observation group were higher than those in the control group (P < 0.05). Seven days after emergency intervention, the hemoglobin, prealbumin, and albumin levels were higher in the observation group than in the control group (P < 0.05). The complication rate in the observation group was 3.39%, lower than that in the control group (13.56%; P < 0.05). Satisfaction with emergency intervention in the observation group was 94.92%, higher than 83.05% in the control group (P < 0.05).

CONCLUSION

The combined application of the SI and EWS in patients with primary liver cancer rupture, hemorrhage, and shock can significantly shorten emergency treatment time, improve respiratory function and serological indicators, reduce the incidence of complications, and enhance patient satisfaction with emergency interventions, with higher clinical treatment efficiency and quality. Therefore, it is worthy of promotion and application.

Key Words: Primary liver cancer; Rupture hemorrhage; Shock index; Early warning score system; Complications

Core Tip: This study demonstrated that combining the shock index (SI, heart rate/systolic blood pressure ratio) with the early warning score (EWS) significantly improves outcomes in primary liver cancer rupture hemorrhage. The SI-EWS protocol reduced emergency response time by 32% and complication rates by 75% (3.39% vs 13.56%), and increased patient satisfaction to 94.92%. This integrated approach enhances hemodynamic monitoring accuracy, enabling faster hemorrhage control and better preservation of respiratory function and nutritional status (hemoglobin/prealbumin levels). These findings support the use of SI-EWS as a standardized triage tool for high-risk abdominal hemorrhage cases.

INTRODUCTION

Primary liver cancer is the sixth most common malignant tumor globally, with the third highest mortality rate. New cases in China account for approximately 55% of the global total, mainly associated with hepatitis B virus infection, aflatoxin exposure, and a high incidence of liver cirrhosis[1,2]. As the disease progresses, rapid tumor growth in primary liver cancer can lead to local ischemic necrosis and erosion of intrahepatic blood vessels. The progression of cirrhosis and exacerbation of portal hypertension further increases vascular fragility, making even a slight increase in abdominal pressure a potential trigger for rupture and hemorrhage, which is one of the most critical clinical complications[3,4]. Notably, 8%-15% of patients with primary liver cancer experience tumor rupture and hemorrhage, which often progresses to shock with a mortality rate as high as 60%-90%, making it one of the most life-threatening emergencies in the emergency department[5,6].

Traditional assessment methods for such critical conditions, which rely on single parameters such as blood pressure and heart rate (HR), have significant limitations owing to their lag in reflecting dynamic changes in patient status. In contrast, the shock index (SI) and early warning score (EWS) systems have emerged as more robust tools for risk stratification and timely intervention.

The SI, calculated as the ratio of HR (beats/min) to systolic blood pressure (SBP) (mmHg), is a simple yet effective hemodynamic parameter that dynamically reflects shock severity. It enables rapid identification of circulatory instability: An SI ≥ 1 indicates high risk, requiring immediate emergency protocols, while values between 0.5 and 1 suggest moderate risk, necessitating intensive monitoring[7,8]. This index integrates two key vital signs to overcome the limitations of isolated parameters and provides a more comprehensive assessment of perfusion status.

The EWS system, on the contrary, is a multi-parametric tool that evaluates HR, SBP, respiratory rate, body temperature, and consciousness. By assigning numerical scores to deviations from normal ranges, it stratifies patients into risk levels (e.g., ≤ 2 points for stable, 3-4 points for severe, and ≥ 5 points for critical conditions), enabling proactive identification of deteriorating status[9,10]. Periodic reassessment (e.g., every 2 hours in the acute phase) ensures timely adjustment of treatment strategies.

Both tools have demonstrated utility in acute care settings; SI enhances the accuracy of hemodynamic monitoring, whereas EWS captures multisystem instability. However, their combined application in primary liver cancer rupture with hemorrhagic shock remains underexplored. Given the high mortality and challenges in early triage for this condition, this study aimed to investigate the efficacy of integrating the SI and EWS system, with the goal of optimizing emergency intervention, improving patient outcomes, and providing a standardized triage approach for clinical practice.

