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Rafieezadeh A, Prabhakaran K, Kirsch J, Klein J, Shnaydman I, Bronstein M, Con J, Zangbar B. Shock Index is a Stronger Predictor of Outcomes in Older Compared to Younger Patients. J Surg Res 2024; 300:8-14. [PMID: 38788482 DOI: 10.1016/j.jss.2024.04.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 04/26/2024] [Accepted: 04/29/2024] [Indexed: 05/26/2024]
Abstract
INTRODUCTION The shock index (SI) is a known predictor of unfavorable outcomes in trauma. This study seeks to examine and compare the SI values between geriatric patients and younger adults. METHODS We conducted a retrospective study of the Trauma Quality Improvement Program database from 2017 to 2019. All patients≥ 25 y with injury severity score ≥ 16 were included. Age groups were defined as 25-44 y (group A), 45-64 y (group B), and ≥65 y (group C). SI was calculated for all patients. The primary outcome was mortality and secondary outcomes were need for blood transfusion and need for major surgical intervention (consisting angiography, exploratory laparotomy, and thoracotomy). RESULTS A total of 244,943 patients were studied. The SI was highest in group A (0.82 ± 0.33) and lowest in group C (0.62 ± 0.30) (P < 0.001). Mortality rate of group C (17%) was significantly higher than group A (9.7%) and B (11.3%) (P < 0.001). In group A, each 0.1 increase in SI was associated with mortality (odds ratio [OR] = 1.079), need for blood transfusion (OR = 1.225) and need for major surgical intervention (OR = 1.347) (P < 0.001 for all). In group C, each 0.1 increase in SI was associated with mortality (OR = 1.126), need for blood transfusion (OR = 1.318), and need for major surgical intervention (OR = 1.648) (P < 0.001 for all). The area under the curve of SI was significantly higher in group C compared to other groups for needing a major surgical intervention and need for blood transfusion (P < 0.05 for both). CONCLUSIONS These results highlight the significance of the SI as a valuable indicator in geriatric patients with severe trauma. The findings show that SI predicts outcomes in geriatrics more strongly than in younger counterparts.
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Affiliation(s)
- Aryan Rafieezadeh
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Kartik Prabhakaran
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jordan Kirsch
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Joshua Klein
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Ilya Shnaydman
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Matthew Bronstein
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Jorge Con
- Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Bardiya Zangbar
- Westchester Medical Center, New York Medical College, Valhalla, New York.
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Jama T, Lefering R, Lauronen J, Handolin L. Factors affecting physicians' decision to start prehospital blood product transfusion in blunt trauma patients: A cohort study of Helsinki Trauma Registry. Transfusion 2024; 64 Suppl 2:S167-S173. [PMID: 38511866 DOI: 10.1111/trf.17791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Revised: 02/29/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Prehospital blood transfusions are increasing as a treatment for bleeding trauma patients at risk for exsanguination. Triggers for starting transfusion in the field are less studied. We analyzed the factors affecting the decision of physicians to start prehospital blood product transfusion (PHBT) in blunt adult trauma patients. STUDY DESIGN AND METHODS Data of all adult blunt trauma patients from the Helsinki Trauma Registry between March 2016 and July 2021 were retrospectively analyzed. Univariate analysis for the identification of predictive factors and multivariate regression analysis for their importance as predictive factors for the initiation of PHBT were applied. RESULTS There were 1652 patients registered in the database. A total of 556 of them were treated by a physician-level prehospital emergency care unit, of which by transfusion-capable unit in 394 patients. PHBT (red blood cells and/or plasma) was started in 19.8% of the patients. We identified three statistically highly important clinical triggers for starting PHBT: high crystalloid volume need, shock index ≥0.9, and need for prehospital pleural decompression. DISCUSSION PHBT in blunt adult trauma patients is initiated in ~20% of the patients in Southern Finland. High crystalloid volume need, shock index ≥0.9 and prehospital pleural decompression are associated with the initiation of PHBT, probably reflecting patients at high risk for bleeding.
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Affiliation(s)
- Timo Jama
- Wellbeing Services County of Päijät-Häme, Lahti, Finland
- University of Helsinki, Helsinki, Finland
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne, Germany
| | - Jouni Lauronen
- University of Helsinki, Helsinki, Finland
- Finnish Red Cross Blood Service, Vantaa, Finland
| | - Lauri Handolin
- University of Helsinki, Helsinki, Finland
- Helsinki University Hospital Trauma Unit, Helsinki, Finland
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Mitra B, Talarico CS, Olaussen A, Anderson D, Meadley B. Blood lactate after pre-hospital blood transfusion for major trauma by helicopter emergency medical services. Vox Sang 2024; 119:460-466. [PMID: 38357735 DOI: 10.1111/vox.13598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 01/16/2024] [Accepted: 01/29/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND OBJECTIVES The appropriate use of blood components is essential for ethical use of a precious, donated product. The aim of this study was to report in-hospital red blood cell (RBC) transfusion after pre-hospital transfusion by helicopter emergency medical service paramedics. A secondary aim was to assess the potential for venous blood lactate to predict ongoing transfusion. MATERIALS AND METHODS All patients who received RBC in air ambulance were transported to a single adult major trauma centre, had venous blood lactate measured on arrival and did not die before ability to transfuse RBC were included. The association of venous blood lactate with ongoing RBC transfusion was assessed using multi-variable logistic regression analysis and reported using adjusted odds ratios (aOR). The discriminative ability of venous blood lactate was assessed using area under receiver operating characteristics curve (AUROC). RESULTS From 1 January 2016 to 15 May 2019, there were 165 eligible patients, and 128 patients were included. In-hospital transfusion occurred in 97 (75.8%) of patients. Blood lactate was associated with ongoing RBC transfusion (aOR: 2.00; 95% confidence interval [CI]: 1.36-2.94). Blood lactate provided acceptable discriminative ability for ongoing transfusion (AUROC: 0.78; 95% CI: 0.70-0.86). CONCLUSIONS After excluding patients with early deaths, a quarter of those who had prehospital RBC transfusion had no further transfusion in hospital. Venous blood lactate appears to provide value in identifying such patients. Lactate levels after pre-hospital transfusion could be used as a biomarker for transfusion requirement after trauma.
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Affiliation(s)
- Biswadev Mitra
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carly S Talarico
- Alfred Health Emergency Service, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alexander Olaussen
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - David Anderson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
| | - Ben Meadley
- Department of Paramedicine, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Doncaster, Victoria, Australia
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LaGrone LN, Stein D, Cribari C, Kaups K, Harris C, Miller AN, Smith B, Dutton R, Bulger E, Napolitano LM. American Association for the Surgery of Trauma/American College of Surgeons Committee on Trauma: Clinical protocol for damage-control resuscitation for the adult trauma patient. J Trauma Acute Care Surg 2024; 96:510-520. [PMID: 37697470 DOI: 10.1097/ta.0000000000004088] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023]
Abstract
ABSTRACT Damage-control resuscitation in the care of critically injured trauma patients aims to limit blood loss and prevent and treat coagulopathy by combining early definitive hemorrhage control, hypotensive resuscitation, and early and balanced use of blood products (hemostatic resuscitation) and the use of other hemostatic agents. This clinical protocol has been developed to provide evidence-based recommendations for optimal damage-control resuscitation in the care of trauma patients with hemorrhage.
