The emergency room transfusion score (ETS): prediction of blood transfusion requirement in initial resuscitation after severe trauma

Abstract

The presented study was initiated to develop a scoring system for the prediction of red blood cell transfusion requirement in the early care of trauma patients. All trauma patients admitted to our institution who needed trauma team activation were evaluated during a 4-year period. A set of nine parameters with possible predictive value for the need of blood transfusion was recorded. All relevant data can be acquired during the first 10 min in the emergency room (ER). The data underwent multivariate logistic regression analysis for correlation and the calculation of predictive power. To transform the model into a practical score, we rounded all coefficients. The predictive power of the score was evaluated based on a linear regression equation. Of the 1103 patients (Injury Severity Score [ISS] 21 +/- 16) included in the study, 116 (10.5%; ISS 39 +/- 18) received blood in the ER. Early transfusion need was significantly correlated with systolic blood pressure (SBP) <90 mmHg (coefficient 2.5), SBP 90-120 mmHg (1.5), free fluid in abdominal ultrasound (2.0), clinically unstable pelvic ring fracture (1.5), age 20-60 years (0.5), age >60 years (1.5), admission from scene (1.0), traffic accident (1.0) and fall from >3 m (1.0). The probability for transfusion exponentially increased with the sum of points in the ER transfusion score, i.e. from 0.7% at one point to 5% at three points and 97% at 9.5 points maximum. To establish a practical cutoff point (risk <5%) a low-risk group was defined at <points (64% of the whole study group). The presented ER transfusion score is based on rapidly assessable parameters. The score identifies patients in need for immediate red blood cell substitution. Cost effectiveness appears to be a further advantage of the score. For patients not in need of urgent transfusion (low-risk group), the costs for transportation, cross-matching and loss by maltreatment of blood products may be avoided.

Uncrossmatched blood transfusions for trauma patients in the emergency department: incidence, outcomes and recommendations

“…10,17 The overall mortality rate of patients requiring URBC products in the ED was 45%. This is similar to a rate of 48% among 116 patients with blunt injuries receiving URBC products, 13 but is substantially higher than the 26% observed in these authors' follow-up study.…”

“…This risk has been reported to be as high as 64%. [13][14][15][16] More specifically, risks of transfusion include hemolysis, transfusion -associated lung injury, infection, immunosuppression (i.e., transfusion related immunomodulation), systemic inflammatory response syndrome 17,18 and death. 19,20 Although the value of early plasma, platelet, cryoprecipi tate and factor VIIa administration to combat the 24%-38% of injured patients who present with coagulopathies is becoming clear, [5][6][7][8][9][10][11][12] these products are rarely stored in a readily usable form within the ED.…”

“…This is far removed from the 64% overtransfusion rate noted in a study using a scoring system (employing age, admission, mechanism, blood pressure, abdominal ultrasonography and clinical pelvic stability) to determine the necessity of ED transfusion. 13 Although this group successfully used their formula to reduce overtransfusion and generate an economic savings in patients with blunt trauma, 14 it appears that our clinicians are not overadministering emergent URBC products in the ED.…”

The pathogenesis of traumatic coagulopathy

“…Algorithms based on these scores shift clinical management from a reactive to a proactive stance [66][67][68][69][70][71]. Unfortunately, none of these scoring systems identify all patients at risk of ATC and death due to bleeding.…”

Utilisation of Blood Components in Trauma Surgery: A Single-Centre, Retrospective Analysis before and after the Implementation of an Educative PBM Initiative

“…Only a minor subset of these patients requires blood components. To predict transfusion requirements in those seriously injured patients, an emergency transfusion score comprising three different clinical risk groups was implemented [4,5]. …”