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Uncontrolled and massive bleeding with derangement of coagulation is a major challenge in the management of both surgical and seriously injured patients. The underlying mechanism of trauma-induced or -associated coagulopathy is tissue injury in the presence of shock and acidosis provoking endothelial damage, activation of inflammation, and coagulation disbalancing. Furthermore, the combination of ongoing blood loss and consumption of blood components that are essential for effective coagulation worsens uncontrolled hemorrhage. Additionally, therapeutic actions, such as resuscitation with replacement fluids or allogeneic blood products, can further aggravate coagulopathy. Of the coagulation factors essential to the clotting process, fibrinogen is the first to be consumed to critical levels during acute bleeding and current evidence suggests that normalizing fibrinogen levels in bleeding patients improves clot formation and clot strength, thereby controlling hemorrhage. Three different therapeutic approaches are discussed controversially. Whole blood transfusion is used especially in the military scenario and is also becoming more and more popular in the civilian world, although it is accompanied by a strong lack of evidence and severe safety issues. Transfusion of allogeneic blood concentrates in fixed ratios without any targets has been investigated extensively with disappointing results. Individualized and target-controlled coagulation management based on point-of-care diagnostics with respect to the huge heterogeneity of massive bleeding situations is an alternative and advanced approach to managing coagulopathy associated with massive bleeding in the trauma as well as the perioperative setting. [ABSTRACT FROM AUTHOR]

Supplemental Digital Content is Available in the Text. Background: Hemorrhage is a leading cause of early mortality following trauma. A massive transfusion protocol (MTP) to guide resuscitation while bleeding is definitively controlled may improve outcomes. Prompts to initiate massive transfusion (MT) include shock index (SI) and the Assessment of Blood Consumption (ABC) score. Objective: To compare SI with the ABC score for association with transfusion requirement, need for emergency hemorrhage interventions, and early mortality. Methods: A retrospective cohort analysis of trauma MTP activations at our Level I trauma center was conducted from January 1, 2012, to December 31, 2016. The study data were obtained from the Trauma Registry and the blood bank. An SI cutoff of 1.0 was chosen for comparison with the positive ABC score. Results: The study cohort included 146 patients. Shock index ≥ 1 had significant association with MT requirement (p =.002) whereas a positive ABC score did not (p =.65). More patients with SI ≥ 1 required bleeding control interventions (67% surgery, 47% interventional radiology) than patients having a positive ABC score (49% surgery, 29% interventional radiology). For geriatric patients who received MT, 65% had SI ≥ 1 but only 30% had a positive ABC score. Three-hour mortality following emergency department arrival was similar (60% SI ≥ 1, 62% positive ABC score). Conclusion: Shock index ≥ 1 outperformed a positive ABC score for association with MT requirement. Shock index is a simple tool registered nurses can independently utilize to anticipate MT. [ABSTRACT FROM AUTHOR]

Background Severe trauma is a global public health issue. Approximately one in 10 mortalities is caused by traumatic injury, resulting in the annual global death of more than 5.8 million individuals. Massive hemorrhage is a major cause of death due to traumatic injury, and early administration of blood products with higher plasma and platelet ratio in trauma resuscitation is associated with decreased mortality. Fibrinogen (Fbg) and base-deficit (BD) levels might also be useful indicators for the need for massive transfusion. However, Modified Trauma-Bleeding Severity Score (TBSS) requires the assessment of several factors, such as vital signs, Focused Assessment with Sonography for Trauma, and pelvic and/or femoral fracture, making them slightly complicated. Thus, we aim to improve the outcome of trauma patients in need of massive blood transfusion at the emergency departments. Patients and methods This was a cross-sectional analytic study performed on two groups, with each group involving 35 patients. Fbg and BD levels were assessed in the first group, whereas the Modified TBSS of patients who attended to the Emergency Department of Suez Canal University Hospital was assessed in the second group. Results During clinical evaluation, respiratory rate was found to be statistically significant between Modified TBSS and Fbg (P=0.04). Modified TBSS (80%) was more sensitive than Fbg (71.5%) and BD (73.3%) (P<0.05). Furthermore, Modified TBSS (65%) was more specific than Fbg (60%) and BD (63%). Conclusion Focused Assessment with Sonography for Trauma and Modified TBSS are more sensitive and specific than BD and Fbg in predicting the need for massive transfusion. [ABSTRACT FROM AUTHOR]