MATERIALS AND METHODS

Research participants

In total, 118 patients who visited the Emergency Department of Nantong Third People's Hospital between January 2023 and December 2024 were selected. After obtaining informed consent from the patients' families, they were randomly divided into an observation group (n = 59) and a control group (n = 59) by drawing lots. Table 1 compares the baseline characteristics of the patients in the observation group (59 cases) and the control group (59 cases), including sex, age, tumor diameter, and distribution type. The results showed that there were no significant differences between the two groups in terms of sex (61.02% and 57.63% males, respectively), mean age (53.78 ± 6.21 years vs 53.42 ± 6.35 years), mean tumor diameter (6.52 ± 1.36 cm vs 6.45 ± 1.39 cm), and tumor distribution type (diffuse type 38.98% vs 37.29%, nodular type 52.54% vs 55.93%, mass type 8.47% vs 6.78%; χ²/t-values were 0.170, 0.311, 0.277, and 0.215, respectively, with all P values > 0.05), indicating that the baseline characteristics of the two groups were balanced and similar.

Table 1 Comparison of baseline data between the two groups, n (%)/(mean ± SD).

Group	Observation (n = 59)	Control (n = 59)	χ2/t	P value
Sex
Male	36 (61.02)	34 (57.63)	0.170	0.680
Female	23 (38.98)	25 (42.37)
Age (years)	53.78 ± 6.21	53.42 ± 6.35	0.311	0.756
Tumor diameter (cm)	6.52 ± 1.36	6.45 ± 1.39	0.277	0.782
Distribution pattern
Diffuse type	23 (38.98)	22 (37.29)	0.215	0.898
Nodular type	31 (52.54)	33 (55.93)
Block type	5 (8.47)	4 (6.78)

Inclusion and exclusion criteria

The inclusion criteria were as follows: (1) Diagnosis of primary liver cancer rupture hemorrhage and shock by imaging and pathological examinations in accordance with the Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)[9]; (2) Expected survival period of > 3 months; (3) Time from rupture hemorrhage and shock to admission of < 24 hours; (4) No other serious complications or comorbidities; and (5) No other specific treatment for liver cancer.

The exclusion criteria were: (1) Presence of other malignant tumors; (2) Severe dysfunction of the heart, lung, kidney, and other organs; (3) Allergic reactions to related therapeutic drugs; (4) Mental illness or cognitive impairment, inability to cooperate with the researcher; and (5) Withdrawal from the study or loss to follow-up midway. This study was approved by the hospital’s ethics committee. There were no significant differences in the baseline data between the two groups (P > 0.05) (Table 1).

Research methods

Control group: Patients in the control group were given routine emergency treatment measures: (1) SBP < 90 mmHg and HR > 100 beats/min as evaluation parameters, and monitored and recorded every hour; (2) Rapidly establishing an intravenous channel, empirically infusing 0.9% normal saline at an initial speed of 15 mL/kg/30 minutes; (3) When hemoglobin (Hb) was < 7 g/dL, infusing concentrated red blood cells to supplement blood volume and maintain blood pressure stability; (4) Giving hemostatic drugs such as tranexamic acid, somatostatin, and thrombin to control bleeding; when blood pressure continued to be low, 5-10 μg/kg/min dopamine was used; (5) Using liver-protecting drugs such as polyene phosphatidylcholine and diammonium glycyrrhizinate to protect liver function; and (6) During the treatment, closely monitoring the patient's vital signs, including blood pressure, HR, respiration, and body temperature, as well as indicators such as liver and kidney functions and electrolytes, and adjusting the treatment plan in a timely manner according to the condition changes.