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Affiliation(s)
- Lacey N LaGrone
- From the Department of Surgery (D.S.), University of Maryland, Baltimore, Maryland; Department of Surgery (L.N.L., C.C.), UCHealth, Loveland, Colorado; Department of Surgery (K.K), University of California San Francisco Fresno, San Francisco, California; Department of Surgery (C.H.), Tulane University, New Orleans, Louisiana; Orthopedic Surgery (A.N.M.), Washington University in St. Louis, St. Louis, Missouri; Department of Surgery (B.S.), University of Pennsylvania, Philadelphia, Pennsylvania; American Society of Anesthesiologists (R.D.), Anesthesia, Waco, Texas; Department of Surgery (E.B.), University of Washington, Seattle, Washington; and Department of Surgery (L.M.N.), University of Michigan, Ann Arbor, Michigan
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Carsetti A, Antolini R, Casarotta E, Damiani E, Gasparri F, Marini B, Adrario E, Donati A. Shock index as predictor of massive transfusion and mortality in patients with trauma: a systematic review and meta-analysis. Crit Care 2023; 27:85. [PMID: 36872322 PMCID: PMC9985849 DOI: 10.1186/s13054-023-04386-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/28/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND Management of bleeding trauma patients is still a difficult challenge. Massive transfusion (MT) requires resources to ensure the safety and timely delivery of blood products. Early prediction of MT need may be useful to shorten the time process of blood product preparation. The primary aim of this study was to assess the accuracy of shock index to predict the need for MT in adult patients with trauma. For the same population, we also assessed the accuracy of SI to predict mortality. METHODS This systematic review and meta-analysis was performed in accordance with the PRISMA guidelines. We performed a systematic search on MEDLINE, Scopus, and Web of Science from inception to March 2022. Studies were included if they reported MT or mortality with SI recorded at arrival in the field or the emergency department. The risk of bias was assessed using the QUADAS-2. RESULTS Thirty-five studies were included in the systematic review and meta-analysis, for a total of 670,728 patients. For MT the overall sensibility was 0.68 [0.57; 0.76], the overall specificity was 0.84 [0.79; 0.88] and the AUC was 0.85 [0.81; 0.88]. Positive and Negative Likelihood Ratio (LR+; LR-) were 4.24 [3.18-5.65] and 0.39 [0.29-0.52], respectively. For mortality the overall sensibility was 0.358 [0.238; 0.498] the overall specificity 0.742 [0.656; 0.813] and the AUC 0.553 (confidence region for sensitivity given specificity: [0.4014; 0.6759]; confidence region for specificity given sensitivity: [0.4799; 0.6332]). LR+ and LR- were 1.39 [1.36-1.42] and 0.87 [0.85-0.89], respectively. CONCLUSIONS Our study demonstrated that SI may have a limited role as the sole tool to predict the need for MT in adult trauma patients. SI is not accurate to predict mortality but may have a role to identify patients with a low risk of mortality.
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Affiliation(s)
- Andrea Carsetti
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy. .,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy.
| | - Riccardo Antolini
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Erika Casarotta
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Elisa Damiani
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Francesco Gasparri
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Benedetto Marini
- Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Erica Adrario
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Abele Donati
- Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Anesthesia and Intensive Care Unit, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
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Lee SM, Lee G, Kim TK, Le T, Hao J, Jung YM, Park CW, Park JS, Jun JK, Lee HC, Kim D. Development and Validation of a Prediction Model for Need for Massive Transfusion During Surgery Using Intraoperative Hemodynamic Monitoring Data. JAMA Netw Open 2022; 5:e2246637. [PMID: 36515949 PMCID: PMC9856486 DOI: 10.1001/jamanetworkopen.2022.46637] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 09/30/2022] [Indexed: 12/15/2022] Open
Abstract
Importance Massive transfusion is essential to prevent complications during uncontrolled intraoperative hemorrhage. As massive transfusion requires time for blood product preparation and additional medical personnel for a team-based approach, early prediction of massive transfusion is crucial for appropriate management. Objective To evaluate a real-time prediction model for massive transfusion during surgery based on the incorporation of preoperative data and intraoperative hemodynamic monitoring data. Design, Setting, and Participants This prognostic study used data sets from patients who underwent surgery with invasive blood pressure monitoring at Seoul National University Hospital (SNUH) from 2016 to 2019 and Boramae Medical Center (BMC) from 2020 to 2021. SNUH represented the development and internal validation data sets (n = 17 986 patients), and BMC represented the external validation data sets (n = 494 patients). Data were analyzed from November 2020 to December 2021. Exposures A deep learning-based real-time prediction model for massive transfusion. Main Outcomes and Measures Massive transfusion was defined as a transfusion of 3 or more units of red blood cells over an hour. A preoperative prediction model for massive transfusion was developed using preoperative variables. Subsequently, a real-time prediction model using preoperative and intraoperative parameters was constructed to predict massive transfusion 10 minutes in advance. A prediction model, the massive transfusion index, calculated the risk of massive transfusion in real time. Results Among 17 986 patients at SNUH (mean [SD] age, 58.65 [14.81] years; 9036 [50.2%] female), 416 patients (2.3%) underwent massive transfusion during the operation (mean [SD] duration of operation, 170.99 [105.03] minutes). The real-time prediction model constructed with the use of preoperative and intraoperative parameters significantly outperformed the preoperative prediction model (area under the receiver characteristic curve [AUROC], 0.972; 95% CI, 0.968-0.976 vs AUROC, 0.824; 95% CI, 0.813-0.834 in the SNUH internal validation data set; P < .001). Patients with the highest massive transfusion index (ie, >90th percentile) had a 47.5-fold increased risk for a massive transfusion compared with those with a lower massive transfusion index (ie, <80th percentile). The real-time prediction model also showed excellent performance in the external validation data set (AUROC of 0.943 [95% CI, 0.919-0.961] in BMC). Conclusions and Relevance The findings of this prognostic study suggest that the real-time prediction model for massive transfusion showed high accuracy of prediction performance, enabling early intervention for high-risk patients. It suggests strong confidence in artificial intelligence-assisted clinical decision support systems in the operating field.
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Affiliation(s)
- Seung Mi Lee
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Garam Lee
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Tae Kyong Kim
- Department of Anesthesiology and Pain Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Trang Le
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Jie Hao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Young Mi Jung
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Chan-Wook Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Joong Shin Park
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Jong Kwan Jun
- Department of Obstetrics and Gynecology, Seoul National University College of Medicine, Seoul, Korea
- Department of Obstetrics and Gynecology, Seoul National University Hospital, Seoul, Korea
| | - Hyung-Chul Lee
- Department of Anesthesiology and Pain Medicine, Seoul National University College of Medicine, Seoul, Korea
| | - Dokyoon Kim
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Institute for Biomedical Informatics, University of Pennsylvania, Philadelphia
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Botteri M, Celi S, Perone G, Prati E, Bera P, Villa GF, Mare C, Sechi GM, Zoli A, Fagoni N. Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma. Injury 2022; 53:1581-1586. [PMID: 35000744 DOI: 10.1016/j.injury.2021.12.047] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/16/2021] [Accepted: 12/29/2021] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Hemorrhage in major trauma is life-threatening and the activation of the Massive Transfusion Protocol (MTP) was found to reduce the time to transfusion and mortality. The purpose was (i) to verify whether MTP activation identifies patients that require massive transfusions once admitted to the Emergency Department (ED), (ii) to establish whether pre-hospital MTP activation reduces the time to transfusion on arrival at the ED, (iii) to identify the variable that best predicts MTP activation. MATERIALS AND METHODS This is a retrospective, single-center study. The MTP was implemented at the end of 2012; it was activated for major trauma in pre-hospital setting on the basis on established criteria. Pre-hospital MTP activation aimed to make blood products available prior to the patients' arrival at the ED. The blood products are transfused when the patient arrives at the hospital. RESULTS The MTP was activated in pre-hospital setting in 219 patients. On arrival at the hospital, the Trauma Team Leader confirmed MTP activation in 146 (66.7%) patients. Patients with MTP criteria received a higher amount of blood products than the patients without MTP criteria, median 7 (IQR 2-13) units versus 2 (0-6) units, respectively (P < 0.001). At the same time, patients with a Shock Index ≥ 0.9 received more transfusions (5.5 [2-13] units) compared with patients characterized by a lower SI (2 [0-7.25] units, P = 0.009). 146 patients were transfused in the first hour of ED admission. Poisson's multiple regression shows that the SI is the variable that better predicted MTP activation compared to age, gender and the number of injured sites. CONCLUSIONS Pre-hospital MTP activation is useful to identify patients that require an urgent blood transfusion on arrival at the ED. Further analysis should be considered to evaluate the implementation of the Shock Index as a criterion to activate MTP.
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Affiliation(s)
- Marco Botteri
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy; Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | - Simone Celi
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | - Giovanna Perone
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | - Enrica Prati
- Immuno-Haematology and Transfusional Medicine Service (SIMT), ASST Spedali Civili University Hospital, Brescia, Italy
| | - Paola Bera
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy
| | | | - Claudio Mare
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | | | - Alberto Zoli
- Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy
| | - Nazzareno Fagoni
- AAT Brescia, Agenzia Regionale Emergenza Urgenza (AREU). Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Spedali Civili, Brescia 1-25123, Italy; Agenzia Regionale Emergenza Urgenza Headquarters (AREU HQ), Milano, Italy; Department of Molecular and Translational Medicine, University of Brescia, Italy.
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Vang M, Østberg M, Steinmetz J, Rasmussen LS. Shock index as a predictor for mortality in trauma patients: a systematic review and meta-analysis. Eur J Trauma Emerg Surg 2022; 48:2559-2566. [PMID: 35258641 DOI: 10.1007/s00068-022-01932-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/20/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1. METHODS This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa. RESULTS We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low. CONCLUSIONS This systematic review found a fourfold increased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.
