Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion

doi:10.1016/j.ajem.2012.06.024

The American Journal of Emergency Medicine

Volume 31, Issue 1, January 2013, Pages 130-136

https://doi.org/10.1016/j.ajem.2012.06.024 Get rights and content

Abstract

Background

The purpose of this study was to define whether the semiquantitative analysis of hemoperitoneum increases the accuracy of early prediction of massive transfusion (MT).

Methods

A retrospective review of severe trauma patients consecutively admitted to our trauma intensive care unit between January 2005 and December 2009 was conducted. Patients diagnosed with blunt abdominal trauma who had a computed tomography scan on admission were included. The hemoperitoneum size was defined using the Federle score on computed tomography as large, moderate, or minimal/none. The association between MT (≥ 10 U of packed red blood cells in the first 24 h) and moderate and large sizes of hemoperitoneum was assessed using a multiple logistic model.

Results

Of the 381 patients meeting the inclusion criteria, 270 (71%) were male; the mean age was 35.5 ± 18.2 years and mean injury severity score was 23.4 ± 17. Ninety-seven (26%) had large hemoperitoneum, 107 (28%) had moderate hemoperitoneum, and 177 (46%) had minimal/no hemoperitoneum. Eighty-three patients (22%) required MT. The positive predictive value for MT of a large hemoperitoneum was 41%, 23% for a moderate hemoperitoneum, and 10% for minimal/no hemoperitoneum (P < .001). The corresponding values for hypotensive patients were 61%, 32%, and 25%, respectively (P < .001). In the multivariate analysis model, only the large size of hemoperitoneum was significantly associated with MT (OR 6.4, 95% CI 2.9−14, P < .001, r² = 0.47).

Conclusion

The assessment of the size of hemoperitoneum on admission substantially improves the prediction of MT in trauma patients and should be used to trigger and guide initial haemostatic resuscitation.

Section snippets

Background

Exsanguinating hemorrhage is the most frequent cause of mortality in the first hours after severe trauma [1], [2], [3].Trauma-induced coagulopathy, which presents in 25% to 40% of major trauma patients, worsens prognosis and increases mortality [4], [5], [6]. In such cases, despite the current debate on the optimal value of ratio of fresh frozen plasma (FFP) to packed red blood cells (PRBC), aggressive administration of blood products (ie, FFP, platelet, and fibrinogen concentrates) is

Study setting and population

A retrospective study was undertaken in the intensive care unit of the Level I Regional Trauma Center of Lapeyronie University Hospital, which receives all patients suspected to have sustained severe trauma from the city of Montpellier (France) and its region, according to the French guidelines for prehospital medical triage [27].

Between January 2005 and December 2009, all consecutive blunt trauma patients admitted to our trauma department who had an abdominal Abbreviated Injury Scale (AIS) ≥ 1

General population

During the 5-year period, 1079 patients were admitted consecutively to our level 1 trauma centre, 420 (39%) had an abdominal AIS ≥ 1. Thirty-nine (9%) were excluded; the medical history for 16 patients was missing important data (death immediately after admission or no CT scan before laparotomy) and 23 were first admitted to another hospital. The remaining 381 patients were included in the study; 270 (71%) were male, their mean age was 35.5 ± 18.2 years, the mean SAPS II was 30.3 ± 20, the mean

Discussion

As we hypothesized, in 381 consecutive patients severely injured with blunt abdominal trauma, a large hemoperitoneum was statistically associated with requirement for MT. More interesting, a large hemoperitoneum predicted the likelihood of MT significantly better than a moderate hemoperitoneum, regardless of the hypotensive status: 41% of patients with a large hemoperitoneum needed MT compared with 23% of patients with a moderate hemoperitoneum; the corresponding rates for hypotensive patients

Conclusion

A large hemoperitoneum was significantly more associated with MT than a moderate hemoperitoneum in severe trauma patients, regardless of their hemodynamic status. This association remains true in the presence of other risk factors for MT. The semiquantitative analysis of hemoperitoneum substantially improves the prediction of MT and should be included in a predictive score for MT. The hemoperitoneum size on admission should be assessed in patients at risk of MT to optimize the initiation and