Aims: Point-of-care viscoelastic tests such as rotational thrombelastometry (ROTEM) and thromboelastography (TEG) give rapid information on the kinetics of clot formation, clot strength and fibrinolysis. We developed a ROTEM algorithm for the management of trauma patients at risk of massive haemorrhage using either 5 or 10 minute EXTEM and FIBTEM ROTEM thresholds. Study aims were (a) to compare time to results for ROTEM testing versus laboratory conventional coagulation testing (CCT) and (b) to compare incidence of Trauma-induced coagulopathy (TIC) for our 5 and 10 minute ROTEM algorithms versus both the CCT-based European guideline algorithm and the ROTEM-based iTACTIC study algorithm, in both MT and non-MT patients. Methods: Single centre, prospective, observational Emergency Department based study. All trauma patients who underwent ROTEM testing were included. Data was collected from the ROTEM Sigma machine and hospital Electronic Patient Records and analysed. Results: Between April 2016 and May 2019, 57 trauma patients were enrolled. Mean age was 47.4 years (SD 19.4) and 44 patients (77.2%) were male. Eleven patients (19.3%) required massive transfusion (MT), 5 patients died in ED (8.8%) and overall in-hospital mortality was 22.8% (n = 13). Median time from admission to CCT result was 83 minutes (IQR 60–93) compared to 51 minutes (IQR 32-93; p = 0.0006) for ROTEM A5 results. This time difference was present for both MT and non-MT patients. Trauma-induced coagulopathy (TIC) was identified in 14 (24.5%) patients using CCT compared to 22 (38.5%) using ROTEM (p = 0.11 ns). Conclusion: Our ROTEM Sigma based algorithm enables a coagulation result to be obtained faster than laboratory CCT and could lead to earlier clinical intervention. [ABSTRACT FROM AUTHOR]

While massive transfusion (MT) recipients account for a small proportion of all transfused patients, they account for approximately 10% of blood products issued. Furthermore, MT events pose organizational and logistical challenges for health care providers, laboratory and transfusion services. Overall, the majority of MT events are to support major bleeding in surgical patients, trauma and gastrointestinal hemorrhage. The clinical context in which the bleeding event occurred, the number of blood products required, patient age and comorbidities are the most important predictors of outcomes for short- and long-term survival. These data are important to inform blood services, clinicians and health care providers in order to improve care and outcomes for patients with major bleeding. There is no standard accepted definition of MT, with most definitions based on number of blood components administered within a certain time-period or activation of MT protocol. The type of definition used has implications for the clinical characteristics of MT recipients included in epidemiological and interventional studies. In order to understand trends in incidence of MT, variation in blood utilization and patient outcomes, and to harmonize research outcomes, a standard and universally accepted definition of MT is urgently required. - Characteristics of massive transfusion (MT) recipients vary depending on the definition used to capture MT events. - The most common indication for MT is surgical bleeding, followed by trauma and gastrointestinal hemorrhage. - A 30-day mortality is reported between 21% and 40%, depending on the definition of MT. - Clinical context in which the bleeding event occurred, the number of blood products required, patient age and comorbidities are important predictors for survival. [ABSTRACT FROM AUTHOR]

• ABO-incompatible plasma transfusion has arisen from recognition of the importance of early provision of plasma in trauma patients. • Studies examining mortality and clinical markers of hemolysis in ABO-incompatible transfusion have focused primarily on trauma patients; results may not be generalizable to other patient populations. • While measuring titers is a practical approach for reducing risk from ABO-incompatible plasma, it is still unknown if titer levels alone are sufficient for predicting in vivo hemolysis. • More work is needed to clarify ABO antibody interactions with complement/endothelium and identify opportunities to minimize risk. The last several decades have seen significant changes in the approach to resuscitation of bleeding patients. These include the adoption of ABO-incompatible plasma transfusion in the form of group A plasma and/or low titer group O whole blood for trauma patients of unknown ABO group. Studies to date have examined the impact of these practices on patient outcomes and clinical markers of hemolysis in recipients of ABO-incompatible plasma compared to those for whom the plasma is ABO-compatible. Risk for increased mortality and/or overt hemolysis appear to be low among recipients of ABO-incompatible plasma; however, nearly all of studies are retrospective and most have focused only on adult trauma patients so results may not be generalizable to other bleeding patients. Work continues to evaluate the role of various titer thresholds in decreasing hemolytic risk and opportunities remain to improve our understanding of anti-A and anti-B antibody interactions with complement/endothelium and identify strategies to minimize risk. [ABSTRACT FROM AUTHOR]

