Trauma Associated Severe Hemorrhage Score Research Articles

Abstract 373: Traumatic Bleeding Severity Score: An External Validation Study for the Predictive Accuracy of the Need for Massive Transfusion

Background: The Traumatic Bleeding Severity Score (TBSS) was developed to predict the need for massive transfusion (MT). The aim of this study was to conduct the first external validation study about the TBSS in Japan, and to compare its prediction value to other pre-existing MT prediction scores. Methods: A multicenter retrospective observational study was conducted in Japan (Japanese observational study for coagulation and Thrombolysis in Early Trauma 2 : J-OCTET 2). Twenty-five tertiary critical care centers in Japan participated in this study, and severe trauma patients (Injury Severity Score : ISS ≥ 16) admitted from 2018 to 2019 were enrolled. At the analysis of the TBSS external validation, patients with isolated head injuries were excluded from the analysis. In this study, MT was defined as 10 units or more of red blood cells transfusion within 24 hours from injuries. The TBSS on admission was retrospectively calculated and its accuracy in predicting MT was analyzed by the area under the receiver operating characteristic curve (AUROC). To compare the predictive value between the TBSS and the pre-existing scores, the Trauma Associated Severe Hemorrhage score (TASH score) and the Assessment of Blood Consumption score (ABC score) on admission was similarly calculated, and the ROC comparison analysis was performed. Results: Totally, 1202 severely injured trauma patients were enrolled in the J-OCTET 2 study, and 889 patients were analyzed after the matching of the exclusion criteria. The median age was 66 years (IQR: 47-77), 71.4 % was male, 97.9% was blunt trauma, median ISS was 22 (IQR:16-29), and 13.8% received MT. The AUROC of the TBSS for was 0.848 (95% CI:0.81-0.88). According to the ROC comparison, the AUROC of the TASH score was 0.848 (95% CI: 0.81-0.88) and there was no significant difference between both prediction scores. (Bonferroni adjusted p=1.00). The AUROC of the ABC score was 0.751(95% CI: 0.70-0.80), which was significantly lower to TBSS’s (Bonferroni adjusted p<0.01). Conclusion: This TBSS external validation study showed that the accuracy of TBSS in the MT prediction was moderate accuracy. The predictive value of the TBSS was comparable to that of the TASH score and superior to the ABC score.

Early packed red blood cell transfusion in major trauma patients: Evaluation and comparison of different prediction scores for massive transfusion.

Our study sought to evaluate and compare different prediction scores for massive transfusion in-hospital packed red blood cell (PRBC) transfusions. Between January 2013 and December 2018, 1843 trauma patients were enrolled in the registry of a level-1 trauma centre. All prehospital and in-hospital variables needed to calculate the Shock Index and RED FLAG, Assessment of Blood Consumption (ABC) and Trauma Associated Severe Hemorrhage (TASH) scores were prospectively collected in the registry. The primary endpoint was the initiation of transfusion within the first hour of the patient's arrival at the hospital. A total of 1767 patients were included for analysis with a mean age of 43 years (±19) and a mean Injury Severity Score of 15 (±14). The in-hospital TASH score had the highest predictive performance overall (area under the curve [AUC]=0.925, 95% confidence interval [CI] [0.904-0.946]), while the RED FLAG score (AUC=0.881, 95% CI [0.854-0.908]) had the greatest prehospital predictive performance compared to the ABC score (AUC=0.798, 95% CI [0.759-0.837]) and Shock Index (AUC=0.795, 95% CI [0.752-0.837]). Using their standard thresholds, the RED FLAG score was the most efficient in predicting early transfusion (sensitivity: 87%, specificity: 76%, positive predictive value: 25%, negative predictive value: 99%, Youden index: 0.63). The RED FLAG score appears to outperform both the ABC score and the Shock Index in predicting early in-hospital transfusion in trauma patients managed by pre-hospital teams. If adopted, this score could be used to give advance warning to trauma centres or even to initiate early transfusion during pre-hospital care.

Validation of the mTICCS Score as a Useful Tool for the Early Prediction of a Massive Transfusion in Patients with a Traumatic Hemorrhage.