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Affiliation(s)
- Malene Vang
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Maria Østberg
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Danish Air Ambulance, Aarhus, Denmark
| | - Lars S Rasmussen
- Department of Anesthesia and Trauma Centre, Centre of Head and Orthopaedics, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Comparison of Shock Index With the Assessment of Blood Consumption Score for Association With Massive Transfusion During Hemorrhage Control for Trauma. J Trauma Nurs 2021; 28:341-349. [PMID: 34766927 DOI: 10.1097/jtn.0000000000000613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. OBJECTIVE To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. METHODS A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. RESULTS The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p = .002) whereas a positive ABC score did not (p = .65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). CONCLUSION Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT.
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Yeates EO, Grigorian A, Inaba K, Dolich M, Schubl SD, Lekawa M, Schellenberg M, de Virgilio M, Nahmias J. Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool. J Surg Res 2021; 270:321-326. [PMID: 34731729 DOI: 10.1016/j.jss.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/14/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple tools predicting massive transfusion (MT) in trauma have been developed but utilize variables that are not immediately available. Additionally, they only differentiate blunt from penetrating trauma and do not account for the large range of blunt mechanisms and their difference in force. We aimed to develop a Blunt trauma Massive Transfusion (B-MaT) score that accounts for high-risk blunt mechanisms and predicts MT needs in blunt trauma patients (BTPs) prior to arrival. MATERIALS AND METHODS The adult 2017 Trauma Quality Improvement Program database was used to identify BTPs who were divided into 2 sets at random (derivation/validation). First, multiple logistic regression models were created to determine risk factors of MT (≥6 units of PRBCs within 4-hours or ≥10 units within 24-hours). Next, the weighted average and relative impact of each independent predictor was used to derive a B-MaT score. Finally, the area under the receiver-operating curve (AROC) was calculated. RESULTS Of 172,423 patients in the derivation-set, 1,160 (0.7%) required MT. Heart rate ≥ 120bpm, systolic blood pressure ≤ 90mmHg, and high-risk blunt mechanisms were identified as independent predictors for MT. B-MaT scores were derived ranging from 0 -9, with scores of 6, 7, and 9 yielding a MT rate of 11.7%, 19.4%, and 32.4%, respectively. The AROC was 0.86. The validation-set had an AROC of 0.85. CONCLUSIONS B-MaT is a novel scoring tool that predicts need for MT in BTPs and can be calculated prior to arrival. B-MaT warrants prospective validation to confirm its accuracy and assess its ability to improve patient outcomes and blood product allocation.
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Affiliation(s)
- Eric O Yeates
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Areg Grigorian
- Department of Surgery, University of California Irvine (UCI), Orange, California; Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Kenji Inaba
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Matthew Dolich
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Sebastian D Schubl
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Michael Lekawa
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | | | - Jeffry Nahmias
- Department of Surgery, University of California Irvine (UCI), Orange, California.
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11
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Yang S, Mackenzie CF, Rock P, Lin C, Floccare D, Scalea T, Stumpf F, Winans C, Galvagno S, Miller C, Stein D, Hu PF. Comparison of massive and emergency transfusion prediction scoring systems after trauma with a new Bleeding Risk Index score applied in-flight. J Trauma Acute Care Surg 2021; 90:268-273. [PMID: 33502145 DOI: 10.1097/ta.0000000000003031] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Assessment of blood consumption (ABC), shock index (SI), and Revised Trauma Score (RTS) are used to estimate the need for blood transfusion and triage. We compared Bleeding Risk Index (BRI) score calculated with trauma patient noninvasive vital signs and hypothesized that prehospital BRI has better performance compared with ABC, RTS, and SI for predicting the need for emergent and massive transfusion (MT). METHODS We analyzed 2-year in-flight data from adult trauma patients transported directly to a Level I trauma center via helicopter. The BRI scores 0 to 1 were derived from continuous features of photoplethymographic and electrocardiographic waveforms, oximetry values, blood pressure trends. The ABC, RTS, and SI were calculated using admission data. The area under the receiver operating characteristic curve (AUROC) with 95% confidence interval (CI) was calculated for predictions of critical administration threshold (CAT, ≥3 units of blood in the first hour) or MT (≥10 units of blood in the first 24 hours). DeLong's method was used to compare AUROCs for different scoring systems. p < 0.05 was considered statistically significant. RESULTS Among 1,396 patients, age was 46.5 ± 20.1 years (SD), 67.1% were male. The MT rate was 3.2% and CAT was 7.6%, most (92.8%) were blunt injury. Mortality was 6.6%. Scene arrival to hospital time was 35.3 ± (10.5) minutes. The BRI prediction of MT with AUROC 0.92 (95% CI, 0.89-0.95) was significantly better than ABC, SI, or RTS (AUROCs = 0.80, 0.83, 0.78, respectively; 95% CIs 0.73-0.87, 0.76-0.90, 0.71-0.85, respectively). The BRI prediction of CAT had an AUROC of 0.91 (95% CI, 0.86-0.94), which was significantly better than ABC (AUROC, 077; 95% CI, 0.73-0.82) or RTS (AUROC, 0.79; 95% CI, 0.74-0.83) and better than SI (AUROC, 0.85; 95% CI, 0.80-0.89). The BRI score threshold for optimal prediction of CAT was 0.25 and for MT was 0.28. CONCLUSION The autonomous continuous noninvasive patient vital signs-based BRI score performs better than ABC, RTS, and SI predictions of MT and CAT. Bleeding Risk Index does not require additional data entry or expert interpretation. LEVEL OF EVIDENCE Prognostic test, level III.
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Affiliation(s)
- Shiming Yang
- From the Departments of Anesthesiology (S.Y., C.F.M., P.R., C.L., F.S., S.G., P.F.H.); Department of Surgery and Program in Trauma (T.S., S.G., D.S., P.F.H.), University of Maryland School of Medicine; Maryland Institute for Emergency Medical Services Systems (MIEMSS) (D.F., C.W.); and US Air Force C-STARS, (C.M.) Baltimore, Maryland
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12
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Hanna K, Harris C, Trust MD, Bernard A, Brown C, Hamidi M, Joseph B. Multicenter Validation of the Revised Assessment of Bleeding and Transfusion (RABT) Score for Predicting Massive Transfusion. World J Surg 2021; 44:1807-1816. [PMID: 32006133 DOI: 10.1007/s00268-020-05394-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Massive transfusion (MT) is a lifesaving treatment for hemorrhaging patients. Predicting the need for MT is crucial to improve survival. The aim of our study was to validate the Revised Assessment of Bleeding and Transfusion (RABT) score to predict MT in a multicenter cohort of trauma patients. METHODS We performed a (2015-2017) analysis of adult (age ≥ 18 year) trauma patients who had a high-level trauma team activation at three Level I trauma centers. The RABT was calculated using the 4-point score [blunt (0)/penetrating trauma (1), shock index ≥ 1 (1), pelvic fracture (1), and FAST positive (1)]. A RABT score of ≥ 2 was used to predict MT (≥ 10 units of packed red blood cells within 24 h). The area under the receiver operating characteristic curve (AUROC) was calculated to assess the score's predictive power compared to the Assessment of Blood Consumption (ABC) score. RESULTS We analyzed 1018 patients: 216 (facility I), 363 (facility II), and 439 (facility III). The mean age was 41 ± 19 year, and the injury severity score (ISS) was 29 [22-36]. The overall MT rate was 19%. The overall AUROC of RABT ≥ 2 was 0.89. The sensitivity of the RABT ≥ 2 was 78%, and the specificity was 91%. The RABT score had a higher sensitivity (78% vs. 69%) and specificity (91% vs. 82%) than the ABC score. CONCLUSION The RABT score is a valid tool to predict MT in severely injured trauma patients. It is an objective score that aids clinicians in predicting the need for MT to mobilize blood products and minimize the waste of resources.
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Affiliation(s)
- Kamil Hanna
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA
| | - Charles Harris
- Divsion of Trauma, Acute Care Surgery, and Critical Care, Tulane University School of Medicine, New Orleans, LA, USA
| | - Marc D Trust
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Andrew Bernard
- Section of Trauma and Acute Surgery, College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Carlos Brown
- Department of Surgery and Perioperative Care, The University of Texas at Austin Dell Medical School, Austin, TX, USA
| | - Mohammad Hamidi
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA
| | - Bellal Joseph
- Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine, University of Arizona, 1501 N. Campbell Ave, Room 5411, P.O. Box 245063, Tucson, AZ, 85724, USA.