Background: Optimal management of severe trauma patients with active hemorrhage relies on adequate initial resuscitation. Early administration of coagulation factors improves post-traumatic coagulation disorders, and four-factor prothrombin complex concentrate (PCC) might be useful in this context. Our main hypothesis is that four-factor PCC in addition to a massive transfusion protocol decreases blood product consumption at day 1 in severe trauma patients with major bleeding.Methods: This is a prospective, randomized, multicenter, double-blind, parallel, controlled superiority trial. Eligible patients are trauma patients with major bleeding admitted to a French level-I trauma center. Patients randomized in the treatment arm receive 1 mL/kg (25 IU/ml of Factor IX/Kg) four-factor PCC within 1-h post-admission while patients randomized in the controlled group receive 1 mL/kg of saline solution 0.9% as a placebo. Treatments are given as soon as possible using syringe pumps (120 mL/h). The primary endpoint is the amount of blood products transfused in the first 24 h post-admission (including red blood cells, frozen fresh plasma, and platelets). The secondary endpoints are the amount of each blood product transfused in the first 24 h, time to achieve prothrombin time ratio < 1.5, time to hemostasis, number of thrombo-embolic events at 28 days, mortality at 24 h and 28 days, number of intensive care unit-free days, number of ventilator-free days, number of hospital-free days within the first 28 days, hospitalization status at day 28, Glasgow outcome scale extended for patients with brain lesions on initial cerebral imaging, and cost of each strategy at days 8 and 28. Inclusions have started in December 2017 and are expected to be complete by June 2021.Discussion: If PCC reduces total blood consumption at day 1 after severe trauma, this therapy, in adjunction to a classic massive transfusion protocol, may be used empirically on admission in patients at risk of massive transfusion to enhance coagulation. Moreover, this treatment may decrease blood product-related complications and may improve clinical outcomes after post-traumatic hemorrhage.Trial Registration: ClinicalTrials.gov NCT03218722 . Registered on July 14, 2017. [ABSTRACT FROM AUTHOR]

Background: We use massive transfusion in various clinical conditions and it is associated with high mortality. Although some massive transfusion protocols improve patient outcomes, the clinical circumstances requiring it are not well defined. Methods: MATRA‐A is a multicenter retrospective study. Six University and Training Research Hospitals in Ankara participated in the study. We collected clinical data on patients (>18 years) who received massive transfusions (≥10 units/24 h) from 2017 through 2019. Results: Overall, 167 (0·27% of transfused patients) received a massive transfusion of 2586 units of red blood cells (1·5% of total RBCs transfused). The median interquartile range values for RBCs, fresh frozen plasma (FFP) and platelets were 13 (11–176), 16 (9–33) and 4 (0–11), respectively. Surgical patients received 90% of massive transfusions. The most common clinical indications for massive transfusion were cardiovascular diseases (42·6%), trauma (20·3%) and malignancies (11%). FFP: RBC: Platelets ratio was 1·9:1:0·5. The overall and trauma‐related mortality rates were 57·4% and 61·8%, respectively. The hospital mortality rates of trauma patients that received high vs. low ratio (FFP: RBCs > 1:1·5 vs. ≤1:1·5) transfusions were 47·6% and 86·6% and the difference was statistically significant (P = 0·03). Conclusion: Cardiovascular diseases and trauma occasion are the most common causes of massive transfusion. It is infrequent in clinical settings and is associated with high mortality rates. Additionally, in massively transfused trauma patients, a high FFP:RBCs ratio seems to be associated with increased survival. Focused prospective studies are required to define the areas that need improvement on a national scale. [ABSTRACT FROM AUTHOR]