The modified Trauma-Induced Coagulopathy Clinical Score (mTICCS) presents a new scoring system for the early detection of the need for a massive transfusion (MT). While validated in a large trauma cohort, the comparison of mTICCS to established scoring systems is missing. This study therefore validated the ability of six scoring systems to stratify patients at risk for an MT at an early stage after trauma. A dataset of severely injured patients (ISS ≥ 16) derived from the database of a level I trauma center (2010–2015) was used. Scoring systems assessed were Trauma-Associated Severe Hemorrhage (TASH) score, Prince of Wales Hospital (PWH) score, Larson score, Assessment of Blood Consumption (ABC) score, Emergency Transfusion Score (ETS), and mTICCS. Demographics, diagnostic data, mechanism of injury, injury pattern (graded by AIS), and outcome (length of stay, mortality) were analyzed. Scores were calculated, and the area under the receiver operating characteristic curves (AUCs) were evaluated. From the AUCs, the cut-off point with the best relationship of sensitivity-to-specificity was used to recalculate sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV). A total of 479 patients were included; of those, blunt trauma occurred in 92.3% of patients. The mean age of patients was 49 ± 22 years with a mean ISS of 25 ± 29. The overall MT rate was 8.4% (n = 40). The TASH score had the highest overall accuracy as reflected by an AUC of 0.782 followed by the mTICCS (0.776). The ETS was the most sensitive (80%), whereas the TASH score had the highest specificity (82%) and the PWH score had the lowest (51.83%). At a cut-off > 5 points, the mTICCS score showed a sensitivity of 77.5% and a specificity of 74.03%. Compared to sophisticated systems, using a higher number of weighted variables, the newly developed mTICCS presents a useful tool to predict the need for an MT in a prehospital situation. This might accelerate the diagnosis of an MT in emergency situations. However, prospective validations are needed to improve the development process and use of scoring systems in the future.

Systematic reviews of scores and predictors to trigger activation of massive transfusion protocols.

The use of massive transfusion protocols (MTPs) in the resuscitation of hemorrhaging trauma patients ensures rapid delivery of blood products to improve outcomes, where the decision to trigger MTPs early is important. Scores and tools to predict the need for MTP activation have been developed for use to aid with clinical judgment. We performed a systematic review to assess (1) the scores and tools available to predict MTP in trauma patients, (2) their clinical value and diagnostic accuracies, and (3) additional predictors of MTP. MEDLINE, EMBASE, and CENTRAL were searched from inception to June 2017. All studies that utilized scores or predictors of MTP activation in adult (age, ≥18 years) trauma patients were included. Data collection for scores and tools included reported sensitivities and specificities and accuracy as defined by the area under the curve of the receiver operating characteristic. Forty-five articles were eligible for analysis, with 11 validated and four unvalidated scores and tools assessed. Of four scores using clinical assessment, laboratory values, and ultrasound assessment the modified Traumatic Bleeding Severity Score had the best performance. Of those scores, the Trauma Associated Severe Hemorrhage score is most well validated and has higher area under the curve of the receiver operating characteristic than the Assessment of Blood Consumption and Prince of Wales scores. Without laboratory results, the Assessment of Blood Consumption score balances accuracy with ease of use. Without ultrasound use, the Vandromme and Schreiber scores have the highest accuracy and sensitivity respectively. The Shock Index uses clinical assessment only with fair performance. Other clinical variables, laboratory values, and use of point-of-care testing results were identified predictors of MTP activation. The use of scores or tools to predict MTP need to be individualized to hospital resources and skill set to aid clinical judgment. Future studies for triggering nontrauma MTP activations are needed. Systematic review, level III.

The Predictive Role of Red Cell Distribution Width (RDW) in Blood Transfusion in Multiple Trauma

Background: To reduce mortality in patients with multiple-trauma, rapid diagnosis for blood transfusion is of great importance. Objectives: The current study aimed at investigating the predictive role of red cell distribution width (RDW) in comparison with other multivariate systems to determine the need for blood transfusions in patients with trauma referred to hospital. Methods: The follow-up study was conducted on patients with multiple-trauma aged ≥ 18 years with an injury severity score (ISS) ≥ 16 referred to the emergency department within the study period. All patients were evaluated based on the ATLS (the advanced trauma life support) guideline; then, blood samples were taken at arrival and 24 hours later to measure RDW. According to the questionnaire, age, gender, ISS, RTS (the revised trauma score), and TASH (the trauma-associated severe hemorrhage) score were recorded by a senior emergency medicine resident. Results: Finally, 200 patients were enrolled in the study, of which 87 (43.5%) received blood transfusion. In the univariate analysis, there was a significant association between the first-day RDW, ∆ RDW (RDW on arrival - the first-day RDW), ISS, RTS, and TASH score, and blood transfusion. However, in the multivariate analysis, only TASH had a significant relationship with the need for blood transfusion (P < 0.0001). Conclusions: In multiple trauma patients, rapid diagnosis of hemorrhage and the need for blood transfusion is crucial. Monitoring the patients based on the RDW test is not helpful in predicting the need for blood transfusion. Multivariate systems such as TASH score are more valuable in determining the need for blood transfusion.

