Original Article

Prehospital ABC Score Accurately Forecasts Patients Who Will Require Immediate Resource Utilization

Authors: Kyle J. Kalkwarf, MD, Michael D. Goodman, MD, Gregory M. Press, MD, Charles E. Wade, PhD, Bryan A. Cotton, MD, MPH

Abstract

Objectives: Scoring systems, such as the Assessment of Blood Consumption (ABC) Score, are used to identify patients at risk for massive transfusion (MT, ≥10 U red blood cells in 24 hours). Our aeromedical transport helicopter uses ultrasound to perform the Focused Assessment with Sonography for Trauma (FAST) examination. Our objective was to evaluate the ability of the Prehospital ABC (PhABC) Score to predict blood transfusions and the need for emergent laparotomy.

Methods: Post hoc analysis of a prospective observational study of trauma patients who underwent an in-flight FAST during aeromedical transport during a 7-month period. PhABC Score was positive if ≥2 of the following were present in flight: penetrating trauma, heart rate >120 bpm, systolic blood pressure <90 mm Hg, or a positive abdominal FAST. The PhABC Score was evaluated by area under the receiver operating characteristic (AUROC) curves and logistic regression.

Results: A total of 291 trauma patients met inclusion criteria, 23 underwent emergent laparotomy, and 12 received an MT. A positive PhABC Score predicted emergent laparotomy, with a positive predictive value of 48% and a negative predictive value of 95% (sensitivity 46%, specificity 96%, AUROC curve 0.83). A positive PhABC Score also predicted receipt of an MT with a positive predictive value of 28% and a negative predictive value of 94% (sensitivity 33%, specificity 93%, AUROC curve 0.77). Multiple logistic regression identified FAST as the most powerful contributor of the PhABC Score to the prediction of both emergent laparotomy (odds ratio 8.5, P < 0.001) and MT (odds ratio 5.9, P < 0.001).

Conclusions: The PhABC Score effectively predicts in-hospital resource utilization. It provides an outstanding undertriage rate from the prehospital setting, and it is helpful to improve trauma team activation, mobilize blood products, and prepare the operating room.

This content is limited to qualifying members.

Existing members, please login first

If you have an existing account please login now to access this article or view purchase options.

Purchase only this article ($25)

Create a free account, then purchase this article to download or access it online for 24 hours.

Purchase an SMJ online subscription ($75)

Create a free account, then purchase a subscription to get complete access to all articles for a full year.

Purchase a membership plan (fees vary)

Premium members can access all articles plus recieve many more benefits. View all membership plans and benefit packages.

