Trauma Associated Severe Hemorrhage (TASH)-Score:Probability of Mass Transfusion as Surrogate for Life Threatening Hemorrhage after Multiple TraumaThe Journal of TRAUMA Intern 洪毓棋
Background • Combined surgical & coagulopathic bleeding are common in multiple trauma and early in-hospital mortality • Trauma induced surgical bleeds • Acute trauma coagulopathy • Emergency measures may augment coagulation disorders • Hemodilution of coagulation factors, reduction of platelet number, hypothermia, acidosis
Background • CT, angiography, lab. are difficult. • Time consuming • Not available at all in some smaller facilities • TASH score • easily and quickly (15 minutes upon ER arrival) • identify patients with high risk for MT after trauma • taken as a surrogate for severe bleeding • strategies to stop bleeding and stabilize coagulation in acute trauma care.
Materials and methods • Data of the German Trauma Registry • Clinical and laboratory variables • Univareate and multivariate logistic regression analysis • MT: administration of 10 units of packed red blood cells (pRBC) between ER and intensive care unit (ICU) admission • Initial resuscitation period: average (median) time: 3.8(3.2) hours
German trauma registry • Patients suffering from severe trauma and thus requiring intensive care • Clinical and lab Data: GCS, ISS, AIS… • 1993-2003: 17200 patients from 100 hospitals
Selection of variables • Prediction • age, sex, systolic blood pressure (SBP) • heart rate (HR), hemoglobin (Hb), platelets, lactate, base excess (BE) • severity of injury (ISS and New ISS) • pattern of injury (maximum AIS for different body regions, i.e. head, thorax, abdomen, extremities). • Logistic regression on 1810 P’t • sex (male), SBP, HR, Hb, BE, relevant injuries to the abdomen and extremities (AIS ≧3).
Discussion • Problems • Time consuming CT, lab. • The quality of prediction to validation set was high. • A TASH-Score of 16 predicts an individual probability for MT of 50% corresponding to an obtained rate for MT of 45% after severe trauma. • Data • Not represent a research base and were not collected specifically to address a given issue • Reflect data that are routinely available from the clinical setting • Missing values for potentially variables cannot be avoided
Discussion • Potentiallly important variables but not included • Temperature, PH not routinely • Lactate: lower coefficient for BE • Injury severity to head and thorax, age, platelets: deficits in early availability or low predictive power • PT, PTT: high correlation with MT but not available within our predefined time window (15 mins after ER admission)
Discussion • Severity of trauma to abd. and extremities • Could only be included indirectly • Abdomen: • AIS criteria based on imaging (time consuming or not available in smaller facilities) • Free intra-abd. fluid on FAST is associated with a relevant abd. injury (AIS ≧3)(not 100% but sufficient) • Extrem.: • Long bone fractures are easily assessed • Instability of the pelvic ring is sensitive for pelvic fracture (96%)
Discussion • An experienced physician may better predict the individual’s risk for MT than a formal score • All variables are easily obtained not only in advanced trauma centers • Available within the first 15 mins upon ER arrival maximum • Decision making • Early operative intervention in surgical bleeding • Early and effective coagulation management • Reminder of ongoing bleeding and increase risk
Editorial comment • Exclude 2/3 of available patients because of missing date, most BE • highly correlates with injury severity, hemorrhage, outcome • Bias toward the most severely injured patients that might inflatethe accuracy. • 3.8 hours from ER to ICU is extremely long • Increase hemorrhage and enhance the formula’s accuracy, but defeat its real purpose • Hypothermia, acidosis, coagulopathy are not included. • Uncontrollable bleeding • Reminder of small hospitals lack resources, better off transferring patients to larger center (not need such reminders) • Most valuable in research
Lets get on with the treatment Thanks for your attention