Trauma Associated Severe Hemorrhage (TASH)
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Transcript Trauma Associated Severe Hemorrhage (TASH)
Trauma Associated Severe Hemorrhage
(TASH)-Score:
Probability of Mass Transfusion as Surrogate
for Life Threatening Hemorrhage
after Multiple Trauma
The 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