Evaluation of Prince of Wales Hospital score in predicting massive blood transfusion in trauma

Objective To evaluate the performance of Prince of Wales Hospital score (PWH score) in predicting the need for massive transfusion (MT) and comparing its performance with Assessment of Blood Consumption (ABC) score and the Trauma-associated Severe Hemorrhage (TASH) score. Background Because of the great risk of massive bleeding that may be life-threatening especially if uncontrolled, early prediction of ongoing bleeding and the need for MT reduce mortality of polytraumatized patients. PWH score was developed for the purpose of early prediction of need of MT. Patients and methods This is a prospective comparative study done on 61 polytraumatized patients, with Injury Severity Score more than or equal to 16, who presented to the Emergency Department of Menoufia University Hospital during the period from September 2017 to September 2018. PWH score was applied to assess its performance and comparing it with ABC and TASH scores. Results PWH, TASH, and ABC scores were applied on 61 patients with trauma meeting inclusion criteria to predict the need for MT. The area under the receiver operating characteristics curve was 0.92 for PWH score, 0.96 for TASH score, and 0.72 for ABC score. PWH was better in performance than ABC score, and TASH score was the most accurate and specific. Conclusion The results of this study support that TASH score has greater area under the (receiver operating characteristics) curve than PWH and ABC scores and is more accurate than both of them at cutoff point of more than or equal to 13.5. PWH performs better than ABC score at cutoff point of more than or equal to 4.5 for PWH and cutoff point of more than or equal to 1.5 for ABC score.

Application of a recursive partitioning decision tree algorithm for the prediction of massive transfusion in civilian trauma: the MTPitt prediction tool

A supervised machine learning algorithm was used to generate decision trees for the prediction of massive transfusion at a Level 1 trauma center. Trauma patients who received at least one unit of RBCs and/or low-titer group O whole blood between January 1, 2015, and December 31, 2017, were included. Massive transfusion was defined as the transfusion of 10 or more units of RBCs and/or low-titer group O whole blood in the first 24 hours of admission. A recursive partitioning algorithm was used to generate two decision trees for prediction of massive transfusion using a training data set (n = 550): the first, MTPitt, was based on demographic and clinical parameters, and the second, MTPitt+Labs, also included laboratory data. Decision tree performance was compared with the Assessment of Blood Consumption score and the Trauma Associated Severe Hemorrhage score. The incidence of massive transfusion in the validation data set (n = 199) was 7.5%. The MTPitt decision tree had a higher balanced accuracy (81.4%) and sensitivity (86.7%) compared to an Assessment of Blood Consumption Score of 2 or higher (77.9% and 66.7%, respectively) and a Trauma Associated Severe Hemorrhage score of 9 or higher (75.0% and 73.3%, respectively), although the 95% confidence intervals overlapped. Addition of laboratory data to the MTPitt decision tree (MTPitt+Labs) resulted in a higher specificity and balanced accuracy compared to MTPitt without an increase in sensitivity. The MTPitt decisions trees are highly sensitive tools for identifying patients who received a massive transfusion and do not require computational resources to be implemented in the trauma setting.

Diagnostic performance of prothrombin time point-of-care to detect acute traumatic coagulopathy on admission: experience of 522 cases in trauma center.