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13
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Wheeler AR, Cuenca C, Fisher AD, April MD, Shackelford SA, Schauer SG. Development of prehospital assessment findings associated with massive transfusion. Transfusion 2020; 60 Suppl 3:S70-S76. [PMID: 32478893 DOI: 10.1111/trf.15595] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 10/28/2019] [Accepted: 10/28/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND Massive transfusion is frequently a component of the resuscitation of combat casualties. Because blood supplies may be limited, activation of a walking blood bank and mobilization of necessary resources must occur in a timely fashion. The development of a risk prediction model to guide clinicians for early transfusion in the prehospital setting was sought. STUDY DESIGN AND METHODS This is a secondary analysis of a previously described data set from the Department of Defense Trauma Registry from January 2007 to August 2016 focusing on casualties undergoing massive transfusion. Serious injury was defined based on an Abbreviated Injury Scale score of 3 or greater by body region. The authors constructed multiple imputations of the model for risk prediction development. Efforts were made to internally validate the model. RESULTS Within the data set, there were 15540 patients, of which 1238 (7.9%) underwent massive transfusion. In the body region injury scale model, explosive injuries (odds ratio [OR], 3.78), serious extremity injuries (OR, 6.59), and tachycardia >120/min (OR, 5.61) were most strongly associated with receiving a massive transfusion. In the simplified model, major amputations (OR, 17.02), tourniquet application (OR, 6.66), and tachycardia >120 beats/min (OR, 8.72) were associated with massive transfusion. Both models had area under the curve receiver operating characteristic values of greater than 0.9 for the model and bootstrap forest analysis. CONCLUSION In the body region injury scale model, explosive mechanisms, serious extremity injuries, and tachycardia were most strongly associated with massive transfusion. In the simplified model, major amputations, tourniquet application, and tachycardia were most strongly associated.
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Affiliation(s)
- Abigail R Wheeler
- University of South Carolina School of Medicine, Columbia, South Carolina
| | - Camaren Cuenca
- US Army Institute of Surgical Research, San Antonio, Texas
| | - Andrew D Fisher
- Texas Army National Guard, Austin, Texas.,Texas A&M College of Medicine, Temple, Texas
| | - Michael D April
- Brooke Army Medical Center, JBSA Fort Sam Houston, San Antonio, Texas
| | - Stacy A Shackelford
- 59th Medical Wing, JBSA Lackland, San Antonio, Texas.,Joint Trauma System, JBSA Fort Sam Houston, San Antonio, Texas
| | - Steven G Schauer
- US Army Institute of Surgical Research, San Antonio, Texas.,59th Medical Wing, JBSA Lackland, San Antonio, Texas.,Uniformed Services University of the Health Sciences, Bethesda, Maryland
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14
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Wang IJ, Bae BK, Park SW, Cho YM, Lee DS, Min MK, Ryu JH, Kim GH, Jang JH. Pre-hospital modified shock index for prediction of massive transfusion and mortality in trauma patients. Am J Emerg Med 2020; 38:187-190. [PMID: 30738590 DOI: 10.1016/j.ajem.2019.01.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Modified shock index (MSI) is a useful predictor in trauma patients. However, the value of prehospital MSI (preMSI) in trauma patients is unknown. The aim of this study was to investigate the accuracy of preMSI in predicting massive transfusion (MT) and hospital mortality among trauma patients. METHODS This was a retrospective, observational, single-center study. Patients presenting consecutively to the trauma center between January 2016 and December 2017, were included. The predictive ability of both prehospital shock index (preSI) and preMSI for MT and hospital mortality was assessed by calculating the areas under the receiver operating characteristic curves (AUROCs). RESULTS A total of 1007 patients were included. Seventy-eight (7.7%) patients received MT, and 30 (3.0%) patients died within 24 h of admission to the trauma center. The AUROCs for predicting MT with preSI and preMSI were 0.773 (95% confidence interval [CI], 0.746-0.798) and 0.765 (95% CI, 0.738-0.791), respectively. The AUROCs for predicting 24-hour mortality with preSI and preMSI were 0.584 (95% CI, 0.553-0.615) and 0.581 (95% CI, 0.550-0.612), respectively. CONCLUSIONS PreSI and preMSI showed moderate accuracy in predicting MT. PreMSI did not have higher predictive power than preSI. Additionally, in predicting hospital mortality, preMSI was not superior to preSI.
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15
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Vasudeva M, Mathew JK, Fitzgerald MC, Cheung Z, Mitra B. Hypocalcaemia and traumatic coagulopathy: an observational analysis. Vox Sang 2019; 115:189-195. [DOI: 10.1111/vox.12875] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/10/2019] [Accepted: 11/18/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Mayank Vasudeva
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
| | - Joseph K. Mathew
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
- Software & Innovation Lab Deakin University Melbourne VIC Australia
| | - Mark C. Fitzgerald
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
- Central Clinical School Monash University Melbourne VIC Australia
- Software & Innovation Lab Deakin University Melbourne VIC Australia
| | - Zoe Cheung
- National Trauma Research Institute Melbourne VIC Australia
- Trauma Service The Alfred Hospital Melbourne VIC Australia
| | - Biswadev Mitra
- National Trauma Research Institute Melbourne VIC Australia
- Emergency & Trauma Centre The Alfred Hospital Melbourne VIC Australia
- Department of Epidemiology & Preventive Medicine Monash University Melbourne VIC Australia
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16
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Jehan F, Con J, McIntyre M, Khan M, Azim A, Prabhakaran K, Latifi R. Pre-hospital shock index correlates with transfusion, resource utilization and mortality; The role of patient first vitals. Am J Surg 2019; 218:1169-1174. [DOI: 10.1016/j.amjsurg.2019.08.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Revised: 08/26/2019] [Accepted: 08/30/2019] [Indexed: 12/21/2022]
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17
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Shock volume: Patient-specific cumulative hypoperfusion predicts organ dysfunction in a prospective cohort of multiply injured patients. J Trauma Acute Care Surg 2019. [PMID: 29521799 DOI: 10.1097/ta.0000000000001871] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Multiply injured patients are at risk of developing hemorrhagic shock and organ dysfunction. We determined how cumulative hypoperfusion predicted organ dysfunction by integrating serial Shock Index measurements. METHODS In this study, we calculated shock volume (SHVL) which is a patient-specific index that quantifies cumulative hypoperfusion by integrating abnormally elevated Shock Index (heart rate/systolic blood pressure ≥ 0.9) values acutely after injury. Shock volume was calculated at three hours (3 hr), six hours (6 hr), and twenty-four hours (24 hr) after injury. Organ dysfunction was quantified using Marshall Organ Dysfunction Scores averaged from days 2 through 5 after injury (aMODSD2-D5). Logistic regression was used to determine correspondence of 3hrSHVL, 6hrSHVL, and 24hrSHVL to organ dysfunction. We compared correspondence of SHVL to organ dysfunction with traditional indices of shock including the initial base deficit (BD) and the lowest pH measurement made in the first 24 hr after injury (minimum pH). RESULTS SHVL at all three time intervals demonstrated higher correspondence to organ dysfunction (R = 0.48 to 0.52) compared to initial BD (R = 0.32) and minimum pH (R = 0.32). Additionally, we compared predictive capabilities of SHVL, initial BD and minimum pH to identify patients at risk of developing high-magnitude organ dysfunction by constructing receiver operator characteristic curves. SHVL at six hours and 24 hours had higher area under the curve compared to initial BD and minimum pH. CONCLUSION SHVL is a non-invasive metric that can predict anticipated organ dysfunction and identify patients at risk for high-magnitude organ dysfunction after injury. LEVEL OF EVIDENCE Prognostic study, level III.
