Jared Wohlgemut (London / GB), Erhan Pisirir (London / GB), Rebecca Stoner (London / GB), Evangelia Kyrimi (London / GB), Gareth Grier (London / GB), Michael Christian (London / GB), William Marsh (London / GB), Zane Perkins (London / GB), Nigel Tai (Birmingham / GB; London / GB)
Abstract text (incl. references and figure legends)
Introduction
Traumatic haemorrhage is the largest cause of potentially preventable death after injury. Pre-hospital diagnosis of major haemorrhage (MH) can be difficult, even for expert clinicians. The aim was to determine the accuracy of pre-hospital MH diagnosis, and analyse factors associated with missed MH diagnosis and mortality.
Material & Methods
Retrospective evaluation of consecutive adult (≥16 years) patients injured in 2019-2020, assessed by expert clinicians in a mature pre-hospital trauma system, and admitted to a Major Trauma Centre. Diagnostic performance to identify MH pre-hospital was compared to in-hospital diagnosis. Pre-hospital MH protocol activation was used as a surrogate for MH diagnosis. MH was defined using the critical admission threshold (CAT+): ≥3 units of red blood cells given within any 60min period in the first 24hr of injury. Multivariate logistical regression analyses were conducted, with different dependent variables: missed MH diagnosis and mortality.
Results
There were 947 patients included in the study. Median age was 31 years (IQR 23-47), 821 (87%) were male, 569 (60%) had blunt injury, median injury severity score was 10 (IQR 4-22), and 79 (8%) died. Pre-hospital clinicians correctly diagnosed MH in 97/138 CAT+ patients (sensitivity 70%; 95% CI 62-77%), and correctly ruled out MH in 764/809 CAT- patients (specificity 94%; 95% CI 93-96%, Tab 1). Factors associated with missed MH diagnosis were penetrating mechanism (OR 2.4; 95% CI 1.2-4.7) and major abdominal bleeding injury (OR 4.0; 95% CI 1.7-8.7, Tab 2). The odds of mortality increased by 3.3 (95% CI 1.1-9.7) when MH was missed.
Conclusions
Clinical assessment by expert clinicians had only moderate ability to identify MH in the pre-hospital setting. Understanding the limitations of clinical assessment, and developing solutions to aid identification of MH are warranted.
Tab 1. Contingency table of MH vs CAT
Tab 2. Multivariate logistic regression of missed MH
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JMW, RSS, EP, EK, WM, ZP, and NT have received research funding from the United States Department of Defense. RSS is also funded by the Royal College of Surgeons of Edinburgh and Orthopaedic Research UK. JMW has received funding from the Royal College of Surgeons of England. For the remaining authors none were declared.