Early identification of acute traumatic coagulopathy is a key challenge during initial management to determine whether to initiate early hemostatic support. We assessed the performance of prothrombin time (PT) at point-of-care in trauma patients to detect moderate and severe coagulopathy on admission. All admitted consecutive trauma patients were analyzed retrospectively between April 2014 and July 2015. PT was measured on admission with both a PT point-of-care device (PTr-CGK) and a standard coagulation test (PTr-STD). The results for PTr-CGK and PTr-STD were compared using analysis of agreement, precision, and accuracy. The diagnostic performance of PTr-CGK to predict coagulopathy was established by analysis of receiver operating characteristic curves. The predictive performance of different thresholds and risk factors for misclassification were also studied. Over a 16-month period, 522 patients were included. PTr-CGK estimated PTr-STD with a bias of 0.00 (95% confidence interval [CI], -0.48 to 0.50) and a precision of 0.25. The optimal threshold was 1.4 to predict severe coagulopathy (sensitivity 81% [95% CI, 68%-94%], negative predictive value 98% [95% CI, 97%-99%]), and 1.2 for moderate coagulopathy (sensitivity 80% [95% CI, 72%-88%], negative predictive value 94% [95% CI, 91%-96%]). A low PTr-CGK in the presence of severity criteria (Injury Severity Score ≥ 16, Trauma Associated Severe Hemorrhage score ≥ 12, hemoglobin level<7 g/dL, fibrinogen level<2 g/L, base deficit ≥ 6 mmol/L) was strongly associated with a false-negative risk. The PT point-of-care device is reliable and accurate for the early identification of coagulopathic trauma patients.

Predictive model integrating dynamic parameters for massive blood transfusion in major trauma patients: The Dynamic MBT score

BackgroundCurrently existing predictive models for massive blood transfusion in major trauma patients had limitations for sequential evaluation of patients and lack of dynamic parameters. ObjectiveTo establish a predictive model for predicting the need of massive blood transfusion major trauma patients, integrating dynamic parameters. DesignMulti-center retrospective cohort study. SettingFour designated trauma centers in Hong Kong. MethodsTrauma patients aged >12years were recruited from the trauma registries from 2005 to 2012. MBT was defined as delivery of ≥10units of packed red cells within 24h. Split sampling method was adopted for model building and validation. Multivariate logistic regression was adopted for model building, with weight assigned based on logarithmic of adjusted odds ratios. The performance of the dynamic MBT score (DMBT) was compared with the PWH score and the Trauma Associated Severe Hemorrhage (TASH) score in the validation data set. Results4991 patients were included in the study. The DMBT was established with 8 parameters: systolic blood pressure, heart rate, hemoglobin, hemoglobin drop within the first 2h, INR, base deficit, unstable pelvic fracture and hemoperitoneum in radiological imaging. At cut-off score of 6 the DMBT achieved sensitivity of 78.2% and specificity of 89.2%. In the validation set, the AUCs of the DMBT, PWH score, and TASH score were 0.907, 0.844, and 0.867 respectively. ConclusionsThe DMBT score allows both snapshot and sequential activation along the trauma care pathway and has better performance than the PWH score and TASH score.

Initiation and Termination of Massive Transfusion Protocols: Current Strategies and Future Prospects.

The advent of massive transfusion protocols (MTP) has had a significant positive impact on hemorrhaging trauma patient morbidity and mortality. Nevertheless, societal MTP guidelines and individual MTPs at academic institutions continue to circulate opposing recommendations on topics critical to MTPs. This narrative review discusses up-to-date information on 2 such topics, the initiation and termination of an MTP. The discussion for each begins with a review of the recommendations and supporting literature presented by MTP guidelines from 3 prominent societies, the American Society of Anesthesiologists, the American College of Surgeons, and the task force for Advanced Bleeding Care in Trauma. This is followed by an in-depth analysis of the main components within those recommendations. Societal recommendations on MTP initiation in hemorrhaging trauma patients emphasize the use of retrospectively validated massive transfusion (MT) prediction score, specifically, the Assessment of Blood Consumption and Trauma-Associated Severe Hemorrhage scores. Validation studies have shown that both scoring systems perform similarly. Both scores reliably identify patients that will not require an MT, while simultaneously overpredicting MT requirements. However, each scoring system has its unique advantages and disadvantages, and this review discusses how specific aspects of each scoring system can affect widespread applicability and statistical performance. In addition, we discuss the often overlooked topic of initiating MT in nontrauma patients and the specific tools physicians have to guide the MT initiation decision in this unique setting. Despite the serious complications that can arise with transfusion of large volumes of blood products, there is considerably less research pertinent to the topic of MTP termination. Societal recommendations on MTP termination emphasize applying clinical reasoning to identify patients who have bleeding source control and are adequately resuscitated. This review, however, focuses primarily on the recommendations presented by the Advanced Bleeding Care in Trauma's MTP guidelines that call for prompt termination of the algorithm-guided model of resuscitation and rapidly transitioning into a resuscitation model guided by laboratory test results. We also discuss the evidence in support of laboratory result-guided resuscitation and how recent literature on viscoelastic hemostatic assays, although limited, highlights the potential to achieve additional benefits from this method of resuscitation.