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Findings requiring immediate surgery in blunt abdominal trauma patients with isolated free fluid without solid organ injury on abdominal computed tomography: Retrospective laboratory, clinical and radiologic analysis. A case control study
2020, International Journal of Surgery
Determining surgical treatment is difficult in blunt abdominal trauma (BAT) patients with isolated free fluid without solid organ injury (IFFWSOI) on abdominal computed tomography (CT). We investigated the laboratory, clinical, and radiologic features of BAT patients with IFFWSOI on abdominal CT requiring surgery.
A retrospective medical record review was performed for patients treated at our government-established regional tertiary trauma center from March 2014 to August 2018. A total of 501 patients were identified and reviewed. Patients were divided into Surgery and No Surgery groups for analysis. The Surgery group included patients who underwent surgery during the index admission, while the No Surgery group included patients who did not undergo surgery.
There were significantly more cases of severe fluid collection (61.5% vs. 11.8%; p < 0.001), car accidents (69.2% vs. 35.3%; p = 0.018), and abdominal pain (87.2% vs. 58.8%; p = 0.031) at the emergency department in the Surgery group. Regarding laboratory studies performed at the emergency department, only the median amylase level was significantly higher in the No Surgery group (54.5 U/L vs. 62.5 U/L; p = 0.048). On multivariate logistic regression analysis with adjustments for age and sex, the odds ratio (OR) for severe fluid collection on abdominal CT to predict surgery was 13.52 (p = 0.006), while the OR for abdominal pain was 7.34 (p = 0.036) and the OR for car accident was 2.14 (p = 0.329). In addition, a multivariate logistic regression with adjustment for age, sex, delta neutrophil index, and C-reactive protein, showed the same propensity as the other model, although statistical significance was retained only for severe fluid collection.
Surgical treatment should be actively considered in the presence of a large volume of intra-abdominal free fluid, especially when concomitant with abdominal pain or after car accidents in BAT patients without solid organ injury.
Clinical Practice Guideline: Massive Transfusion Scoring Systems
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Citation Excerpt :
Twenty-three studies investigated the use of vital signs, serum studies, and trauma-related variables, in combination or alone, to predict which patients may need MT. The findings of these studies vary in terms of which variables may be useful in predicting the need for MT. Fifteen studies reported findings regarding the use of vital signs to predict the need for MT. A systolic blood pressure of 90 mm Hg or lower predicted the need for MT in eight studies (Blackmore et al., 2006; Burkhardt et al., 2014; Callcut, Johannigman, Kadon, Hanseman, & Robinson, 2011; Charbit et al., 2013; Dente et al., 2010; Parimi et al., 2016; Reed et al., 2016; Umemura, Nakamura, Nishida, Hoshino & Ishikura, 2016). Six other studies found that blood pressure may also predict MT need and all but one (Tonglet, Minon, Seidel, Poplavsky, & Vergnion, 2014) did not use the 90 mm Hg cutoff point (Fligor et al., 2016; Mina, Winkler & Dente, 2013; Rau et al., 2016; Shackelford et al., 2015; Vandromme, Griffin, Weinberg, Rue & Kerby, 2010).
Hemoperitoneum after blunt abdominal trauma 27 years after splenectomy: Better think twice
2016, American Journal of Emergency Medicine
Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)
2016, Revista Espanola de Anestesiologia y Reanimacion
La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos).
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
Multidisciplinary consensus document on the management of massive haemorrhage (HEMOMAS document)
2015, Medicina Intensiva
La hemorragia masiva es una entidad frecuente que se asocia a una elevada morbimortalidad. Ante la necesidad de la implementación y estandarización de su manejo, se realizó una revisión sistemática de la literatura, con extracción de recomendaciones en base a las evidencias existentes. A partir de las mismas se redactó un documento de consenso multidisciplinar. Desde las definiciones de hemorragia masiva y transfusión masiva, se establecen recomendaciones de actuación estructuradas en las medidas generales de manejo de las mismas (valoración clínica de la hemorragia, manejo de la hipotermia, reposición de la volemia, reanimación hipotensiva y cirugía de contención de daños), monitorización de la volemia, administración de hemocomponentes (concentrado de hematíes, plasma fresco, plaquetas, y óptima relación de administración entre ellos), y de hemostáticos (complejo protrombínico, fibrinógeno, factor VIIa, antifibrinolíticos).
Massive haemorrhage is common and often associated with high morbidity and mortality. We perform a systematic review of the literature, with extraction of the recommendations from the existing evidences because of the need for its improvement and the management standardization. From the results we found, we wrote a multidisciplinary consensus document. We begin with the agreement in the definitions of massive haemorrhage and massive transfusion, and we do structured recommendations on their general management (clinical assessment of bleeding, hypothermia management, fluid therapy, hypotensive resuscitation and damage control surgery), blood volume monitoring, blood products transfusion (red blood cells, fresh frozen plasma, platelets and their best transfusion ratio), and administration of hemostatic components (prothrombin complex, fibrinogen, factor VIIa, antifibrinolytic agents).
A simple assessment of haemothoraces thickness predicts abundant transfusion: A series of 525 blunt trauma patients
2015, Injury
Citation Excerpt :
Those presenting the following criteria were excluded: (1) death immediately after admission; (2) transfer from another hospital; (3) lack of important clinical data in the hospital database; (4) absence of a CT scan within the first two hours after admission or before interventional thoracic procedure, including chest tube insertion. Some of the patients and data have been included in a previous study about relationship between haemoperitoneum semi-quantitative analysis and massive transfusion [17]. Main demographic, anthropometric, clinical and biological data upon hospital admission were recorded for each patient, as well as their initial management and outcome.
The goal of this study was to evaluate the performance of haemothorax quantification to predict an abundant transfusion in blunt thoracic trauma patients.
This study included all severe trauma patients admitted into our trauma centre from January 2005 to January 2010, who presented a blunt thoracic trauma (thoracic AIS ≥1) and had a CT scan within the first hour following admission. For each haemothorax, thickness of dominant side and the cumulated thicknesses of both sides (Dominant-t, Cumulated-t), as well as lengths (Dominant-l, Cumulated-l) and the calculated volumes (Dominant-v, Cumulated-v provided by a previously validated formula) were retrospectively measured by CT scan. A multiple logistic regression was performed to define the independent risk factors for an abundant transfusion (≥5 packed red blood cells in the first 24 h). Finally, ROC curves have been drawn on an isolated thoracic trauma subgroup to predict abundant transfusion. The more specific cut-offs were extracted from this analysis.
From the 525 blunt thoracic trauma patients (75% males, mean age 38.2 (SD18.7) years, mean ISS 22.5 (SD16.4)), 31% received an abundant transfusion. In multivariable analysis, Cumulated-t was significantly associated with an abundant transfusion (OR 1.3 [95% CI 1.1–1.4], P = 0.002). In isolated thoracic trauma subgroup (n = 251), the global abilities of different CT measurements to predict abundant transfusion were significantly comparable (AUCs 0.69–0.70). The more specific cut-offs were established at 28 mm for Cumulated-t (specificity 92%, positive predictive value 47%) and at 24 mm for Dominant-t (specificity 92%; positive predictive value 43%).
The haemothorax quantification upon admission may help to predict transfusion needs. Cumulated-t was found independent risk factor for abundant transfusion in a large population of severe trauma patients. Beyond a Cumulated-t of 28 mm or a Dominant-t of 24 mm, abundant transfusion will be very frequently necessary.
Retrospective review, level III.

