Massive transfusion prediction with inclusion of the pre-hospital Shock Index
Section snippets
Background
Haemorrhagic shock (HS) is responsible for a third of all trauma deaths [1]. Timely diagnosis is therefore crucial, but remains challenging [2]. Diagnosis of HS relies primarily on the clinician's gestalt as traditional vital signs are commonly insufficient to diagnose HS [3]. The time-critical nature of the initial trauma resuscitation has necessitated reliance on single time-point measurements – rather than trends – that may add to delays in diagnosis and treatment of HS [4].
A key component
Setting
The state of Victoria in Australia has three Major Trauma Services (MTS) within metropolitan Melbourne, of which The Alfred Hospital is the largest. In 2008 a massive transfusion protocol (MTP) was introduced. This guideline recommended a 2:1 units ratio of Red Blood Cells (RBC) to Fresh Frozen Plasma (FFP), and 4:1 units of RBCs and leucocyte depleted platelets. Each unit of RBC has an average volume of 260 (SD 19) mL, each unit of FFP has an average volume of 280 (14) mL, and each unit of
Results
There were 6990 major trauma patients and 360 (5.2%) received MT. The mean age of the total cohort was 47.4 (21.9) years. The median ISS was 24 (17–29), and the overall mortality at hospital discharge was 9.7%. Blunt mechanism of injury was commonest (93.8%), whilst penetrating mechanisms only accounted for 2.5%. The remaining injuries comprised burns and ‘unknown’. Demographics, initial vital signs and initial pathology results are presented in Table 2.
The phSI was available in 5694 cases, of
Discussion
This study demonstrated statistically significant improvements in prediction of MT by incorporating pre-hospital SI. The ‘Combination’ SI, defined as: 0.5 × phSI + tcSI, was only marginally more accurate than tcSI alone, thus of limited clinical significance. Regardless of in-hospital values, this study demonstrated an association between phSI and subsequent in-hospital MT and highlights the potential utility of early, pre-hospital variables to predict MT.
Improved prediction of haemorrhage
Conclusion
The initial pre-hospital SI is associated with in-hospital massive transfusion. However, pre-hospital objective measures of haemorrhagic shock did not clinically augment massive transfusion decision when combined with in-hospital values. The simplicity and absence of pathology, radiology or other resources make the SI a favourable option to explore further. Adding further time points and continuing real-time computer assisted predictive models throughout the patient's journey may improve
Conflict of interest
None.
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Cited by (44)
Effectiveness of massive transfusion protocol activation in pre-hospital setting for major trauma
2022, InjuryCitation Excerpt :Before transfusion, nurses take a blood sample for the typing of red blood cells, then blood products are administered directly in the ED. The choice of the 2:1:1 ratio (PRBCs:FFP:PLT) for the “first pack” is borrowed from the analysis of previous studies [20,38–40], and the administration of FFP aims to reduce the ACT [14]. This study also aimed to analyze if the pre-hospital activations of MTP were confirmed upon admission to the ED, and if the inclusion criteria were effective in identifying the patients requiring massive transfusions.
Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool
2022, Journal of Surgical ResearchCitation Excerpt :We observed a MT rate of 0.7% which is lower than most other studies, however this may be expected as this study focuses on blunt trauma patients.7-14, 32 Next, the definition of MT is rather controversial and differs between studies.2, 14, 30, 32, 35-36 This study used a combination of the traditional definition and a shorter time frame (≥ 10 units of PRBCs within 24 hours or ≥ 6 units of PRBCs transfused within 4 hours), though an alternative definition may have yielded different results.
Pre-hospital modified shock index for prediction of massive transfusion and mortality in trauma patients
2020, American Journal of Emergency MedicineCitation Excerpt :However, SI and MSI are simple and quick to calculate, so they are well-suited for use in the pre-hospital stage. Previous studies have evaluated the utility of preSI in trauma patients [6,10,12,13,22]. These studies found that preSI was a useful predictor for MT, hospital resource use, mortality, and major hemorrhage.
Pre-hospital shock index correlates with transfusion, resource utilization and mortality; The role of patient first vitals
2019, American Journal of SurgeryWhole Blood in Trauma: A Review for Emergency Clinicians
2019, Journal of Emergency MedicineCitation Excerpt :They include blood pressure, heart rate, and end-tidal carbon dioxide parameters. These are based on previous trials showing that the initial prehospital shock index values of 1.0 and 1.2 were associated with the need for massive transfusion (48,49). Studies also show that low end-tidal carbon dioxide has a strong association with standard indicators for shock and is predictive of patients requiring operative intervention (50,51).
Prediction of massive bleeding in a prehospital setting: validation of six scoring systems
2019, Medicina Intensiva