Early Prediction of Massive Transfusion in Trauma: Simple as ABC (Assessment of Blood Consumption)?
ABSTRACT Massive transfusion (MT) occurs in about 3% of civilian and 8% of military trauma patients. Although many centers have implemented MT protocols, most do not have a standardized initiation policy. The purpose of this study was to validate previously described MT scoring systems and compare these to a simplified nonlaboratory dependent scoring system (Assessment of Blood Consumption [ABC] score).
Retrospective cohort of all level I adult trauma patients transported directly from the scene (July 2005 to June 2006). Trauma-Associated Severe Hemorrhage (TASH) and McLaughlin scores calculated according to published methods. ABC score was assigned based on four nonweighted parameters: penetrating mechanism, positive focused assessment sonography for trauma, arrival systolic blood pressure of 90 mm Hg or less, and arrival heart rate > or = 120 bpm. Area under the receiver operating characteristic curve (AUROC) used to compare scoring systems.
Five hundred ninety-six patients were available for analysis; and the overall MT rate of 12.4%. Patients receiving MT had higher TASH (median, 6 vs. 13; p < 0.001), McLaughlin (median, 2.4 vs. 3.4; p < 0.001) and ABC (median, 1 vs. 2; p < 0.001) scores. TASH (AUROC = 0.842), McLaughlin (AUROC = 0.846), and ABC (AUROC = 0.842) scores were all good predictors of MT, and the difference between the scores was not statistically significant. ABC score of 2 or greater was 75% sensitive and 86% specific for predicting MT (correctly classified 85%).
The ABC score, which uses nonlaboratory, nonweighted parameters, is a simple and accurate in identifying patients who will require MT as compared with those previously published scores.
- SourceAvailable from: Timothy Pohlman
Article: Damage Control Resuscitation[Show abstract] [Hide abstract]
ABSTRACT: The early recognition and management of hemorrhage shock are among the most difficult tasks challenging the clinician during primary assessment of the acutely bleeding patient. Often with little time, within a chaotic setting, and without sufficient clinical data, a decision must be reached to begin transfusion of blood components in massive amounts. The practice of massive transfusion has advanced considerably and is now a more complete and, arguably, more effective process. This new therapeutic paradigm, referred to as damage control resuscitation (DCR), differs considerably in many important respects from previous management strategies for catastrophic blood loss. We review several important elements of DCR including immediate correction of specific coagulopathies induced by hemorrhage and management of several extreme homeostatic imbalances that may appear in the aftermath of resuscitation. We also emphasize that the foremost objective in managing exsanguinating hemorrhage is always expedient and definitive control of the source of bleeding. Copyright © 2015. Published by Elsevier Ltd.Blood Reviews 01/2015; 46. DOI:10.1016/j.blre.2014.12.006 · 5.45 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: BACKGROUND About 5% of civilian trauma requires massive transfusion. Protocolized resuscitation with blood products to achieve high plasma:RBC ratio has been advocated to improve survival. Our objectives were to measure compliance to our institutional MTP, to identify quality assurance activities that could improve protocol compliance and to determine if protocol compliance was related to patient outcome. METHODS The investigators determined 13 compliance criteria based upon our institutional protocol. We measured compliance in 72 consecutive MTP activations between January 2010 and September 2011 at a Level I trauma center. Data elements were retrospectively retrieved from blood bank, trauma registry and clinical records. Patients were stratified into 3 groups based on compliance level, and mortality differences were compared. RESULTS Average compliance for the cohort (n = 72) was 66%. The most common cause of non-compliance was failure to send a complete hemorrhage panel from the trauma bay (96%). Failure to monitoring blood work every 30 minutes occurred in 89% of cases. Delay in activation and deactivation occurred in 50% and 50% respectively. Non-compliance to protocol-based administration of blood products happened in 47%. The cohort was stratified into three groups based on compliance, A: <60%, B: 60–80% and C: >80% (low, moderate and high compliance groups). There was no statistical significance with regards to median age, median ISS, ED SBP, ED GCS and AIS of the head/spine, chest and abdomen. The mortality rates in each group were 62%, 50% and 10% in the low, moderate and high compliance groups respectively. Mortality differences were compared using adjusted logistic regression. The OR for mortality between Group A and B = 1.1, [95% CI 0.258 - 4.687, (P = 0.899)] while the OR for mortality between Group C and B = 0.02, [95% CI <0.001 - 0.855, (P = 0.041)]. CONCLUSIONS Measures should be directed towards provider and system factors to improve compliance. In this study, there was an association between survival and higher level of compliance.Injury 10/2014; 46(1). DOI:10.1016/j.injury.2014.09.020 · 2.46 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: The traditional method to identify hemorrhage after trauma has been vital signs-based. More recent attempts have used mathematical prediction models, but these are limited by the need for additional data including a Focused Assessment with Sonography for Trauma exam, or an arterial blood gas. Shock Index (SI) is the mathematical relationship of the heart rate divided by the systolic blood pressure; the cutoff of >0.9 has been associated with bleeding. A total of 4292 trauma patients were identified in database over an 11 year period. Inclusion criteria included age >16 years and initial presentation to our trauma center. Patients were excluded for incomplete data, traumatic brain injury, or transfer leaving 4277 patients for analysis. Patients were further subdivided by age, and by mechanism of injury (blunt versus penetrating). Finally, patients were divided into bleeding versus nonbleeding, and the SI formula was applied to their initial hospital vital signs. Across our dataset, using the standard SI cutoff of >0.9 as the threshold for bleeding, the sensitivity is 54.5%, with a specificity of 93.6%. In the geriatric subanalysis, there was no difference for sensitivity between the age groups, but SI is more specific in the older patients. There was no difference in sensitivity using SI in blunt versus penetrating. Lowering the SI to ≥0.8 increases the sensitivity to 76.1%, with a specificity of 87.4%. SI, at a lowered threshold of ≥0.8, can be used to identify trauma patients that will require intervention for hemostasis.The American journal of emergency medicine 06/2013; 31(8). DOI:10.1016/j.ajem.2013.05.027 · 1.15 Impact Factor