References

1. Hoyt DB, Bulger EM, Knudson MM, et al. Death in the operating room: an analysis of a multi-center experience. J Trauma 1994;37:426–432.   2. Holcomb JB, Jenkins D, Rhee P, et al. Damage control resuscitation: directly addressing the early coagulopathy of trauma. J Trauma 2007;62:307–310.   3. Huber-Wagner S, Qvick M, Mussack T, et al. Massive blood transfusion and outcome in 1062 polytrauma patients: a prospective study based on the Trauma Registry of the German Trauma Society. Vox Sang 2007;92:69–78.   4. Cotton BA, Au BK, Nunez TC, et al. Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications. J Trauma 2009;66:41–49.   5. Rowell SE, Barbosa RR, Diggs BS, et al. Effect of high product ratio massive transfusion on mortality in blunt and penetrating trauma patients. J Trauma 2011;71:S353–S357.   6. Young PP, Cotton BA, Goodnough LT. Massive transfusion protocols for patients with substantial hemorrhage. Transf Med Rev 2011;25:293–303.   7. Joseph B, Azim A, Zangbar B, et al. Improving mortality in trauma laparotomy through the evolution of damage control resuscitation: analysis of 1,030 consecutive trauma laparotomies. J Trauma 2017;82:328–333.   8. Cotton BA, Dossett LA, Haut ER, et al. Multicenter validation of a simplified score to predict massive transfusion in trauma. J Trauma 2010;69:S33–S39.   9. Krumrei NJ, Park MS, Cotton BA, et al. Comparison of massive blood transfusion predictive models in the rural setting. J Trauma 2012;72:211–215.   10. Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 2009;66:346–352.   11. Rozycki GS, Ballard RB, Feliciano DV, et al. Surgeon-performed ultrasound for the assessment of truncal injuries: lessons learned from 1540 patients. Ann Surg 1998;228:557.   12. Scalea TM, Rodriguez A, Chiu WC, et al. Focused assessment with sonography for trauma (FAST): results from an international consensus conference. J Trauma 1999;46:466–472.   13. Lee BC, Ormsby EL, McGahan JP, et al. The utility of sonography for the triage of blunt abdominal trauma patients to exploratory laparotomy. Am J Roentgenol 2007;188:415–421.   14. Polk JD, Fallon WF Jr, Kovach B, et al. The "Airmedical F.A.S.T." for trauma patients—the initial report of a novel application for sonography. Aviat Space Environ Med 2001;72:432–436.   15. Price DD, Wilson SR, Murphy TG. Trauma ultrasound feasibility during helicopter transport. Air Med J 2000;19:144–146.   16. Melanson SW, McCarthy J, Stromski CJ, et al. Aeromedical trauma sonography by flight crews with a miniature ultrasound unit. Prehosp Emerg Care 2001;5:399–402.   17. Walcher F, Weinlich M, Conrad G, et al. Prehospital ultrasound imaging improves management of abdominal trauma. Br J Surg 2006;93:238–242.   18. Press GM, Miller SK, Hassan IA, et al. Prospective evaluation of prehospital trauma ultrasound during aeromedical transport. J Emerg Med 2014;47:638–645.   19. Yates JG, Baylous D. Aeromedical ultrasound: the evaluation of point-ofcare ultrasound during helicopter transport. Air Med J 2017;36:110–115.   20. UTHealth Department of Surgery. Division of Acute Care Surgery clinical practice policies, guidelines, and algorithms: trauma team clinical practice policy. https://med.uth.edu/surgery/wp-content/uploads/sites/66/2020/06/ED-Trauma-Activation-Policy-2019b.pdf. Updated September 2019. Accessed August 30, 2020.   21. Pommerening MJ, Goodman MD, Holcomb JB, et al. Clinical gestalt and the prediction of massive transfusion after trauma. Injury 2015;46:807–813.   22. Johansson PI, Stensballe J, Oliveri R, et al. How I treat patients with massive hemorrhage. Blood 2014;124:3052–3058.   23. UTHealth Department of Surgery. Division of Acute Care Surgery clinical practice policies, guidelines, and algorithms: adult massive transfusion protocol, clinical practice policy. https://med.uth.edu/surgery/wp-content/uploads/sites/66/2017/06/Massive-Transfusion-Protocol.pdf. Updated October 2014. Accessed August 30, 2020.   24. Press GM, Miller SK, Hassan IA, et al. Evaluation of a training curriculum for prehospital trauma ultrasound. J Emerg Med 2013;45:856–864.   25. Lim RC Jr, Olcott CO4th, Robinson AJ, et al. Platelet response and coagulation changes following massive blood replacement. J Trauma 1973;13:577–582.   26. Sauaia A, Moore FA, Moore EE, et al. Epidemiology of trauma deaths: a reassessment. J Trauma 1995;38:185–193.   27. Acosta JA, Yang JC, Winchell RJ, et al. Lethal injuries and time to death in a level I trauma center. J Am Coll Surg 1998;186:528–533.   28. Eastridge BJ, Mabry RL, Seguin P, et al. Death on the battlefield (2001–2011): implications for the future of combat casualty care. J Trauma 2012;73:S431–S437.   29. Riskin DJ, Tsai TC, Riskin L, et al. Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction. J Am Coll Surg 2009;209:198–205.   30. Oyeniyi BT, Fox EE, Scerbo M, et al. Trends in 1029 trauma deaths at a level 1 trauma center: impact of a bleeding control bundle of care. Injury 2017;48:5–12.   