Observation group: On the basis of routine emergency treatment, the SI and EWS system were combined to assess the condition of patients in the observation group, and for intervention: (1) After admission, the patient's shock degree was immediately evaluated by the formula SI = pulse (beats/min)/SBP (mmHg), and it was monitored and calculated every 1 hour. Combined with other indicators such as lactate and urine output, the resuscitation effect was assessed, and hierarchical management was performed according to the obtained scores: For patients with SI ≥ 1, it indicated a high risk, and an emergency treatment process needed to be started. A multidisciplinary team of emergency, critical care medicine, interventional radiology, gastroenterology, hepatobiliary surgery, transfusion, and other physicians and nursing teams conducted emergency consultations to consider blood transfusion, vasoactive drugs, or emergency surgery, etc.; for those with SI between 0.5 and 1, it indicated a moderate risk, and intensive monitoring was required to optimize fluid resuscitation, maintain hemodynamic stability, and prepare necessary treatment measures; and for those with SI < 0.5, it indicated a low risk, indicating stable circulatory status, but continuous attention to condition changes was still required. The EWS system was used to comprehensively evaluate the patients’ HR, SBP, respiratory rate, body temperature, consciousness status, and other indicators. Evaluations were conducted every 2 hours during the acute phase and every 4 hours during the stable phase. If the total score was continuously < 5 points twice, it was adjusted to two times per day. The specific scoring criteria for "0 points" included: SBP 101-199 mmHg, HR 60-100 beats/min, respiratory rate 12-20 breaths/min, body temperature 35.0-38.4 ℃, and clear consciousness; "1 point" indicators included: SBP 81-100 mmHg, HR 51-60 beats/min or 101-120 beats/min, respiratory rate 9-11 breaths/min or 21-25 breaths/min, and consciousness responsive to sound; "2 points" indicators included: SBP 71-80 mmHg or 200-219 mmHg, HR 41-50 beats/min or 121-139 beats/min, respiratory rate 26-29 breaths/min or ≤ 8 breaths/min, body temperature < 35.0 ℃ or 38.5-39.9 ℃, and consciousness responsive to pain; "3 points" indicators included: SBP ≤ 70 mmHg or ≥ 220 mmHg, HR ≤ 40 beats/min or ≥ 140 beats/min, respiratory rate ≥ 30 breaths/min, and unconsciousness. According to the evaluation results, corresponding treatment measures were taken: When the total score was ≥ 5 points, it indicated that the patient's condition was critical, and immediate intensive monitoring and rapid intervention were required, such as increasing the speed of fluid resuscitation, adjusting the dose of vasoactive drugs, and preparing for mechanical ventilation; a total score of 3-4 points indicated that the patient's condition was severe, and close attention to the condition changes was required, strengthening fluid management, and preparing necessary treatment equipment; and a total score of ≤ 2 points indicated that the patient's condition was relatively stable, but regular evaluation was still required to prevent the condition from worsening. By combining the SI and EWS, the patients were divided into three levels: Green (SI < 1.0, EWS < 5), yellow (SI ≥ 1.0 or EWS ≥ 5), and red (SI > 1.5, EWS > 7), corresponding to low, moderate, and high risk, respectively. Corresponding treatment measures were taken at different levels: Green, routine monitoring to avoid excessive intervention; yellow, multidisciplinary team consultation to optimize fluid resuscitation and hemostasis strategies; and red, immediate transfer to the intensive care unit (ICU) to start advanced life support treatment measures such as mechanical ventilation and continuous renal replacement therapy.

Observation indicators

The clinical treatment situation, specifically defined as the time intervals and durations reflecting the efficiency of emergency management; respiratory function indicators, which quantify the oxygenation and ventilation status of the respiratory system; serological indicators, which assess the body's nutritional status, hematopoietic function, and organ synthesis capacity; complications, including adverse events related to hemorrhage, infection, and organ dysfunction; and satisfaction with emergency intervention before and after the emergency intervention, were compared between the two groups.

Clinical treatment situation

This included emergency time (from patient arrival at the emergency department to initiation of targeted first aid measures such as venous access establishment or blood transfusion preparation), triage time (from initial patient assessment to determination of priority level for treatment), waiting time (from completion of triage to the start of specific hemostatic intervention), hemostasis time (from confirmation of bleeding site to clinical cessation of active hemostasis, as indicated by stable vital signs and no fresh bleeding in drainage fluid), and hospital stay (total duration from admission to discharge).

Respiratory function indicators

An ABL90 FLEX arterial blood gas analyzer (produced by Radiometer Medical ApS, Denmark) was used for detection. Blood oxygen saturation (SpO₂, a key indicator of oxygenation status, normal range 95%-100%) and partial pressure of oxygen (PaO₂, reflecting the oxygen pressure in arterial blood, normal range 80-100 mmHg) were recorded at admission and at 48 h after the emergency intervention to evaluate the improvement in respiratory function.

Serological indicators

Fasting venous blood (5 mL) was collected from patients at admission and at 7 days after the emergency intervention. Hb, a core indicator of red blood cell oxygen-carrying capacity (normal range 120-160 g/L for males and 110-150 g/L for females), prealbumin (PAB, a sensitive marker of acute nutritional status, normal range 200-400 mg/L), and albumin (Alb, reflecting liver synthetic function and systemic nutritional status, normal range 35-50 g/L) were measured. Hb levels were measured using an automatic blood cell analyzer, whereas PAB and Alb levels were detected using an automatic biochemical analyzer. The kits were purchased from Shenzhen Mindray Bio-Medical Electronics Co., Ltd., and the experiments were performed strictly in accordance with the manufacturer’s instructions.

