Elsevier

Injury

Volume 48, Issue 5, May 2017, Pages 1006-1012
Injury

Early predictors for massive transfusion in older adult severe trauma patients

https://doi.org/10.1016/j.injury.2016.12.028Get rights and content

Abstract

Background

Many scoring systems for the early prediction of the need for massive transfusion (MT) have been reported; in most of these, vital signs are regarded as important. However, the validity of these scoring systems in older patients remains unclear because older trauma patients often present with normal vital signs. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.

Methods

We prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16 years) admitted from January 2007 to March 2015. Trauma Associated Severe Hemorrhage (TASH), Assessment of Blood Consumption (ABC), and Prince of Wales Hospital (PWH) scores were compared between a younger and an older group. Furthermore, the predictors associated with MT in older severe trauma patients were assessed using multivariable logistic regression analyses.

Results

The area under the curve (AUC) was significantly smaller for older group than for younger group for all three scoring systems (p < 0.05). The most important risk factors to predict the need for MT were related to anatomical factors including FAST results (odds ratio (OR): 5.58, 95% confidence interval (CI): 2.10–14.99), unstable pelvic fracture (OR: 21.56, 95% CI: 6.05–90.78), and long bone open fracture of the lower limbs (OR: 12.21, 95% CI: 4.04–39.09), along with pre-injury anticoagulant agent use (OR: 5.22, 95% CI: 1.30–19.61), antiplatelet agent use (OR: 3.81, 95% CI: 1.57–9.04), lactate levels (OR: 1.20, 95% CI: 1.04–1.39) and shock index (OR: 2.67, 95% CI: 1.05–6.84). Traditional vital signs were not early risk factors.

Conclusion

We suggest that MT in older trauma patients should be considered on the basis of anatomical factors, pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.

Introduction

In recent years, the size of the older adult population and life expectancy have both increased in most developed countries [1]. In Japan, 33.1% of the population was over 60 years of age in 2015, and the percentage is projected to reach 42.5% by 2050 [2]. The percentage of older persons assessed in trauma fatalities has also been increasing annually. From 2009 to 2013, 50.1% of fatalities resulting from trauma occurred among individuals ≥65 years of age [3]. As a result of these changes, the number of older severe trauma patients is increasing in emergency departments.

Older patients are reported to have higher mortality resulting from trauma than younger patients because of physiological differences related to declining baseline functions [4], [5], [6], [7].

Therefore, early aggressive resuscitation and careful monitoring may be warranted in older severe trauma patients [8], [9], [10].

Several scoring systems for the early prediction of the need for massive transfusion (MT) have been reported [11], [12], [13], with most systems scoring vital signs or blood test results. However, older severe trauma patients often present with normal vital signs because of physiological differences compared with younger patients [14], and are frequently under-triaged [15], [16], [17]. Therefore, the validity of these scoring systems in older patients remains unclear. In this study, we investigated the effectiveness of previously described scoring systems, as well as risk factors that can provide early prediction of the need for MT in older severe trauma patients.

Section snippets

Study design and patient selection

We prospectively collected data from a cohort of severe trauma patients (ISS ≥16 and age ≥16 years) admitted to the Kochi Health Sciences Center from January 2007 to March 2015. The objective of this study was to validate previously described scoring systems and to determine the early risk factors for MT in older severe trauma patients. Exclusion criteria were isolated head injury, which has minimal influence on massive haemorrhage; dead on arrival; and missing data.

Setting

Kochi Health Sciences Center

Baseline characteristics

During the 8-year, 3-month study period, 1259 severe trauma patients were enrolled in a large observational trial, and 714 patients met the sub-study inclusion criteria for this analysis. The younger group included 334 patients (47%); the older group included 380 patients (53%) (Fig. 1). In the older group, 57 patients (15%) were taking anticoagulants or antiplatelet agents before injury. There were significant differences in sex, pre-injury anticoagulant or antiplatelet agent use, mechanism of

Discussion

This study compared the scores of older and younger severe trauma patients from three scoring systems based on findings at admission; scores for all three systems were less accurate in older patients than in younger patients. Several studies have evaluated the effectiveness of MT scoring systems [25], [26], [27]; however, to the best of our knowledge, ours is the first study to compare MT scoring systems according to patient age. TASH, ABC, and PWH scores rely on SBP and HR, which are

Conclusions

We suggest that MT in older trauma patients should be considered on the basis of anatomical factors (such as FAST results, unstable pelvic fracture, and long bone open fracture of the lower limbs), pre-injury anticoagulant or antiplatelet agent use, lactate level and SI even if traditional vital signs are normal.

Conflict of interest statement

The authors have no conflicts of interest to declare.

Acknowledgement

We thank the support with data provided by Ms Sachi Motomura in the Kochi Health Sciences Center.

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