Viscoelastic Tissue Plasminogen Activator Challenge Predicts Massive Transfusion in 15 Minutes

Coagulopathy is associated with massive transfusion in trauma, yet most clinical scores to predict this end point do not incorporate coagulation assays. Previous work has identified that shock increases circulating tissue plasminogen activator (tPA). When tPA levels saturate endogenous inhibitors, systemic hyperfibrinolysis can occur. Therefore, the addition of tPA to a patient's blood sample could stratify a patients underlying degree of shock and early coagulation changes to predict progression to massive transfusion. We hypothesized that a modified thrombelastography (TEG) assay with exogenous tPA would unmask patients' impending risk for massive transfusion. Trauma activations were analyzed using rapid TEG and a modified TEG assay with a low and high dose of tPA. Clinical scores (shock index, assessment of blood consumption, and trauma-associated severe hemorrhage) were compared with TEG measurements to predict the need for massive transfusion using areas under the receiver operating characteristic curves. Three hundred and twenty-four patients were analyzed, 17% required massive transfusion. Massive transfusion patients had a median shock index of 1.2, assessment of blood consumption score of 1, and trauma-associated severe hemorrhage score of 12. Rapid TEG and tPA TEG parameters were significantly different in all massive transfusion patients compared with non-massive transfusion patients (all p < 0.02). The low-dose tPA lysis at 30 minutes had the largest the area under the receiver operating characteristic curve (0.86; 95% CI 0.79 to 0.93) for prediction of massive transfusion, similar to international normalized ratio of prothrombin time of 0.86 (95% CI 0.81 to 0.91), followed by trauma-associated severe hemorrhage score (0.83; 95% CI 0.77 to 0.89). Combing trauma-associated severe hemorrhage and tPA-TEG variables results in a positive prediction of massive transfusion in 49% of patients with a 98% negative predictive value. The tPA-TEG identifies trauma patients who require massive transfusion efficiently in a single assay that can be completed in a shorter time than other scoring systems, which has improved performance when combined with international normalized ratio. This new method is consistent with our understanding of the molecular events responsible for trauma-induced coagulopathy.

Relationship between Obesity and Massive Transfusion Needs in Trauma Patients, and Validation of TASH Score in Obese Population: A Retrospective Study on 910 Trauma Patients.

BackgroundPrediction of massive transfusion (MT) is challenging in management of trauma patients. However, MT and its prediction were poorly studied in obese patients. The main objective was to assess the relationship between obesity and MT needs in trauma patients. The secondary objectives were to validate the Trauma Associated Severe Hemorrhage (TASH) score in predicting MT in obese patients and to use a grey zone approach to optimize its ability to predict MT.Methods and FindingsAn observational retrospective study was conducted in a Level I Regional Trauma Center Trauma in obese and non-obese patients. MT was defined as ≥10U of packed red blood cells in the first 24h and obesity as a BMI≥30kg/m². Between January 2008 and December 2012, 119 obese and 791 non-obese trauma patients were included. The rate of MT was 10% (94/910) in the whole population. The MT rate tended to be higher in obese patients than in non-obese patients: 15% (18/119, 95%CI 9‒23%) versus 10% (76/791, 95%CI 8‒12%), OR, 1.68 [95%CI 0.97‒2.92], p = 0.07. After adjusting for Injury Severity Score (ISS), obesity was significantly associated with MT rate (OR, 1.79[95%CI 1.00‒3.21], p = 0.049). The TASH score was higher in the obese group than in the non-obese group: 7(4–11) versus 5(2–10)(p<0.001). The area under the ROC curves of the TASH score in predicting MT was very high and comparable between the obese and non-obese groups: 0.93 (95%CI, 0.89‒0.98) and 0.94 (95%CI, 0.92‒0.96), respectively (p = 0.80). The grey zone ranged respectively from 10 to 13 and from 9 to 12 in obese and non obese patients, and allowed separating patients at low, intermediate or high risk of MT using the TASH score.ConclusionsObesity was associated with a higher rate of MT in trauma patients. The predictive performance of the TASH score and the grey zones were robust and comparable between obese and non-obese patients.