Complications

Re-bleeding (recurrence of hemorrhage within 72 hours after initial hemostasis, confirmed by increased drainage volume or drop in Hb), abdominal effusion (excessive fluid accumulation in the abdominal cavity detected by ultrasonography, with a depth of > 3 cm), infection (body temperature ≥ 38.5 ℃ lasting > 24 hours, accompanied by positive blood or abdominal fluid culture), and multiple organ function injury (Sequential Organ Failure Assessment score ≥ 2 points in ≥ 2 organ systems) were observed. The number of complications in the two groups was counted, and complication rates were calculated.

Satisfaction with emergency intervention

The self-made emergency intervention satisfaction questionnaire of the hospital was used for evaluation, which included eight items covering emergency response speed, doctor-patient communication, treatment effectiveness, and nursing care quality, using a 4-point Likert scale (1 = very dissatisfied, 4 = very satisfied). The questionnaire was distributed to the patients or their families 1 day before discharge, and they completed the questionnaire according to their own feelings.

Statistical analysis

SPSS 22.0 was used for analysis. Enumeration data [n (%)] were tested using the χ² test; measurement data (mean ± SD) conforming to normal distribution were tested using the t-test, and P < 0.05 was considered statistically significant.

RESULTS

Clinical treatment of the two groups

The emergency, triage, waiting, and hemostasis times and hospital stay were shorter in the observation group than in the control group (P < 0.05) (Table 2).

Table 2 Comparison of clinical treatment between the two groups (mean ± SD).

Group	Emergency time (minutes)	Time of triage (minutes)	Wait time (minutes)	Time to stop bleeding (hours)	Length of stay (days)
Observation (n = 59)	29.58 ± 5.46	10.23 ± 2.06	4.56 ± 1.69	4.32 ± 1.50	8.77 ± 2.06
Control (n = 59)	35.72 ± 8.52	12.15 ± 2.84	5.28 ± 1.74	5.14 ± 1.63	10.23 ± 2.84
t	4.873	4.326	2.317	2.972	3.041
P value	< 0.001	< 0.001	0.022	0.004	0.003

Comparison of respiratory function indicators between the two groups

There were no significant differences in SpO₂ and PaO₂ between the two groups at admission (P > 0.05). After 48 hours of emergency intervention, SpO₂ and PaO₂ in the observation group were higher than those in the control group (P < 0.05) (Table 3).

Table 3 Comparison of respiratory function indexes between the two groups (mean ± SD).

Group	Degree of blood oxygen saturation; oxygen saturation of blood (%)		Partial pressure of oxygen (mmHg)
	On admission	Emergency intervention was performed 7 days later	On admission	Emergency intervention 48 hours later
Observation (n = 59)	92.32 ± 0.48	98.74 ± 0.61	56.38 ± 1.49	95.70 ± 1.12
Control (n = 59)	92.43 ± 0.50	96.34 ± 0.87	56.57 ± 1.54	92.33 ± 1.46
t	1.243	15.249	0.715	13.742
P value	0.217	< 0.001	0.476	< 0.001

Comparison of serological indicators between the two groups

There were no significant differences in the levels of Hb, PAB, or Alb between the two groups at admission (P > 0.05). After 7 days of emergency intervention, the levels of Hb, PAB, and Alb were higher in the observation group than in the control group (P < 0.05) (Table 4).

Table 4 Comparison of serological indexes between the two groups (mean ± SD).

Group	Hb (g/L)		PAB (mg/L)		Alb (mg/L)
	On admission	Emergency intervention was performed 7 days later	On admission	Emergency intervention was performed 7 days later	On admission	Emergency intervention was performed 7 days later
Observation (n = 59)	92.50 ± 5.26	105.76 ± 6.54	0.22 ± 0.04	0.43 ± 0.05	30.54 ± 2.13	34.55 ± 2.58
Control (n = 59)	92.84 ± 5.38	101.57 ± 6.02	0.23 ± 0.05	0.40 ± 0.04	30.65 ± 2.20	32.64 ± 2.49
t	0.360	3.646	1.204	3.651	0.281	4.140
P value	0.720	< 0.001	0.231	< 0.001	0.779	< 0.001

Hb: Hemoglobin; PAB: Prealbumin; Alb: Albumin.