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18
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Mitra B, Bade-Boon J, Fitzgerald MC, Beck B, Cameron PA. Timely completion of multiple life-saving interventions for traumatic haemorrhagic shock: a retrospective cohort study. BURNS & TRAUMA 2019; 7:22. [PMID: 31360731 PMCID: PMC6637602 DOI: 10.1186/s41038-019-0160-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 05/07/2019] [Indexed: 11/10/2022]
Abstract
Background Early control of haemorrhage and optimisation of physiology are guiding principles of resuscitation after injury. Improved outcomes have been previously associated with single, timely interventions. The aim of this study was to assess the association between multiple timely life-saving interventions (LSIs) and outcomes of traumatic haemorrhagic shock patients. Methods A retrospective cohort study was undertaken of injured patients with haemorrhagic shock who presented to Alfered Emergency & Trauma Centre between July 01, 2010 and July 31, 2014. LSIs studied included chest decompression, control of external haemorrhage, pelvic binder application, transfusion of red cells and coagulation products and surgical control of bleeding through angio-embolisation or operative intervention. The primary exposure variable was timely initiation of ≥ 50% of the indicated interventions. The association between the primary exposure variable and outcome of death at hospital discharge was adjusted for potential confounders using multivariable logistic regression analysis. The association between total pre-hospital times and pre-hospital care times (time from ambulance at scene to trauma centre), in-hospital mortality and timely initiation of ≥ 50% of the indicated interventions were assessed. Results Of the 168 patients, 54 (32.1%) patients had ≥ 50% of indicated LSI completed within the specified time period. Timely delivery of LSI was independently associated with improved survival to hospital discharge (adjusted odds ratio (OR) for in-hospital death 0.17; 95% confidence interval (CI) 0.03–0.83; p = 0.028). This association was independent of patient age, pre-hospital care time, injury severity score, initial serum lactate levels and coagulopathy. Among patients with pre-hospital time of ≥ 2 h, 2 (3.6%) received timely LSIs. Pre-hospital care times of ≥ 2 h were associated with delayed LSIs and with in-hospital death (unadjusted OR 4.3; 95% CI 1.4–13.0). Conclusions Timely completion of LSI when indicated was completed in a small proportion of patients and reflects previous research demonstrating delayed processes and errors even in advanced trauma systems. Timely delivery of a high proportion of LSIs was associated with improved outcomes among patients presenting with haemorrhagic shock after injury. Provision of LSIs in the pre-hospital phase of trauma care has the potential to improve outcomes.
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Affiliation(s)
- Biswadev Mitra
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Jordan Bade-Boon
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Mark C Fitzgerald
- 4Trauma Service, The Alfred Hospital, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Ben Beck
- 3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,5Faculty of Medicine, Laval University, Quebec City, Quebec Canada
| | - Peter A Cameron
- 1National Trauma Research Institute, The Alfred Hospital, 89 Commercial Road, Melbourne, VIC 3004 Australia.,2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia.,3School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Weymouth W, Long B, Koyfman A, Winckler C. Whole Blood in Trauma: A Review for Emergency Clinicians. J Emerg Med 2019; 56:491-498. [DOI: 10.1016/j.jemermed.2019.01.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Revised: 01/09/2019] [Accepted: 01/21/2019] [Indexed: 11/26/2022]
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20
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Wu SC, Rau CS, Kuo SCH, Hsu SY, Hsieh HY, Hsieh CH. Shock index increase from the field to the emergency room is associated with higher odds of massive transfusion in trauma patients with stable blood pressure: A cross-sectional analysis. PLoS One 2019; 14:e0216153. [PMID: 31022295 PMCID: PMC6483361 DOI: 10.1371/journal.pone.0216153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 04/15/2019] [Indexed: 11/30/2022] Open
Abstract
Background The shock index (SI) is defined as the ratio of heart rate/systolic blood pressure. This study aimed to determine the performance of delta shock index (ΔSI), a difference between SI upon arrival at the emergency room (ER) and that in the field, in predicting the need for massive transfusion (MT) among adult trauma patients with stable blood pressure. Methods This study included registered data from all trauma patients aged 20 years and above who were hospitalized from January 1, 2009 to December 31, 2016. Only patients who were transferred by emergency medical service from the accident site with a systolic blood pressure ≥ 90 mm Hg at the ER were included. The 7,957 enrolled trauma patients were divided into 2 groups, those who had received blood transfusion ≥ 10 U (MT, n = 82) and those who had not (non-MT, n = 7,875). The odds ratios with 95% confidence intervals for the need for MT by a given ΔSI were measured. The plot of specific receiver operating characteristic (ROC) curves was used to evaluate the best cutoff point of ΔSI that could predict the patient’s probability of receiving MT. Results ROC curve analysis showed that a ΔSI of 0.06 as the cutoff point had the highest AUC of 0.61, with a sensitivity of 0.415 and specificity of 0.841. Patients with a ΔSI ≥ 0.00 had a significant 1.8-fold increase in need for MT than those patients with a ΔSI less than 0.00 (1.4% vs. 0.8%, p = 0.01). The larger the ΔSI, the higher the odds of need for an MT. Using the cutoff point of ΔSI of 0.06, patients with a ΔSI ≥ 0.06 had a significant 3.7-fold increase in need for MT than those patients with a ΔSI less than 0.06 (2.7% vs. 0.7%, p < 0.001). Conclusions This study indicated that, in trauma patients with stable blood pressure at the ER, the accuracy of prediction of the requirement for MT by ΔSI is low. However, the size of the delta is significantly associated with need for MT and a lack of improvement in the patient’s SI at the ER compared to that in the field significantly increases the odds of a need for MT.
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Affiliation(s)
- Shao-Chun Wu
- Department of Anesthesiology, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
| | - Cheng-Shyuan Rau
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
| | - Spencer C. H. Kuo
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
| | - Shiun-Yuan Hsu
- Department of Trauma Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
| | - Hsiao-Yun Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
| | - Ching-Hua Hsieh
- Department of Plastic Surgery, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University and College of Medicine, Kaohsiung, Taiwan
- * E-mail:
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21
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Kamikawa Y, Hayashi H. Predicting in-hospital mortality among non-trauma patients based on vital sign changes between prehospital and in-hospital: An observational cohort study. PLoS One 2019; 14:e0211580. [PMID: 30703160 PMCID: PMC6355016 DOI: 10.1371/journal.pone.0211580] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/16/2019] [Indexed: 11/18/2022] Open
Abstract
Objective To prevent misjudgment of the severity of patients in the emergency department who initially seem non-severe but are in a critical state, methods that differ from the conventional viewpoint are needed. We aimed to determine whether vital sign changes between prehospital and in-hospital could predict in-hospital mortality among non-trauma patients. Methods This observational cohort study was conducted in two tertiary care hospitals. Patients were included if they were transported by ambulance for non-trauma-related conditions but were excluded if they experienced prehospital cardiopulmonary arrest, were pregnant, were aged <15 years, had undergone inter-hospital transfer, or had complete missing data regarding prehospital or in-hospital vital signs. The main outcome was in-hospital mortality, and the study variables were changes in vital signs, pulse pressure, and/or shock index between the prehospital and in-hospital assessments. Logistic regression analyses were performed to obtain adjusted odds ratios for each variable. Receiver operating characteristic curve analyses were performed to identify cut-off values that produced a positive likelihood ratio of ≥2. Results Among the 2,586 eligible patients, 170 died in the two hospitals. Significantly elevated risks of in-hospital mortality were associated with changes in the Glasgow Coma Scale (cut-off ≤–3), respiratory rate (no clinically significant cut-off), systolic blood pressure (cut-off ≥47 mmHg), pulse pressure (cut-off ≥55 mmHg), and shock index (cut-off ≥0.3). Conclusions Non-trauma patients who exhibit changes in some vital signs between prehospital and in-hospital have an increased risk of in-hospital mortality. Therefore, it is useful to incorporate these changes in vital signs to improve triaging and predict the occurrence of in-hospital mortality.
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Affiliation(s)
- Yohei Kamikawa
- Department of Emergency Medicine, University of Fukui Hospital, Fukui, Japan
| | - Hiroyuki Hayashi
- Department of Family Medicine, University of Fukui Hospital, Fukui, Japan
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Estebaranz-Santamaría C, Palmar-Santos AM, Pedraz-Marcos A. Massive transfusion triggers in severe trauma: Scoping review. Rev Lat Am Enfermagem 2018; 26:e3102. [PMID: 30517587 PMCID: PMC6280179 DOI: 10.1590/1518-8345.2574.3102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 10/08/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE to identify the predictive variables or the massive transfusion triggers in severely traumatized patients through the existing scales. METHOD a review of the literature was carried out using the Scoping Review method across the electronic databases CINAHL, MEDLINE, LILACS, the Cochrane and IBECS libraries, and the Google Scholar search tool. RESULTS in total, 578 articles were identified in the search and the 36 articles published in the last ten years were included, of which 29 were original articles and 7 review articles. From the analysis, scales for massive transfusion and their predictive triggers were examined. CONCLUSION the absence of universal criteria regarding the massive transfusion triggers in traumatized patients has led to the development of different scales, and the studies on their validation are considered relevant for the studies about when to initiate this strategy.