31. Kalkwarf KJ, Drake SA, Yang Y, et al. Bleeding to death in a big city: an analysis of all trauma deaths from hemorrhage in a metropolitan area over one year. J Trauma 2020;89:716–722.   32. Clarke JR, Trooskin SZ, Doshi PJ, et al. Time to laparotomy for intra-abdominal bleeding from trauma does affect survival for delays up to 90 minutes. J Trauma 2002;52:420–425.   33. Meyer DE, Vincent LA, Fox EE, et al. Every minute counts: time to delivery of initial massive transfusion cooler and its impact on mortality. J Trauma 2017;83:19–24.   34. Martin M, Izenberg S, Cole F, et al. A decade of experience with a selective policy for direct to operating room trauma resuscitations. Am J Surg 2012;204:187–192.   35. Liu NT, Holcomb JB, Wade CE, et al. Improving the prediction of mortality and the need for life-saving interventions in trauma patients using standard vital signs with heart-rate variability and complexity. Shock 2015;43:549–555.   36. Cannon CM, Braxton CC, Kling-Smith M, et al. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma 2009;67:1426–1430.   37. Vandromme MJ, Griffin RL, Kerby JD, M, et al. Identifying risk for massive transfusion in the relatively normotensive patient: utility of the prehospital shock index. J Trauma 2011;70:384–390.   38. McNab A, Burns B, Bhullar I, et al. A prehospital shock index for trauma correlates with measures of hospital resource use and mortality. Surgery 2012;152:473–476.   39. Bruijns SR, Guly HR, Bouamra O, et al. The value of the difference between ED and prehospital vital signs in predicting outcome in trauma. Emerg Med J 2014;31:579–582.   40. Mackenzie CF, Wang Y, Hu PF, et al. Automated prediction of early blood transfusion and mortality in trauma patients. J Trauma 2014;76:1379–1385.   41. Guyette FX, Meier EN, Newgard C, et al. A comparison of prehospital lactate and systolic blood pressure for predicting the need for resuscitative care in trauma transported by ground. J Trauma 2015;78:600–606.   42. Foroutan A, Paydar S, Heydari ST, et al. Predictive potential of heart rate complexity measurement: an indication for laparotomy following solid organ injury. Trauma Mon 2015;20:e17215.   43. Shackelford S, Yang S, Hu P, et al. Predicting blood transfusion using automated analysis of pulse oximetry signals and laboratory values. J Trauma 2015;79:S175–S180.   44. Lewis CT, Naumann DN, Crombie N, et al. Prehospital point-of-care lactate following trauma: a systematic review. J Trauma 2016;81:748–755.   45. Brown JB, Lerner EB, Sperry JL, et al. Prehospital lactate improves accuracy of prehospital criteria for designating trauma activation level. J Trauma 2016;81:445–452.   46. Gladden AA, Peltz ED, McIntyre RC Jr, et al. Effect of pre-hospital use of the assessment of blood consumption score and pre-thawed fresh frozen plasma on resuscitation and trauma mortality. J Am Coll Surg 2019;228:141–147.   47. Lehmann RK, Arthurs ZM, Cuadrado DG, et al. Trauma team activation: simplified criteria safely reduces overtriage. Am J Surg 2007;193:630–635.   48. Lehmann R, Brounts L, Lesperance K, et al. A simplified set of trauma triage criteria to safely reduce overtriage: a prospective study. Arch Surg 2009;144:853–858.   49. Walcher F, Kirschning T, Muller MP, et al. Accuracy of prehospital focused abdominal sonography for trauma after a 1-day hands-on training course. Emerg Med J 2010;27:345–349.   50. Kim CH, Shin SD, Song KJ, et al. Diagnostic accuracy of focused assessment with sonography for trauma (FAST) examinations performed by emergency medical technicians. Prehosp Emerg Care 2012;16:400–406.   51. Thomas B, Falcone RE, Vasquez D, et al. Ultrasound evaluation of blunt abdominal trauma: program implementation, initial experience, and learning curve. J Trauma 1997;42:384–390.   52. Gracias VH, Frankel HL, Gupta R, et al. Defining the learning curve for the focused abdominal sonogram for trauma (FAST) examination: implications for credentialing. Am Surg 2001;67:364–368.   53. Kirkpatrick AW, Simons RK, Brown R, et al. The hand-held FAST: experience with hand-held trauma sonography in a level-I urban trauma center. Injury 2002;33:303–308.   54. Hsu JM, Joseph AP, Tarlinton LJ, et al. The accuracy of focused assessment with sonography in trauma (FAST) in blunt trauma patients: experience of an Australian major trauma service. Injury 2007;38:71–75.   55. Branney SW, Wolfe RE, Moore EE, et al. Quantitative sensitivity of ultrasound in detecting free intraperitoneal fluid. J Trauma 1995;39:375–380.   56. Adams BJ, Sukumvanich P, Seibel R, et al. Ultrasound for the detection of intraperitoneal fluid: the role of Trendelenberg positioning. Am J Emerg Med 1999;17:117–120.   57. Miller MT, Pasquale MD, Bromberg WJ. Not so FAST. J Trauma 2003;54:52–60.   58. Udobi KF, Rodriguez A, Chiu WC, et al. Role of ultrasonography in penetrating abdominal trauma: a prospective clinical study. J Trauma 2001;50:475–479.   59. Stengel D, Bauwens K, Sehouli J, et al. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015;9:CD004446