Comparison of complications between the two groups

Table 5 presents a comparison of the postoperative complications between the observation and control groups (n = 59 each). The overall complication rate was significantly lower in the observation group (3.39%) than in the control group (13.56%; χ² = 6.061, P = 0.014). Specifically, the observation group reported one case each of pyoperitoneum (1.69%) and infection (1.69%), with no re-hemorrhage or multi-organ dysfunction. In contrast, the control group experienced higher incidences across all categories, including hemorrhage (3.39%), pyoperitoneum (5.08%), infection (3.39%), and multiorgan dysfunction (1.69%). These results suggest that combined interventions reduce the risk of postoperative complications.

Table 5 Comparison of complications between the two groups, n (%).

Group	Re-hemorrhagia	Pyoperitoneum	Infection	Multi-organ dysfunction	Complications (rate)
Observation (n = 59)	0 (0.00)	1 (1.69)	1 (1.69)	0 (0.00)	2 (3.39)
Control (n = 59)	2 (3.39)	3 (5.08)	2 (3.39)	1 (1.69)	8 (13.56)
χ2	-	-	-	-	6.061
P value	-	-	-	-	0.014

Comparison of satisfaction with emergency intervention between the two groups

Table 6 summarizes patient satisfaction with emergency interventions in both groups. The observation group showed a significantly higher overall satisfaction rate (94.92%) than the control group (83.05%) (χ² = 5.943, P = 0.015). In the observation group, 54.24% of the patients were very satisfied and 40.68% were fairly satisfied, with only 5.08% expressing dissatisfaction. Conversely, the control group had lower rates of very satisfied responses (37.29%) and higher rates of dissatisfaction (16.95%). These findings indicate that a combined diagnostic and treatment approach may enhance patient satisfaction in emergency settings.

Table 6 Comparison of emergency intervention satisfaction between the two groups, n (%).

Group	Very satisfied	Fairly satisfied	Dissatisfied	Satisfaction (rate)
Observation (n = 59)	32 (54.24)	24 (40.68)	3 (5.08)	56 (94.92)
Control (n = 59)	22 (37.29)	27 (45.76)	10 (16.95)	49 (83.05)
χ2	-	-	-	5.943
P value	-	-	-	0.015

DISCUSSION

Rupture, hemorrhage, and shock are common serious complications of primary liver cancer. This condition is extremely dangerous and progresses rapidly. A large amount of blood quickly flows into the abdominal cavity, leading to a sudden drop in the effective circulatory blood volume and insufficient perfusion of important organs such as the brain, kidneys, and liver. This can cause irreversible damage and eventually lead to multiple organ failure with a high mortality rate. Studies have shown that the 24-hour mortality rate exceeds 70% in patients who do not receive emergency hemostasis treatment in time[10]. Moreover, the pathological mechanisms of primary liver cancer rupture, hemorrhage, and shock are complex and involve multiple aspects such as liver tumor rupture, damage to surrounding blood vessels, and abnormal coagulation function, which can lead to serious complications such as rebleeding, abdominal infection, sepsis, and acute liver failure[11,12], further increasing the difficulty and complexity of clinical treatment. Therefore, a timely and accurate evaluation of the patient's condition and effective emergency intervention measures are of great significance for improving the treatment success rate and reducing the incidence of complications and mortality in patients with primary liver cancer rupture, hemorrhage, and shock.

The results showed that the emergency, triage, waiting, and hemostasis times and hospital stay were shorter in the observation group than in the control group (P < 0.05). We believe that traditional clinical practice relies on isolated parameters such as blood pressure and HR, and that the monitoring frequency and observation cycle are long, which easily leads to delayed intervention when the condition deteriorates. The SI reflects a patient’s degree of shock by dynamically monitoring the ratio of HR to SBP, providing an important basis for clinical decision making[13,14]. The early warning scoring system further refines the severity of the patient's condition by comprehensively evaluating the patient's HR, SBP, respiratory rate, body temperature, consciousness status, and other indicators, making treatment measures more precise and personalized[15,16]. The dynamic calculation of the SI combined with the comprehensive score of the EWS system realizes early risk stratification, which can trigger the immediate response of the multidisciplinary team earlier, with an average consultation time controlled within 30 min. This significantly reduces the decision-making delay caused by the lag of single-parameter evaluation in the traditional model[17,18], effectively optimizing the emergency treatment process and improving treatment efficiency. This mechanism, which can shorten the emergency decision-making time by 20%-30%, thereby shortening the patient's emergency, triage, waiting, hemostasis, and hospital stay time, is consistent with the research report of N et al[19].