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^☆: Support was provided only from institutional sources.

^☆☆: No conflict of interest was declared.

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Original ContributionHemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion☆,☆☆

Abstract

Background

Methods

Results

Conclusion

Section snippets

Background

Study setting and population

General population

Discussion

Conclusion

J Am Coll Surg

Transfus Med Rev

J Am Coll Surg

Am J Surg

Resuscitation

J Am Coll Surg

Epidemiology of trauma deaths: a reassessment

J Trauma

Impact of hemorrhage on trauma outcome: an overview of epidemiology, clinical presentations, and therapeutic considerations

J Trauma

Acute traumatic coagulopathy

J Trauma

Early coagulopathy predicts mortality in trauma

J Trauma

Damage control resuscitation: directly addressing the early coagulopathy of trauma

J Trauma

The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital

J Trauma

Increased plasma and platelet to red blood cell ratios improves outcome in 466 massively transfused civilian trauma patients

Ann Surg

Red-blood-cell to plasma ratios transfused during massive transfusion are associated with mortality in severe multiple injury: a retrospective analysis from the Trauma Registry of the Deutsche Gesellschaft fur Unfallchirurgie

Vox Sang

Impact of plasma transfusion in massively transfused trauma patients

J Trauma

The relationship of blood product ratio to mortality: survival benefit or survival bias?

J Trauma

Transfusion therapy in hemorrhagic shock

Curr Opin Crit Care

Fresh frozen plasma should be given earlier to patients requiring massive transfusion

J Trauma

Damage control hematology: the impact of a trauma exsanguination protocol on survival and blood product utilization

J Trauma

Original Contribution
Hemoperitoneum semiquantitative analysis on admission of blunt trauma patients improves the prediction of massive transfusion☆,☆☆