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Sohn C, Kim YJ, Seo D, Won HS, Shim JY, Lim KS, Kim W. Blood lactate concentration and shock index associated with massive transfusion in emergency department patients with primary postpartum haemorrhage. Br J Anaesth 2018; 121:378-383. [DOI: 10.1016/j.bja.2018.04.039] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Revised: 03/19/2018] [Accepted: 05/05/2018] [Indexed: 02/04/2023] Open
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Bade-Boon J, Mathew JK, Fitzgerald MC, Mitra B. Traumatic aortic injury presenting to an adult major trauma centre. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408618773547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction Traumatic aortic injury is an uncommon condition. Timely diagnosis may enable early haemostatic resuscitation, essential to prevent worsening of the injury prior to definitive management. The aim of this study was to assess the utility of initial vital signs and presenting clinical characteristics to confirm or rule out aortic injury. Methods A retrospective review of patients from The Alfred Trauma Registry was conducted. Patients presenting between January 2006 and July 2014 and diagnosed with aortic injury were identified. Demographics and presenting clinical characteristics were extracted. Sensitivity of individual clinical variables for the detection of aortic injury was calculated. Results There were 77 patients identified with aortic injury, with an in-hospital mortality rate of 19.5% (95% CI: 10.6–28.3%). Of these, 68 (88.3%) patients presented after high-energy blunt mechanisms. Clinical signs and early chest X-ray findings were poorly sensitive to detect aortic injury. Patients who presented with hypotension had a greater severity of aortic injury, more commonly had associated abnormal investigation findings and were more likely to require blood products and inotropic agents (p < 0.05). However, sensitivity of initial hypotension to rule out aortic injury was 39.0% (95% CI: 28.1–49.9%). Conclusions The diagnosis of aortic injury was uncommon in hospital. Most injuries were secondary to high-velocity road traffic crashes or high falls. Clinical signs were not adequately sensitive to be used for the exclusion of aortic injury. We recommend a high degree of clinical suspicion and liberal imaging among cases where aortic injury is possible.
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Affiliation(s)
- Jordan Bade-Boon
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Epidemiology & Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC, Australia
| | - Joseph K Mathew
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, VIC, Australia
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - Mark C Fitzgerald
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, VIC, Australia
- Trauma Service, The Alfred Hospital, Melbourne, VIC, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Melbourne, VIC, Australia
- National Trauma Research Institute, The Alfred Hospital, Melbourne, VIC, Australia
- Department of Epidemiology & Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC, Australia
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Wertheimer A, Olaussen A, Perera S, Liew S, Mitra B. Fractures of the femur and blood transfusions. Injury 2018; 49:846-851. [PMID: 29566986 DOI: 10.1016/j.injury.2018.03.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 03/02/2018] [Accepted: 03/07/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Blood loss estimation after trauma (i.e. physical injury) and early identification of potential sources of bleeding are important for planning of investigation and management of trauma. Long bone fractures have been reported to be associated with substantial volumes of blood loss requiring blood transfusion. The aim of this study was to assess rates and amounts of blood transfusion in the setting of isolated extra capsular femur fractures and to determine variables associated with the need for transfusion within the first 48 h of admission. METHODS A retrospective cohort study was conducted of patients in The Alfred Trauma Registry with isolated extra capsular femur fractures over a 7-year period. We compared patients with a femoral shaft fracture (FSF) to patients with either distal femur or proximal femur fractures (i.e. extremity fracture). We collected data potentially associated with blood transfusion within 48 h as well as operation details and patient outcomes. RESULTS There were 293 patients included, of which 121 had FSF and 172 extremity fracture. 105 (36%) patients received a blood transfusion during their admission. Admission haemoglobin (AOR 0.92; 95%CI 0.89-0.94, p < 0.01) was the only independently associated variable with blood transfusion within the first 48 h of hospital admission. CONCLUSION Volume of blood transfused to patients with extra-capsular femoral fractures was low and usually in the post-operative period. FSF, compared to femoral extremity fractures, were not more likely to receive blood transfusion within the first 48 h of admission, and did not receive a higher volume of blood overall. In the setting of major trauma with haemorrhagic shock, alternate sources of bleeding should be sought.
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Affiliation(s)
- Adam Wertheimer
- Department of Orthopaedic Surgery, The Alfred Hospital, Australia.
| | - Alexander Olaussen
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia; National Trauma Research Institute, The Alfred Hospital, Australia
| | - Shanaka Perera
- Department of Orthopaedic Surgery, The Alfred Hospital, Australia
| | - Susan Liew
- Department of Orthopaedic Surgery, The Alfred Hospital, Australia
| | - Biswadev Mitra
- Emergency & Trauma Centre, The Alfred Hospital, Australia; Department of Epidemiology & Preventive Medicine, Monash University, Australia; National Trauma Research Institute, The Alfred Hospital, Australia
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26
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Bade-Boon J, Mathew JK, Fitzgerald MC, Mitra B. Do patients with blunt thoracic aortic injury present to hospital with unstable vital signs? A systematic review and meta-analysis. Emerg Med J 2018; 35:231-237. [PMID: 29440235 DOI: 10.1136/emermed-2017-206688] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 01/12/2018] [Accepted: 01/19/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND Blunt thoracic aortic injury (BTAI) is an uncommon diagnosis, usually developing as a consequence of high-impact acceleration-deceleration mechanisms. Timely diagnosis may enable early resuscitation and reduction of shear forces, essential to prevent worsening of the injury prior to definitive management. Death is commonly due to haemorrhagic shock, but clinical features may be absent until sudden and massive haemorrhage. OBJECTIVES The aim of this systematic review was to determine the proportion of patients with BTAI who present with unstable vital signs. METHODS Manuscripts were identified through a search of MEDLINE, EMBASE and the Cochrane Library databases, focusing on subject headings and keywords related to the aorta and trauma. Mechanisms of injury, haemodynamic status and mortality from the included manuscripts were reviewed. Meta-analysis of presenting haemodynamic status among a select group of similar papers was conducted. RESULTS Nineteen studies were included, with five selected for meta-analysis. Most reported cases of BTAI (80.0%-100%) were caused by road traffic incidents, with mortality consistently higher among initially unstable patients. There was statistically significant heterogeneity among the included studies (P<0.01). The pooled proportion of patients with haemodynamic instability in the setting of BTAI was 48.8% (95% CI 8.3 to 89.4). CONCLUSIONS Normal vital signs do not rule out aortic injury. A high degree of clinical suspicion and liberal use of imaging is necessary to prevent missed or delayed diagnoses.
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Affiliation(s)
- Jordan Bade-Boon
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joseph K Mathew
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark C Fitzgerald
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.,Trauma Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, The Alfred Hospital, Melbourne, Victoria, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Clayton, Victoria, Australia
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Terceros-Almanza LJ, García-Fuentes C, Bermejo-Aznárez S, Prieto Del Portillo IJ, Mudarra-Reche C, Domínguez-Aguado H, Viejo-Moreno R, Barea-Mendoza J, Gómez-Soler R, Casado-Flores I, Chico-Fernández M. Prediction of massive bleeding in a prehospital setting: validation of six scoring systems. Med Intensiva 2018; 43:131-138. [PMID: 29415812 DOI: 10.1016/j.medin.2017.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/01/2022]
Abstract
OBJECTIVE To validate the diagnostic ability of six different scores to predict massive bleeding in a prehospital setting. DESIGN Retrospective cohort. SETTING Prehospital attention of patients with severe trauma. SUBJECTS Subjects with more than 15 years, a history of severe trauma (defined by code 15 criteria), that were initially assisted in a prehospital setting by the emergency services between January 2010 and December 2015 and were then transferred to a level one trauma center in Madrid. VARIABLES To validate: 1. Trauma Associated Severe Haemorrhage Score. 2. Assessment of Blood Consumption Score. 3. Emergency Transfusión Score. 4. Índice de Shock. 5. Prince of Wales Hospital/Rainer Score. 6. Larson Score. RESULTS 548 subjects were studied, 76,8% (420) were male, median age was 38 (interquartile range [IQR]: 27-50). Injury Severity Score was 18 (IQR: 9-29). Blunt trauma represented 82,5% (452) of the cases. Overall, frequency of MB was 9,2% (48), median intensive care unit admission days was 2,1 (IQR: 0,8 - 6,2) and hospital mortality rate was 11,2% (59). Emergency Transfusión Score had the highest precisions (AUC 0,85), followed by Trauma Associated Severe Haemorrhage score and Prince of Wales Hospital/Rainer Score (AUC 0,82); Assessment of Blood Consumption Score was the less precise (AUC 0,68). CONCLUSION In the prehospital setting the application of any the six scoring systems predicts the presence of massive hemorrhage and allows the activation of massive transfusion protocols while the patient is transferred to a hospital.