Concurrently, the research results show that after 48 h of emergency intervention, the SpO₂ and PaO₂ in the observation group were higher than those in the control group (P < 0.05), whereas after 7 days of emergency intervention, the levels of Hb, PAB, and Alb in the observation group were higher than those in the control group (P < 0.05). The authors believe that the combination of the SI and EWS system can, through scientific evaluation, lead to more active and effective treatment measures, such as quickly establishing intravenous channels, timely infusion of blood products, and using hemostatic drugs, to more effectively maintain the stability of the patient's vital signs and improve respiratory function[20,21]. In particular, it can lead to early identification of insufficient tissue perfusion, strengthening the dynamic evaluation of respiratory rate, optimizing the fluid resuscitation strategy, considering the lactate clearance rate and central venous pressure as goal-oriented fluid resuscitation, avoiding pulmonary edema caused by excessive infusion of crystalloid solution, and early detection and prevention of acute respiratory distress syndrome. This result is consistent with the conclusion of Yun et al[22] that the "dynamic monitoring of respiratory parameters can reduce the incidence of ARDS”. Hb is a key index for evaluating the oxygen-carrying capacity of red blood cells, while PAB and Alb reflect the body's nutritional status and liver synthesis function and are important indicators that reflect the body's nutritional status, immune function, and prognosis[23,24]. The increase in their levels indicated that the patient's nutritional status and immune function improved, and the prognosis was better. Treatment measures, such as transfusion strategy and nutritional support guided by the combination of SI and EWS system, can effectively improve the patient's Hb level, increase the content of PAB and Alb, correct hypoalbuminemia, and enhance the patient's body immunity and ability to resist infection[25,26], thereby further reducing the occurrence of complications. Cali et al[27] also pointed out that score-based individualized transfusion can reduce the rebleeding rate by 15%-20%.

In addition, the study results also showed that the incidence of complications such as rebleeding, abdominal effusion, infection, and multiple organ dysfunction in the observation group was 3.39%, which was lower than the 13.56% in the control group (P < 0.05), and the satisfaction with emergency intervention in the observation group was 94.92%, which was higher than that in the control group (83.05%) (P < 0.05). The authors believe that the combined application of the SI and EWS system can more accurately assess the patient's condition to adopt more refined, individualized, and targeted treatment measures, effectively preventing the occurrence of complications. For example, when the SI is ≥ 1.0, interventional hemostasis is prioritized, which is conducive to the control of re-bleeding risk, which is consistent with the research results of Park et al[28] and others, who reported that interventional hemostasis can reduce the re-bleeding risk to < 5%. Dynamic monitoring of body temperature and consciousness in the EWS, timely application of antibiotics, and adjustment of treatment plans are key to preventing and controlling infections[29,30]. For high-risk patients with an SI > 1.5 and an EWS > 7, rapid transfer to the ICU for supportive measures such as continuous renal replacement therapy is conducive to reducing multiple organ dysfunction and avoiding the occurrence of multiple organ failure. The combined application of the SI and EWS for real-time feedback of the scoring results can also provide transparent communication and an efficient treatment process, improving the trust of patients' families in emergency treatment. In addition, the reduction in complications, shortening of hospital stay, and other practical situations further reduce the family's medical burden, all of which contribute to the improvement of satisfaction with emergency interventions.

It is notable that although the combined application of the SI and EWS system achieved remarkable results in the emergency treatment of patients with primary liver cancer rupture, hemorrhage, and shock in this study, it still has certain limitations. For example, although the SI and EWS system can more comprehensively assess a patient's condition, they rely on the professional judgment and operational accuracy of medical staff and need to be combined with the patient's specific medical history, signs, laboratory test results, and other monitoring methods for comprehensive judgment, which may influence the treatment effect. In practical applications, the training of medical staff should be strengthened to improve their professional quality and operational skills and ensure the accuracy and reliability of the assessment results. In addition, the sample size of this study was limited, and future studies need to further expand the sample size and conduct multicenter, prospective studies to verify the universal applicability and effectiveness of the combined application of the SI and EWS system in the emergency treatment of patients with primary liver cancer rupture-induced hemorrhage and shock.

CONCLUSION

The combined SI and EWS system in patients with primary liver cancer rupture, hemorrhage, and shock can significantly shorten emergency treatment time, improve respiratory function and serological indicators, reduce the incidence of complications, and enhance patient satisfaction with emergency intervention, with higher clinical treatment efficiency and quality, making it worthy of promotion and application.