Background: The paediatric massive transfusion protocol (MTP) is activated in the paediatric population for both trauma and non-trauma related indications. While it helps to improve the efficiency and efficacy of the delivery of blood products, it can also result in increased wastage. We aimed to evaluate the wastage rates from our paediatric MTP activations from 2013 to 2018. Method: As part of an audit, we retrospectively reviewed the records of the paediatric patients who had MTP activations. We collected the following data: reason for MTP activation, weight of patient, number of cycles of MTP required, blood products used, blood products wasted, deviation from our institution’s recommended MTP blood product ratio, and reason for wastage. Result: We had 26 paediatric MTP activations within the audit period. There was an overall wastage rate of 1.5%, with wastage occurring in 3 out of 26 patients. The reason for all wastage was demise of the patient. Most patients’ transfusion ratios deviated from our institution’s MTP protocol. Conclusion: Our wastage rates are low likely because of clear MTP activation guidelines and a flexible MTP workflow.

Background: A risk assessment model for predicting the risk of haemolytic disease of the fetus and newborn (HDFN) in future pregnancies following the transfusion of Rh(D)‐positive red blood cell (RBC)‐containing products to females of childbearing potential (FCP) was developed, accounting for the age that the FCP is transfused in various countries. Methods: The HDFN risk prediction model included the following inputs: risk of FCP death in trauma, Rh(D) alloimmunization rate following Rh(D)‐positive RBC transfusion, expected number of live births following resuscitation, probability of carrying an Rh(D)‐positive fetus, the probability of HDFN in an Rh(D)‐positive fetus carried by an alloimmunized mother. The model was implemented in Microsoft R Open, and one million FCPs of each age between 18 and 49 years old were simulated. Published data from eight countries, including the United States, were utilized to generate country‐specific HDFN risk estimates. Results: The risk predictions showed similar characteristics for each country in that the overall risk of having a pregnancy affected by HDFN was higher if the FCP was younger when she received her Rh(D)‐positive transfusion than if she was older. In the United States, the overall risk of HDFN if the FCP was transfused at age 18 was 3·4% (mild: 1·20%, moderate: 0·45%; severe: 1·15%; IUFD: 0·57%); the risk was approximately 0% if the FCP was 43 years or older at the time of transfusion. Conclusion: This model can be used to predict HDFN outcomes when establishing transfusion policies as it relates to the administration of Rh(D)‐positive products for massively bleeding FCPs. [ABSTRACT FROM AUTHOR]

Background and Purpose: Previous studies have identified that the reverse shock index multiplied by the Glasgow Coma Scale score (rSIG) is a good predictor of mortality in trauma patients. However, it is unknown if rSIG has utility as a predictor for massive transfusion (MT) in trauma patients. The present study evaluated the ability of rSIG to predict MT in trauma patients.Methods: This was a retrospective, observational study performed at a level 1 trauma center. Consecutive patients who presented to the trauma center emergency department between January 2016 and December 2018 were included. The predictive ability of rSIG for MT was assessed as our primary outcome measure. Our secondary outcome measures were the predictive ability of rSIG for coagulopathy, in-hospital mortality, and 24-h mortality. We compared the prognostic performance of rSIG with the shock index, age shock index, and quick Sequential Organ Failure Assessment.Results: In total, 1627 patients were included and 117 (7.2%) patients received MT. rSIG showed the highest area under the receiver operating characteristic (AUROC) curve (0.842; 95% confidence interval [CI], 0.806--0.878) for predicting MT. rSIG also showed the highest AUROC for predicting coagulopathy (0.769; 95% CI, 0.728-0.809), in-hospital mortality (AUROC 0.812; 95% CI, 0.772-0.852), and 24-h mortality (AUROC 0.826; 95% CI, 0.789-0.864). The sensitivity of rSIG for MT was 0.79, and the specificity of rSIG for MT was 0.77. All tools had a high negative predictive value and low positive predictive value.Conclusion: rSIG is a useful, rapid, and accurate predictor for MT, coagulopathy, in-hospital mortality, and 24- h mortality in trauma patients. [ABSTRACT FROM AUTHOR]