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Affiliation(s)
- L J Terceros-Almanza
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre.
| | - C García-Fuentes
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - S Bermejo-Aznárez
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - I J Prieto Del Portillo
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - C Mudarra-Reche
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - H Domínguez-Aguado
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - R Viejo-Moreno
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - J Barea-Mendoza
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
| | - R Gómez-Soler
- Servicio de Asistencia Municipal de Urgencia y Rescate - SAMUR-Protección Civil
| | - I Casado-Flores
- Servicio de Asistencia Municipal de Urgencia y Rescate - SAMUR-Protección Civil
| | - M Chico-Fernández
- Unidad de Trauma y Emergencias, Servicio de Medicina Intensiva, Hospital Universitario 12 de Octubre
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McGowan EE, Marryott K, Drobatz KJ, Reineke EL. Evaluation of the use of shock index in identifying acute blood loss in healthy blood donor dogs. J Vet Emerg Crit Care (San Antonio) 2017; 27:524-531. [DOI: 10.1111/vec.12640] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/28/2016] [Accepted: 03/25/2016] [Indexed: 10/19/2022]
Affiliation(s)
- Erin E. McGowan
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine; University of Pennsylvania; PA 19104
| | - Kimberly Marryott
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine; University of Pennsylvania; PA 19104
| | - Kenneth J. Drobatz
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine; University of Pennsylvania; PA 19104
| | - Erica L. Reineke
- Department of Clinical Studies-Philadelphia, School of Veterinary Medicine; University of Pennsylvania; PA 19104
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29
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Abstract
The elderly population is rapidly increasing in number. Therefore, geriatric trauma is becoming more prevalent. All practitioners caring for geriatric trauma patients should be familiar with the structural and functional changes naturally occurring in the aging heart, as well as common preexisting cardiac diseases in the geriatric population. Identification of the shock state related to cardiac dysfunction and targeted assessment of perfusion and resuscitation are important when managing elderly patients. Finally, management of cardiac dysfunction in the trauma patient includes an appreciation of the inherent effects of trauma on cardiac function.
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30
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Ruseckaite R, McQuilten ZK, Oldroyd JC, Richter TH, Cameron PA, Isbister JP, Wood EM. Descriptive characteristics and in-hospital mortality of critically bleeding patients requiring massive transfusion: results from the Australian and New Zealand Massive Transfusion Registry. Vox Sang 2017; 112:240-248. [DOI: 10.1111/vox.12487] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Revised: 11/10/2016] [Accepted: 12/10/2016] [Indexed: 11/29/2022]
Affiliation(s)
- R. Ruseckaite
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - Z. K. McQuilten
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - J. C. Oldroyd
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - T. H. Richter
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
| | - P. A. Cameron
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
- Emergency and Trauma Centre; The Alfred Hospital; Melbourne Vic. Australia
| | - J. P. Isbister
- Department of Haematology; Royal North Shore Hospital; University of Sydney; St Leonards NSW Australia
| | - E. M Wood
- Department of Epidemiology and Preventive Medicine; Monash University; Melbourne Vic. Australia
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31
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Fröhlich M, Driessen A, Böhmer A, Nienaber U, Igressa A, Probst C, Bouillon B, Maegele M, Mutschler M. Is the shock index based classification of hypovolemic shock applicable in multiple injured patients with severe traumatic brain injury?-an analysis of the TraumaRegister DGU ®. Scand J Trauma Resusc Emerg Med 2016; 24:148. [PMID: 27955692 PMCID: PMC5153863 DOI: 10.1186/s13049-016-0340-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/30/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND A new classification of hypovolemic shock based on the shock index (SI) was proposed in 2013. This classification contains four classes of shock and shows good correlation with acidosis, blood product need and mortality. Since their applicability was questioned, the aim of this study was to verify the validity of the new classification in multiple injured patients with traumatic brain injury. METHODS Between 2002 and 2013, data from 40 888 patients from the TraumaRegister DGU® were analysed. Patients were classified according to their initial SI at hospital admission (Class I: SI < 0.6, class II: SI ≥0.6 to <1.0, class III SI ≥1.0 to <1.4, class IV: SI ≥1.4). Patients with an additional severe TBI (AIS ≥ 3) were compared to patients without severe TBI. RESULTS 16,760 multiple injured patients with TBI (AIShead ≥3) were compared to 24,128 patients without severe TBI. With worsening of SI class, mortality rate increased from 20 to 53% in TBI patients. Worsening SI classes were associated with decreased haemoglobin, platelet counts and Quick's values. The number of blood units transfused correlated with worsening of SI. Massive transfusion rates increased from 3% in class I to 46% in class IV. The accuracy for predicting transfusion requirements did not differ between TBI and Non TBI patients. DISCUSSION The use of the SI based classification enables a quick assessment of patients in hypovolemic shock based on universally available parameters. Although the pathophysiology in TBI and Non TBI patients and early treatment methods such as the use of vasopressors differ, both groups showed an identical probability of recieving blood products within the respective SI class. CONCLUSION Regardless of the presence of TBI, the classification of hypovolemic shock based on the SI enables a fast and reliable assessment of hypovolemic shock in the emergency department. Therefore, the presented study supports the SI as a feasible tool to assess patients at risk for blood product transfusions, even in the presence of severe TBI.
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Affiliation(s)
- Matthias Fröhlich
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany. .,Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne Merheim Medical Center (CMMC), Ostmerheimerstr.200, D-51109, Cologne, Germany. .,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany.
| | - Arne Driessen
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Andreas Böhmer
- Department of Anaesthesiology and Intensive Care Medicine, Cologne-Merheim Medical Centre, Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Ulrike Nienaber
- AUC-Academy for Trauma Surgery, Straße des 17. Juni 106-108, D-10623, Berlin, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Alhadi Igressa
- Department of Neurosurgery, Cologne-Merheim Medical Centre, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Christian Probst
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Bertil Bouillon
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Marc Maegele
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
| | - Manuel Mutschler
- Department of Orthopaedic Surgery, Traumatology and Sports Traumatology, Cologne-Merheim Medical Centre (CMMC), Witten/Herdecke University, Ostmerheimer Str. 200, D-51109, Cologne, Germany.,Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society (Sektion NIS), Berlin, Germany
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Torabi M, Moeinaddini S, Mirafzal A, Rastegari A, Sadeghkhani N. Shock index, modified shock index, and age shock index for prediction of mortality in Emergency Severity Index level 3. Am J Emerg Med 2016; 34:2079-2083. [DOI: 10.1016/j.ajem.2016.07.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 07/11/2016] [Indexed: 10/21/2022] Open
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Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma. J Trauma Acute Care Surg 2016; 81:713-22. [DOI: 10.1097/ta.0000000000001191] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Prediction of Massive Transfusion in Trauma Patients with Shock Index, Modified Shock Index, and Age Shock Index. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070683. [PMID: 27399737 PMCID: PMC4962224 DOI: 10.3390/ijerph13070683] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 01/06/2023]
Abstract
Objectives: The shock index (SI) and its derivations, the modified shock index (MSI) and the age shock index (Age SI), have been used to identify trauma patients with unstable hemodynamic status. The aim of this study was to evaluate their use in predicting the requirement for massive transfusion (MT) in trauma patients upon arrival at the hospital. Participants: A patient receiving transfusion of 10 or more units of packed red blood cells or whole blood within 24 h of arrival at the emergency department was defined as having received MT. Detailed data of 2490 patients hospitalized for trauma between 1 January 2009, and 31 December 2014, who had received blood transfusion within 24 h of arrival at the emergency department, were retrieved from the Trauma Registry System of a level I regional trauma center. These included 99 patients who received MT and 2391 patients who did not. Patients with incomplete registration data were excluded from the study. The two-sided Fisher exact test or Pearson chi-square test were used to compare categorical data. The unpaired Student t-test was used to analyze normally distributed continuous data, and the Mann-Whitney U-test was used to compare non-normally distributed data. Parameters including systolic blood pressure (SBP), heart rate (HR), hemoglobin level (Hb), base deficit (BD), SI, MSI, and Age SI that could provide cut-off points for predicting the patients’ probability of receiving MT were identified by the development of specific receiver operating characteristic (ROC) curves. High accuracy was defined as an area under the curve (AUC) of more than 0.9, moderate accuracy was defined as an AUC between 0.9 and 0.7, and low accuracy was defined as an AUC less than 0.7. Results: In addition to a significantly higher Injury Severity Score (ISS) and worse outcome, the patients requiring MT presented with a significantly higher HR and lower SBP, Hb, and BD, as well as significantly increased SI, MSI, and Age SI. Among these, only four parameters (SBP, BD, SI, and MSI) had a discriminating power of moderate accuracy (AUC > 0.7) as would be expected. A SI of 0.95 and a MSI of 1.15 were identified as the cut-off points for predicting the requirement of MT, with an AUC of 0.760 (sensitivity: 0.563 and specificity: 0.876) and 0.756 (sensitivity: 0.615 and specificity: 0.823), respectively. However, in the groups of patients with comorbidities such as hypertension, diabetes mellitus, or coronary artery disease, the discriminating power of these three indices in predicting the requirement of MT was compromised. Conclusions: This study reveals that the SI is moderately accurate in predicting the need for MT. However, this predictive power may be compromised in patients with HTN, DM or CAD. Moreover, the more complex calculations of MSI and Age SI failed to provide better discriminating power than the SI.