Modified traumatic bleeding severity score: early determination of the need for massive transfusion

BackgroundDetermination of the need for massive transfusion (MT) is essential for early activation of a MT protocol. The Traumatic Bleeding Severity Score (TBSS) predicts the need for MT accurately, but takes time to determine because systolic blood pressure after a 1000mL of crystalloid infusion is used. The aim of this study is to determine the how well the Modified TBSS (age, sonography, pelvic fracture, serum lactate and systolic blood pressure on arrival) predicts the need for MT (accuracy). MethodsThis is a single-center retrospective study of trauma patients (Injury Severity Score ≧16) admitted between 2010 and 2014. The TBSS, the Trauma Associated Severe Hemorrhage (TASH) Score, and the Modified TBSS were calculated. MT is defined as ≧10 U packed red blood cell transfusion within 24hours of injury, and the predictive value of the need for MT was compared by area under the receiver operating characteristic curve (AUC) analysis among three scores. ResultsThree hundred patients were enrolled, and MT given to 25% of patients. Although the AUC of the TBSS was higher than that of the TASH score (0.956 vs 0.912, P=.006) and the Modified TBSS (0.956 vs 0.915, P=.001), there was no difference between the AUC of the Modified TBSS and the TASH score. The Modified TBSS has high accuracy, within an AUC >0.9. ConclusionThe predictive value of the Modified TBSS of the need for MT is still high and is equivalent to the TASH score. The Modified TBSS is calculated earlier in resuscitation than the original TBSS.

Fibrinogen and base excess levels as predictive markers of the need for massive blood transfusion after blunt trauma.

BackgroundAssessment blood consumption and trauma-associated severe hemorrhage scores are useful for predicting the need for massive transfusion (MT) in severe trauma patients. However, fibrinogen (Fbg) and base excess (BE) levels might also be useful indicators for the need for MT. We evaluated the accuracy of prediction for MT of the scoring system vs. Fbg and BE.MethodsThe subjects of this retrospective single center observational study were patients with injury severity score ≥16 trauma, divided into a non-MT group and an MT group. We compared variables, including the scoring system (comprising vital signs and focused assessment with sonography for trauma; FAST) and Fbg between the groups. We then performed a multiple logistic regression modeling and a receiver operating characteristic analysis to clarify which value was the most useful predictive indicator for MT.ResultsThere were 114 patients in the non-MT group and 39 in the MT group. The level of Fbg and BE were independent predictors of MT. The area under the curve values for Fbg and BE were 0.765 and 0.845, respectively, and the optimal cutoff values of Fbg and BE were 211 mg/dL and −1.4, respectively.ConclusionsFbg and BE levels can be used as an independent predictor for MT.

Abstract 344: Massive Transfusion Prediction Scores Can Also Predict Early Traumatic Coagulopathy

BACK GROUND: The aggressive administration of plasma has been recommended for the improvement of traumatic coagulopathy. The survival benefit has been found in trauma resuscitation with rich plasma, and this benefit seems to be related to early use of this blood product. However, to our knowledge, no method for the recognition or prediction of traumatic cougulopathy at the point of a patient’s arrival has been established. The aim of this study was to test the predictive value of massive transfusion prediction scores for early traumatic coagulopathy. METHOD: We reviewed records of severe trauma patients admitted to our center from Jan. 2008 to Mar. 2014, whose Injury Severity Score was 16 or more. Traumatic Bleeding Severity Score (TBSS), Trauma Associated Severe Hemorrhage Score (TASH Score), and Assessment of Blood Consumption Score (ABC Score) were calculated. Early traumatic coagulopathy was defined as 150mg/dl or less of fibrinogen and 1.5 or more of PT-INR within 6 hours from injury, although transfusion and crystalloid infusion was provider dependent. Cardiopulmonary arrest patients on arrival and simple head or spine trauma patients were excluded. Each predictive value for early traumatic coagilopathy was tested by area under the receiver operating characteristic curve (AUC). Receiver operating characteristic curve comparison was performed to compare the accuracy between TBSS, TASH Score, and ABC Score. Each spearman’s rank correlation coefficient for the amount of fresh frozen plasma transfused within 24 hours form injury was checked. RESULT: 388 patients were enrolled in this study. The AUC of TBSS (0.927) was significantly higher than that of TASH Score (0.856) or ABC Score (0.726) (both Bonferoni adjusted p&lt;0.01). Each Spearman’s rank correlation coefficient for the amount of fresh frozen plasma was 0.732 (TBSS, p&lt;0.01), 0.658 (TASH Score, p&lt;0.01), and 0.471 (ABC Score, p&lt;0.01). Conclusion: Massive transfusion prediction scores can also predict the early traumatic coagulopathy. TBSS had the highest predictive value and strong correlation between the score and the needed plasma. The calculation of TBSS is simple. Therefore, TBSS will rapidly predict the need for rich plasma transfusion.