Background: Civilian and military guidelines recommend early balanced transfusion to patients with life-threatening bleeding. Low titer group O whole blood was introduced as the primary blood product for resuscitation of massive hemorrhage at Haukeland University Hospital, Bergen, Norway, in December 2017. In this report, we describe the whole blood program and present results from the first years of routine use.Study Design and Methods: Patients who received whole blood from December 2017 to April 2020 were included in our quality registry for massive transfusions. Post-transfusion blood samples were collected to analyze isohemagglutinin (anti-A/-B) and hemolysis markers. Administration of other blood products, transfusion reactions, and patient survival (days 1 and 30) were recorded. User experiences were surveyed for both clinical and laboratory staff.Results: Two hundred and five patients (64% male and 36% female) received 836 units in 226 transfusion episodes. Patients received a mean of 3.7 units (range 1-35) in each transfusion episode. The main indications for transfusion were trauma (26%), gastrointestinal (22%), cardiothoracic/vascular (18%), surgical (18%), obstetric (11%), and medical (5%) bleeding. There was no difference in survival between patients with blood type O when compared with non-group O. Haptoglobin level was lower in the transfusion episodes for non-O group patients, however no clinical hemolysis was reported. No patients had conclusive transfusion-associated adverse events. Both clinical and laboratory staff preferred whole blood to component therapy for massive transfusion.Discussion: The experience from Haukeland University Hospital indicates that whole blood is feasible, safe, and effective for in-hospital treatment of bleeding. [ABSTRACT FROM AUTHOR]

Background: Massive transfusions are associated with a high mortality rate, but there is little evidence indicating when such efforts are futile. The purpose of this study was to identify clinical variables that could be used as futility indicators in massively transfused patients. Methods: We retrospectively analyzed 138 adult surgical patients at our institution receiving a massive transfusion (2016–2019). Peak lactate and nadir pH within 24 h of massive transfusion initiation, along with other clinical variables, were assessed as predictors of the primary outcome, in‐hospital mortality. Results: The overall rate of in‐hospital mortality among our patient population was 52.9% (n = 73). Increasing lactate and decreasing pH were associated with greater mortality among massively transfused patients. Mortality rates were ~2‐fold higher for patients in the highest lactate category (≥10.0 mmol/L: 25 of 37; 67.6%) compared to the lowest category (0.0–4.9 mmol/L: 17 of 48; 35.4%) (p =.005), and ~2.5‐fold higher for patients in the lowest pH category (<7.00: 8 of 9; 88.9%) compared to the highest category (≥7.40: 8 of 23; 34.7%) (p =.016). Increasing age was also associated with higher mortality (≥65 years: 24 of 33; 72.7%) when compared to younger patients (18–64 years: 49 of 105; 46.7%) (p =.010). Conclusions: Peak lactate ≥10.0 mmol/L, nadir pH <7.00, and age ≥65 years were significantly associated with higher rates of in‐hospital mortality among massively transfused patients. Incorporating these clinical parameters into a futility index for massive transfusions will be useful in situations where blood products are scarce and/or mortality may be unavoidable. [ABSTRACT FROM AUTHOR]

Background: Rapid infusion of warmed blood products is the cornerstone of trauma resuscitation and treatment of surgical and obstetric massive hemorrhage. Integral to optimizing this delivery is selection of an intravenous (IV) catheter and use of a rapid infusion device (RID). We investigated which IV catheter and RID system enabled the greatest infusion rate of blood products and the governing catheter characteristics. Study Design and Methods: The maximum flow rates of nine IV catheters were measured while infusing a mixture of packed red blood cells and fresh frozen plasma at a 1:1 ratio using a RID with and without a patient line extension. To account for IV catheters that achieved the RID's maximum 1000 ml/min, the conductance of each infusion circuit configuration was calculated. Results: IV catheters of 7‐Fr caliber or higher reached the maximum pressurized flow rate. The 9‐Fr multi‐lumen access catheter (MAC) achieved the greatest conductance, over sevenfold greater than the 18 g peripheral catheter (4.6 vs. 0.6 ml/min/mmHg, p <.001). Conductance was positively correlated with internal radius (β = 1.098, 95% CI 4.286–5.025, p <.001) and negatively correlated with length (β= − 0.495, 95% CI −0.007 to 0.005, p <.001). Use of an extension line (β= − 0.094, 95% CI −0.505 to −0.095, p =.005) was independently associated with reduced conductance in large caliber catheters. Conclusion: Short, large‐diameter catheters provided the greatest infusion rates of massive transfusion blood products for the least pressure. For patients requiring the highest transfusion flow rates, extension tubing should be avoided when possible. [ABSTRACT FROM AUTHOR]

