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