1. 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

2. 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

3. 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.

4. 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

5. 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

6. 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).

13. 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

14. 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)

15. 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%)

16. 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

17. 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

18. Lets get on with the treatment Thanks for your attention