Elsevier

Resuscitation

Volume 82, Issue 6, June 2011, Pages 724-729
Resuscitation

Clinical paper
Early risk stratification of patients with major trauma requiring massive blood transfusion

https://doi.org/10.1016/j.resuscitation.2011.02.016Get rights and content

Abstract

Background

There is limited evidence to guide the recognition of patients with massive, uncontrolled hemorrhage who require initiation of a massive transfusion (MT) protocol.

Objective

To risk stratify patients with major trauma and to predict need for MT.

Designs

Retrospective analysis of an administrative trauma database of major trauma patients.

A regional trauma Centre

A regional trauma centres in Hong Kong.

Patients

Patients with Injury Severity Score ≥9 and age ≥12 years were included. Burn patients, patients with known severe anemia and renal failure, or died within 24 h were excluded.

Main outcome measures

Delivery of ≥10 units of packed red blood cells (RBC) within 24 h.

Results

Between 01/01/2001 and 30/06/2009, 1891 patients met the inclusion criteria. 92 patients required ≥10 units RBC within 24 h. Seven variables which were easy to be measured in the ED and significantly predicted the need for MT are heart rate ≥120/min; systolic blood pressure ≤90 mmHg; Glasgow coma scale ≤8; displaced pelvic fracture; CT scan or FAST positive for fluid; base deficit >5 mmol/L; hemoglobin ≤7 g/dL; and hemoglobin 7.1–10 g/dL. At a cut off of ≥6, the overall correct classification for predicting need for MT was 96.9%, with a sensitivity of 31.5% and specificity of 99.7%, and an incidence of MT of 82.9%. The area under the curve was 0.889.

Conclusion

A prediction rule for determining an increased likelihood for the need for massive transfusion has been derived. This needs validation in an independent data set.

Section snippets

Background

Trauma is the leading cause of death worldwide in people under 45 years of age, is currently fifth for all ages, and is projected to become the second leading cause of death by 2020 worldwide.1, 2, 3 Exsanguination plays a critical role in 40% of these deaths and uncontrolled hemorrhage after traumatic injury is the most common cause of potentially preventable death.4, 5 Early coagulopathy, acidosis and hypothermia are also associated with increased mortality.6, 7 After the onset of injury a

Study design

Ethical approval was obtained from the joint Chinese University of Hong Kong/New Territories East Cluster Clinical Research Ethics Committee in Hong Kong to conduct a retrospective study to derive a clinical prediction rule for major trauma patients requiring massive blood transfusion. The period of study was from 1st January 2001 to 31 August 2009.

Setting

95% of the population in Hong Kong are Chinese. The Prince of Wales Hospital (PWH) is a university tertiary referral centre situated in the New

Results

Between 1st January 2001 and 30th June 2009, 4336 patients were included in the trauma database. Fig. 1 shows the selection of patients for the study. 355 patients required one or more units of packed red blood cells (range 1–54 units) of whom 125 patients required 1–5 units, 138 patients 6–9 units, and 92 (4.9%) of 1891 patients required ≥10 units within 24 h.

Table 1 shows baseline characteristics of this group. Although the majority of patients receiving a massive transfusion were either

Discussion

In this study we have derived a simple 10-point score for classifying civilian patients with major trauma likely to need a MT. Seven variables, easily measured or identified in the trauma resuscitation room were identified, and weighted scores assigned according to their odds ratios. At a cut off ≥6, the overall correct classification for predicting need for MT was 96.6%, with a specificity of 99.7% and the positive predictive value was 82.9%.

The proportion of patients requiring a MT in our

Funding

None.

Conflict of interest

None.

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    A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.016.

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