Shock index and pulse pressure as triggers for massive transfusion

Abstract

BACKGROUND Hemorrhage is the most common cause of preventable death in trauma patients. These mortalities might be prevented with prehospital transfusion. We sought to characterize injured patients requiring massive transfusion to determine the potential impact of a prehospital whole blood transfusion program. The primary goal of this analysis was to determine a method to identify patients at risk of massive transfusion in the prehospital environment. Many of the existing predictive models require laboratory values and/or sonographic evaluation of the patient after arrival at the hospital. Development of an algorithm to predict massive transfusion protocol (MTP) activation could lead to an easy-to-use tool for prehospital personnel to determine when a patient needs blood transfusion. METHODS Using our Level I trauma center's registry, we retrospectively identified all adult trauma patients from January 2015 to August 2017 requiring activation of the MTP. Patients who were younger than 18 years, older than 89 years, prisoners, pregnant women, and/or with nontraumatic hemorrhage were excluded from the study. We retrospectively collected data including demographics, blood utilization, variable outcome data (survival, length of stay, intensive care unit days, ventilator days), prehospital vital signs, prehospital transport times, and Injury Severity Score. The independent-samples t test and χ2 test were used to compare the group who died to the group who survived. p < 0.05 was considered significant. Based on age and mechanism of injury, relative risk of death was calculated. Graphs were generated using Microsoft Excel software to plot patient variables. RESULTS Our study population of 102 MTP patients had an average age of 42 years and average Injury Severity Score of 29, consisted of 80% males (82/102), and was 66% blunt trauma (67/102). The all-cause mortality was 67% (68/102). The positive predictive value of death for patients with pulse pressure of less than 45 and shock index of greater than 1 was 0.78 for all patients, but was 0.79 and 0.92 for blunt injury and elderly patients, respectively. CONCLUSIONS Our data demonstrate a high mortality rate in trauma patients who require MTP despite short transport times, indicating the need for early intervention in the prehospital environment. Given our understanding that the most severely injured patients in hemorrhagic shock require blood resuscitation, this study demonstrates that this subset of trauma patients requiring massive transfusion can be identified in the prehospital setting. We recommend using Emergency Medical Services pulse pressure in combination with shock index to serve as a trigger for initiation of prehospital whole blood transfusion. LEVEL OF EVIDENCE Therapeutic/care management, level V.

Executive Summary 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

“…The 2020 CoSTR for PLS addresses the topic of graded volume resuscitation for infants and children with traumatic haemorrhagic shock as well as management of the child with cardiac arrest after trauma. The ScopRev on graded volume resuscitation identified a single observational study in the prehospital setting assessing the volume of fluid given to children with traumatic injuries, 44 with an additional 4 studies comparing total crystalloid volume given over 24 hours 45 , 46 , 47 , 48 and 1 study evaluating the volume of crystalloids given to children who needed transfusion. 49 The task force agreed that the evidence was sufficient to consider a SysRev in the near future.…”

Pediatric Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

“…Seven retrospective pediatric studies were identified. [41][42][43][44][45][46][47] All were derived from trauma registries. Only 1 study assessed the volume of fluid given to children with traumatic injuries in the prehospital setting.…”

“…For the critical outcome of survival to discharge, 4 studies found no benefit associated with graded/limited volume administration compared with standard care. 41,44,46,47 One study reported lower survival to hospital discharge associated with high-volume crystalloid administration (greater than 60 mL/kg per 24 hours) compared with low-and moderate-volume crystalloid administration (ie, 0-40 mL/kg per 24 hours or 40-60 mL/kg per 24 hours), 42 and 1 reported lower survival rates associated with higher administered crystalloid volumes (ie, greater than 150 mL/kg per 24 hours compared with 150 mL/kg or less per 24 hours) among those receiving massive transfusions. 43 Five studies reported an increased hospital or intensive care length of stay associated with higher crystalloid volume administration in the first 24 hours.…”

Pediatric Life Support

“…For the critical outcome of survival to discharge, 4 studies found no benefit associated with graded/limited volume administration compared with standard care. 41 , 44 , 46 , 47 One study reported lower survival to hospital discharge associated with high-volume crystalloid administration (greater than 60 mL/kg per 24 hours) compared with low- and moderate-volume crystalloid administration (ie, 0–40 mL/kg per 24 hours or 40–60 mL/kg per 24 hours), 42 and 1 reported lower survival rates associated with higher transfusion volumes (ie, greater than 50 mL/kg per 24 hours compared with those receiving 150 mL/kg or less per 24 hours). 43 Five studies reported an increased hospital or intensive care length of stay associated with higher crystalloid volume administration in the first 24 hours.…”

“… 43 Five studies reported an increased hospital or intensive care length of stay associated with higher crystalloid volume administration in the first 24 hours. 42 , 43 , 44 , 46 , 47 All studies were retrospective, and they reported different interventions on differing patient populations and differing associated outcomes. Although it is difficult to compare results, there is a suggestion of a possible advantage of using limited volume resuscitation.…”