Predicting the need for massive transfusion in trauma patients: the Traumatic Bleeding Severity Score.

The ability to easily predict the need for massive transfusion may improve the process of care, allowing early mobilization of resources. There are currently no clear criteria to activate massive transfusion in severely injured trauma patients. The aims of this study were to create a scoring system to predict the need for massive transfusion and then to validate this scoring system. We reviewed the records of 119 severely injured trauma patients and identified massive transfusion predictors using statistical methods. Each predictor was converted into a simple score based on the odds ratio in a multivariate logistic regression analysis. The Traumatic Bleeding Severity Score (TBSS) was defined as the sum of the component scores. The predictive value of the TBSS for massive transfusion was then validated, using data from 113 severely injured trauma patients. Receiver operating characteristic curve analysis was performed to compare the results of TBSS with the Trauma-Associated Severe Hemorrhage score and the Assessment of Blood Consumption score. In the development phase, five predictors of massive transfusion were identified, including age, systolic blood pressure, the Focused Assessment with Sonography for Trauma scan, severity of pelvic fracture, and lactate level. The maximum TBSS is 57 points. In the validation study, the average TBSS in patients who received massive transfusion was significantly greater (24.2 [6.7]) than the score of patients who did not (6.2 [4.7]) (p < 0.01). The area under the receiver operating characteristic curve, sensitivity, and specificity for a TBSS greater than 15 points was 0.985 (significantly higher than the other scoring systems evaluated at 0.892 and 0.813, respectively), 97.4%, and 96.2%, respectively. The TBSS is simple to calculate using an available iOS application and is accurate in predicting the need for massive transfusion. Additional multicenter studies are needed to further validate this scoring system and further assess its utility. Prognostic study, level III.

Assessing the Efficiency of Scoring System for Predicting the Probability of Massive Transfusion in Trauma Patients

Background: Management of hemorrhage plays a critical role in acute trauma care, owing to its significant association with morbidity and mortality in severely injured patients. We aimed at comparing the accuracy of three prediction models Trauma Associated Severe Hemorrhage (TASH) score, Assessment of Blood Consumption (ABC) score and Emergency Transfusion Score (ETS) for early estimation of the probability of massive transfusion, and its prognostic significance following trauma. Methods and Materials: retrospective analysis all cases of trauma, who required transfusion of >3 units of packed red blood cells (PRBC) was conducted for the duration of six months. Massive transfusion was defined as transfusion of >10 units of packed red blood cells within 24 hours. Correlation of all scoring systems with the probability of mass transfusion, severity of injury and in hospital mortality was done. Area under receiver operating characteristic (AUROC) Curve used to compare the scoring systems. Sensitivity, specificity, positive and negative predictive values were calculated for different prediction models. Results: 13.7% of the patients included in the study received massive transfusion. The accuracy was the highest for TASH score (57.1%) followed by ETS score (22.8%) and ABC score (13.1%). Statistically significant association was observed between TASH score and PRBC units transfused (p 0.003). 87 patients died within the duration of this study, association of lower ETS score with in hospital mortality was fund to be statistically significant Conclusion: TASH score predicts the individual’s risk for massive transfusion at a very early stage following severe injury. The scoring system may indicate risk and impact trauma care management strategies to stop bleeding and stabilize coagulation.

Defining the need for a massive transfusion in severe blunt traumatic patients

We do not have enough criteria to make a judgment of the need for a massive transfusion (MT) in severe blunt traumatic patients. As a scoring system to predict the need for a MT, we usually use the Assessment Blood Consumption score (ABCs) and/or the Trauma-Associated Severe Hemorrhage score (TASHs). However, for these scoring systems, the procedure is slightly complicated. The aim of this study was to establish a predictor of a MT using coagulation or fibrinolysis markers.

