Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome
Background Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how a...
| Main Authors: | , , , , , , , , |
|---|---|
| Format: | Article |
| Language: | English |
| Published: |
BMJ Publishing Group
2024-11-01
|
| Series: | Trauma Surgery & Acute Care Open |
| Online Access: | https://tsaco.bmj.com/content/9/1/e001214.full |
| _version_ | 1826891745077493760 |
|---|---|
| author | Nigel R M Tai Evangelia Kyrimi Jared M Wohlgemut Zane B Perkins William Marsh Michael Christian Erhan Pisirir Rebecca S Stoner Thomas Hurst |
| author_facet | Nigel R M Tai Evangelia Kyrimi Jared M Wohlgemut Zane B Perkins William Marsh Michael Christian Erhan Pisirir Rebecca S Stoner Thomas Hurst |
| author_sort | Nigel R M Tai |
| collection | DOAJ |
| description | Background Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality.Methods Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019–2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality.Results Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC.Conclusion Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted.Level of evidence Level III—Retrospective study with up to two negative criteria.Study type Original research; diagnostic accuracy study. |
| first_indexed | 2024-03-08T14:27:13Z |
| format | Article |
| id | doaj.art-7ecd0e1f975e41d0befd16ae9f0ae924 |
| institution | Directory Open Access Journal |
| issn | 2397-5776 |
| language | English |
| last_indexed | 2025-02-17T04:07:44Z |
| publishDate | 2024-11-01 |
| publisher | BMJ Publishing Group |
| record_format | Article |
| series | Trauma Surgery & Acute Care Open |
| spelling | doaj.art-7ecd0e1f975e41d0befd16ae9f0ae9242025-01-09T19:15:10ZengBMJ Publishing GroupTrauma Surgery & Acute Care Open2397-57762024-11-019110.1136/tsaco-2023-001214Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcomeNigel R M Tai0Evangelia Kyrimi1Jared M Wohlgemut2Zane B Perkins3William Marsh4Michael Christian5Erhan Pisirir6Rebecca S Stoner7Thomas Hurst8Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UKSchool of Electronic Engineering and Computer Science, Queen Mary University of London, London, UKSchool of Medicine, Medical Sciences and Nutrition, University of Aberdeen Division of Applied Health Sciences, Aberdeen, UKCentre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UKSchool of Electronic Engineering and Computer Science, Queen Mary University of London, London, UKLondon’s Air Ambulance, London, UKSchool of Electronic Engineering and Computer Science, Queen Mary University of London, London, UKCentre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UKLondon’s Air Ambulance, London, UKBackground Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality.Methods Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019–2020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of ≥3 U of red blood cells during any 60-minute period within 24 hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality.Results Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC.Conclusion Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted.Level of evidence Level III—Retrospective study with up to two negative criteria.Study type Original research; diagnostic accuracy study.https://tsaco.bmj.com/content/9/1/e001214.full |
| spellingShingle | Nigel R M Tai Evangelia Kyrimi Jared M Wohlgemut Zane B Perkins William Marsh Michael Christian Erhan Pisirir Rebecca S Stoner Thomas Hurst Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome Trauma Surgery & Acute Care Open |
| title | Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome |
| title_full | Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome |
| title_fullStr | Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome |
| title_full_unstemmed | Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome |
| title_short | Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome |
| title_sort | identification of major hemorrhage in trauma patients in the prehospital setting diagnostic accuracy and impact on outcome |
| url | https://tsaco.bmj.com/content/9/1/e001214.full |
| work_keys_str_mv | AT nigelrmtai identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT evangeliakyrimi identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT jaredmwohlgemut identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT zanebperkins identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT williammarsh identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT michaelchristian identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT erhanpisirir identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT rebeccasstoner identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome AT thomashurst identificationofmajorhemorrhageintraumapatientsintheprehospitalsettingdiagnosticaccuracyandimpactonoutcome |