Analysis of risk classification for massive transfusion in severe trauma using the gray zone approach☆☆☆★
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Fig. 1
The Traumatic Bleeding Severity Score. Abbreviations: SBP, systolic blood pressure (after rapid infusion of 1000-mL crystalloid); FAST, Focused Assessment with Sonography for Trauma; AO, Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association classification.
Fig. 2
Study flowchart. 
Of these 264 patients, data for 113 of these patients were included in the original TBSS validation study, admitted from January 2010 to March 2012.
Fig. 3
The receiver operating characteristic curve of the TBSS and TASH scores for MT. The AUC of TBSS for MT is 0.967, significantly higher than that of the TASH Score (0.889; P < .01).
Fig. 4
Risk classification for MT and definition of the gray zone, based on the TBSS.
Fig. 5
A clinical decision rule to guide activation of an MT protocol in the care of injured patients.
Abstract
Background
The Traumatic Bleeding Severity Score (TBSS) was developed to predict the need for massive transfusion (MT). The aim of this study is evaluation of clinical thresholds for activation of a MT protocol using the gray zone approach based on TBSS.
Methods
This is a single-center retrospective study of trauma patients, admitted from 2010 to 2013. The TBSS on admission was calculated, and the accuracy of predicting MT was analyzed using area under the receiver operating characteristic curve. Risk classification for MT was made using sensitivity/specificity. The gray zone (indeterminate risk) was defined from a sensitivity of 95% to a specificity of 95%, patients were separated into MT and non-MT groups, and their clinical characteristics were compared.
Results
A total of 264 patients were enrolled, with an area under the TBSS curve of 0.967 (95% confidence interval, 0.94-0.99). A TBSS of 10 points or less resulted in a sensitivity of 96.5% with 146 patients in this group, and 3.4% (5/146) of them received MT. A TBSS of 17 points or higher had a specificity of 97.8%, which included 72 patients, and 94.4% (68/72) of them received MT. Forty-six patients had a TBSS from 11 to 16 points (gray zone), and 26.1% (12/46) of them received MT. Comparing the MT group (12/46) and non-MT group (34/46), coagulopathy and extravasation on computed tomographic scan were more prevalent in the MT group.
Conclusion
The TBSS is highly accurate in predicting the need for MT, and a risk classification for needing MT was created based on TBSS.
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☆Source of support: This work received no financial support.
☆☆Conflicts of interest: All authors report no conflicts of interest.
★Previous presentations: American Heart Association Resuscitation Science Symposium 2013, Dallas, TX, USA.