Abstract 336: The Novel and Useful Scoring System to Predit Massive Transfusion for Trauma Patients: Traumatic Bleeding Severity Score (TBSS)

Background: There is no clear criterion to activate massive transfusion (MT) for trauma patients. Several studies showed that Trauma Associated Severe Hemorrhage (TASH) score and Assessment of Blood Consumption (ABC) Score were high accuracy in predicting the necessity of MT for trauma patients. However, some study showed that the accuracy of these scoring systems for elderly patients was not perfect. In japan, since the population is aging and the number of elderly trauma patient increases, these scoring systems are not useful so much. The aim of this study was to create new scoring system and predict the necessity of MT for trauma patients using it. Methods: In the first analysis, new scoring system was created. We enrolled 119 severe trauma patients admitted to our center between January 2008 and December 2010. MT predictors were found by statistical methods from clinical and laboratory variables in the Primary Survey. Each MT predictor was converted into the simple score based on each odds ratio in multivariate logistic regression analysis. TBSS was defined as the total of each score. In the second analysis, the accuracy of TBSS was tested. 114 patients admitted between January 2010 and March 2012 were examined. Receiver operating characteristic curve analysis were performed to compare the accuracy between TBSS and conventional scoring systems (TASH Score and ABC Score). Results: In the first analysis, five preditors of MT were identified: age (&gt; 60 year-old = 6pts), systolic blood pressure (&lt; 110 mmHg = 4pts, &lt; 100 mmHg = 8pts, &lt; 90 mmHg = 12pts), positive focused assessment with sonography for trauma (FAST) ( [the number of regions with positive FAST] × 3pts), severity of pelvic fracture (stable fracture = 3pts, incomplete unstable fracture = 6pts, complete unstable fracture = 9pts), and lactate (&gt; 2.5 mmol/L = 4pts, &gt; 5.0 mmol/L = 8pts, &gt; 7.5 mmol/L = 12pts). In the second analysis, TBSS excellently predicted MT (area under the curve (AUC) =0.985, p&lt;0.01). The AUC of TBSS was higher than that of TASH Score (AUC=0.887) and ABC Score (AUC=0.809) (both Bonferoni adjusted p&lt;0.05). Conclusion: TBSS based on the Primary Survey is high accuracy in predicting the necessity of MT. TBSS provide more useful information to predict MT compared with TASH Score and ABC Score.

Predicting on-going hemorrhage and transfusion requirement after severe trauma: a validation of six scoring systems and algorithms on the TraumaRegister DGU®

IntroductionThe early aggressive management of the acute coagulopathy of trauma may improve survival in the trauma population. However, the timely identification of lethal exsanguination remains challenging. This study validated six scoring systems and algorithms to stratify patients for the risk of massive transfusion (MT) at a very early stage after trauma on one single dataset of severely injured patients derived from the TR-DGU (TraumaRegister DGU® of the German Trauma Society (DGU)) database.MethodsRetrospective internal and external validation of six scoring systems and algorithms (four civilian and two military systems) to predict the risk of massive transfusion at a very early stage after trauma on one single dataset of severely injured patients derived from the TraumaRegister DGU® database (2002-2010). Scoring systems and algorithms assessed were: TASH (Trauma-Associated Severe Hemorrhage) score, PWH (Prince of Wales Hospital/Rainer) score, Vandromme score, ABC (Assessment of Blood Consumption/Nunez) score, Schreiber score and Larsen score. Data from 56,573 patients were screened to extract one complete dataset matching all variables needed to calculate all systems assessed in this study. Scores were applied and area-under-the-receiver-operating-characteristic curves (AUCs) were calculated. From the AUC curves the cut-off with the best relation of sensitivity-to-specificity was used to recalculate sensitivity, specificity, positive predictive values (PPV), and negative predictive values (NPV).ResultsA total of 5,147 patients with blunt trauma (95%) was extracted from the TR-DGU. The mean age of patients was 45.7 ± 19.3 years with a mean ISS of 24.3 ± 13.2. The overall MT rate was 5.6% (n = 289). 95% (n = 4,889) patients had sustained a blunt trauma. The TASH score had the highest overall accuracy as reflected by an AUC of 0.889 followed by the PWH-Score (0.860). At the defined cut-off values for each score the highest sensitivity was observed for the Schreiber score (85.8%) but also the lowest specificity (61.7%). The TASH score at a cut-off ≥ 8.5 showed a sensitivity of 84.4% and also a high specificity (78.4%). The PWH score had a lower sensitivity (80.6%) with comparable specificity. The Larson score showed the lowest sensitivity (70.9%) at a specificity of 80.4%.ConclusionsWeighted and more sophisticated systems such as TASH and PWH scores including higher numbers of variables perform superior over simple non-weighted models. Prospective validations are needed to improve the development process and use of scoring systems in the future.