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35
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Wang H, Umejiego J, Robinson RD, Schrader CD, Leuck J, Barra M, Buca S, Shedd A, Bui A, Zenarosa NR. A Derivation and Validation Study of an Early Blood Transfusion Needs Score for Severe Trauma Patients. J Clin Med Res 2016; 8:591-7. [PMID: 27429680 PMCID: PMC4931805 DOI: 10.14740/jocmr2598w] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2016] [Indexed: 01/11/2023] Open
Abstract
Background There is no existing adequate blood transfusion needs determination tool that Emergency Medical Services (EMS) personnel can use for prehospital blood transfusion initiation. In this study, a simple and pragmatic prehospital blood transfusion needs scoring system was derived and validated. Methods Local trauma registry data were reviewed retrospectively from 2004 through 2013. Patients were randomly assigned to derivation and validation cohorts. Multivariate logistic regression was used to identify the independent approachable risks associated with early blood transfusion needs in the derivation cohort in which a scoring system was derived. Sensitivity, specificity, and area under the receiver operational characteristic (AUC) were calculated and compared using both the derivation and validation data. Results A total of 24,303 patients were included with 12,151 patients in the derivation and 12,152 patients in the validation cohorts. Age, penetrating injury, heart rate, systolic blood pressure, and Glasgow coma scale (GCS) were risks predictive of early blood transfusion needs. An early blood transfusion needs score was derived. A score > 5 indicated risk of early blood transfusion need with a sensitivity of 83% and a specificity of 80%. A sensitivity of 82% and a specificity of 80% were also found in the validation study and their AUC showed no statistically significant difference (AUC of the derivation = 0.87 versus AUC of the validation = 0.86, P > 0.05). Conclusions An early blood transfusion scoring system was derived and internally validated to predict severe trauma patients requiring blood transfusion during prehospital or initial emergency department resuscitation.
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Affiliation(s)
- Hao Wang
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Johnbosco Umejiego
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Richard D Robinson
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Chet D Schrader
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - JoAnna Leuck
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Michael Barra
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Stefan Buca
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Shedd
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Andrew Bui
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
| | - Nestor R Zenarosa
- Department of Emergency Medicine, Integrative Emergency Services, John Peter Smith Health Network, 1500 S. Main St., Fort Worth, TX 76104, USA
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36
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Olaussen A, Thaveenthiran P, Fitzgerald MC, Jennings PA, Hocking J, Mitra B. Prediction of critical haemorrhage following trauma: A narrative review. JOURNAL OF EMERGENCY MEDICINE, TRAUMA AND ACUTE CARE 2016. [DOI: 10.5339/jemtac.2016.3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Introduction: Traumatic haemorrhagic shock can be difficult to diagnose. Models for predicting critical bleeding and massive transfusion have been developed to aid clinicians. The aim of this review is to outline the various available models and report on their performance and validation. Methods: A review of the English and non-English literature in Medline, PubMed and Google Scholar was conducted from 1990 to September 2015. We combined several terms for i) haemorrhage AND ii) prediction, in the setting of iii) trauma. We included models that had at least two data points. We extracted information about the models, their developments, performance and validation. Results: There were 36 different models identified that diagnose critical bleeding, which included a total of 36 unique variables. All models were developed retrospectively. The models performed with variable predictive abilities–the most superior with an area under the receiver operating characteristics curve of 0.985, but included detailed findings on imaging and was based on a small cohort. The most commonly included variable was systolic blood pressure, featuring in all but five models. Pattern or mechanism of injury were used by 16 models. Pathology results were used by 15 models, of which nine included base deficit and eight models included haemoglobin. Imaging was utilised in eight models. Thirteen models were known to be validated, with only one being prospectively validated. Conclusions: Several models for predicting critical bleeding exist, however none were deemed accurate enough to dictate treatment. Potential areas of improvement identified include measures of variability in vital signs and point of care imaging and pathology testing.
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Affiliation(s)
- Alexander Olaussen
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 5Monash School of Medicine, Monash University, Australia
- 3Trauma Service, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 1Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
| | - Prasanthan Thaveenthiran
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 5Monash School of Medicine, Monash University, Australia
| | - Mark C. Fitzgerald
- 3Trauma Service, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
| | - Paul A. Jennings
- 1Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Australia
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 6College of Health and Biomedicine, Victoria University, Melbourne, Australia
| | - Jessica Hocking
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
| | - Biswadev Mitra
- 2Emergency & Trauma Centre, The Alfred Hospital, Melbourne, Australia
- 4National Trauma Research Institute, The Alfred Hospital, Melbourne, Australia
- 7Department of Epidemiology & Preventive Medicine, Monash University, Australia
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Ohmori T, Kitamura T, Tanaka K, Saisaka Y, Ishihara J, Onishi H, Nojima T, Yamamoto K, Matsumoto T, Tokioka T. Bleeding sites in elderly trauma patients who required massive transfusion: a comparison with younger patients. Am J Emerg Med 2015; 34:123-7. [PMID: 26573783 DOI: 10.1016/j.ajem.2015.09.047] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 09/22/2015] [Accepted: 09/22/2015] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Among elderly patients with severe trauma, the sites of massive hemorrhage and their clinical characteristics are not well understood. Therefore, we investigated the sites of massive hemorrhage in patients with severe trauma, and compared the results for younger and elderly patients. METHODS A cohort of severe trauma patients (Injury Severity Score ≥16) admitted from March 2007 to December 2014 was reviewed retrospectively. The inclusion criterion was massive bleeding, which was defined as bleeding that required the transfusion of ≥10 red cell concentrate units within 24 hours of admission, or as cases of early death that occurred despite continuous blood transfusion and before the patient could receive ≥10 red cell concentrate units within the first 24 hours after their admission. RESULTS Eighty-four patients met our inclusion criterion. The younger group (<65 years old) included 40 patients (48%), whereas the older group (≥65 years old) included 44 patients (52%). The percentage of nondiagnosable cases at the primary survey (massive bleeding due to multisite damage caused by a bone fracture or contusion, retroperitoneal hematoma without a pelvic ring fracture and with stable pelvic ring fracture) was 14% in the younger group and 40% in the older group (odds ratio, 3.92; 95% confidence interval, 1.37-11.27, P = .017). CONCLUSIONS Even if no abnormalities are observed at the primary survey of elderly patients with severe trauma, physicians should consider the possibility of massive bleeding.
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Affiliation(s)
- Takao Ohmori
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555.
| | - Taisuke Kitamura
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Kimiaki Tanaka
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Yuichi Saisaka
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Junko Ishihara
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Hirokazu Onishi
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Tsuyoshi Nojima
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Kotaro Yamamoto
- Emergency & Critical Care Center, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Toshiyuki Matsumoto
- Department of Orthopaedic Surgery, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
| | - Takamitsu Tokioka
- Department of Orthopaedic Surgery, Kochi Health Sciences Center, 2125-1, IKe, Kochi, Japan, 781-8555
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The traditional vs "1:1:1" approach debate on massive transfusion in trauma should not be treated as a dichotomy. Am J Emerg Med 2015; 33:1501-4. [PMID: 26184524 DOI: 10.1016/j.ajem.2015.06.065] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2015] [Revised: 06/22/2015] [Accepted: 06/25/2015] [Indexed: 11/21/2022] Open
Abstract
Traditional transfusion guidelines suggest that fresh frozen plasma (FFP) should be given based on laboratory or clinical evidence of coagulopathy or acute loss of 1 blood volume. This approach tends to result in a significant lag time between the first units of erythrocytes and FFP in trauma requiring massive transfusion. In severe trauma, observational studies have found an association between increased survival and aggressive use of FFP and platelets such that FFP:platelet:erythrocyte ratio approaches 1:1:1 to 2 from the first units of erythrocytes given. There are considerable concerns over either approach, and no randomized controlled trials have been published comparing the 2 approaches. Nowadays, trauma clinicans are incorporating the strenghts of both approaches and are no longer treating them as a dichotomy. Specifically, "1:1:1" proponents have devised 1:1:1 activation criteria to minimize unnecessary FFP and platelet transfusion and are prepared to deactivate the protocol as soon as patient is stabilized. Similarly, 1:1:1 skeptics are more mindful of the need to be proactive about trauma coagulopathy and the inherent delays in FFP administration in trauma patients.
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