Background: The use of whole blood (WB) to treat trauma patients is becoming more common. Similar to the treatment of individual components, pathogen inactivation (PI) technologies are available to treat WB. The impact of PI on WB function is not well understood. This study investigated the impact of PI of WB with riboflavin/ultraviolet (UV) light on its hemostatic function by modeling transfusion scenarios for trauma patients and assessing transfusion efficacy by rotational thromboelastometry (ROTEM). As fibrinogen is affected by PI of WB, the effect of fibrinogen supplementation commonly used in trauma patients was also analyzed in this model. Study Design and Methods: Trauma transfusion scenarios were simulated by mixing untreated WB or WB treated with the Mirasol PI technology (riboflavin/UV) in different ratios with hemodiluted blood, and the thromboelasticity was monitored by ROTEM. The impact of supplementation with the fibrinogen concentrate RiaSTAP was investigated in this model. Results: Pathogen‐inactivated WB (PI‐WB) showed decreased activity in the hemostatic profile compared to the untreated control. Hemodiluted blood at a hematocrit (hct) of 20%, which was reconstituted with PI‐WB or untreated WB, exhibited increased alpha values, maximum clot firmness, and clot formation time. Simulating transfusion scenarios by blood replacement with PI‐WB resulted in a significant difference in ROTEM parameters between reconstituted PI‐treated and ‐untreated WB (p ≥.05). The effect of PI treatment waned when PI‐WB was enriched with fibrinogen. Conclusion: ROTEM investigations suggest that PI treatment has a negative impact on WB clot formation unless fibrinogen supplementation is used. [ABSTRACT FROM AUTHOR]

• Severe trauma patients often require emergent interventions, such as massive transfusion, resuscitative procedures, and surgical procedures. • Recent studies showed Reverse Shock Index multiplied by Glasgow Coma Scale score (rSIG) is a promising predictor of mortality. • Our study revealed rSIG is superior in predicting emergent interventions compared with T-RTS, PSP, ABC and FASILA score. • This study concludes that rSIG is a simple and effective point-of-care predictor of emergent interventions during initial management of trauma. Severe trauma patients often require emergent interventions, such as massive transfusion, resuscitative procedures, and surgical procedures, and consume considerable human and medical resources. However, few practical indices can be easily used for emergent interventions. In recent years, it has become clear that rSIG (Reverse Shock Index multiplied by Glasgow Coma Scale [GCS] score), which can be easily calculated from vital signs, is a promising predictor of mortality. However, it is unclear whether rSIG is useful for emergent interventions. Data collected by the Japan Trauma Data Bank for adult patients admitted directly from the scene of trauma between April 2019 and December 2020 were analysed. The outcomes were massive transfusion, resuscitative procedures, surgical procedures and emergent interventions. Emergent interventions were defined as the composite outcome of massive transfusion, resuscitative procedures, and surgical procedures. The ability of rSIG to predict massive transfusion was compared with that of the ABC score and FASILA score by receiver-operating characteristic curve analysis. The ability of rSIG to predict resuscitative and surgical procedures was compared with that of the Shock Index (SI), GCS, Triage Revised Trauma score (T-RTS), and Previous Simple Prediction (PSP) score. The ability of rSIG to predict emergent interventions was compared with that of T-RTS, PSP, ABC, and FASILA. In addition to rSIG, rSIM (Reverse Shock Index multiplied by best motor response score) was also analysed as a supplement. The study included 32,201 patients, 6,371 of whom required emergent interventions. The area under the receiver-operating characteristic curve (AUROC) for massive transfusion was highest for rSIG (0.846 [95 % confidence interval 0.832–0.859]) and significantly higher for rSIG than for rSIM, ABC and FASILA (all p < 0.0001). AUROCs for resuscitative and surgical procedures were highest for rSIG (0.777 [0.769–0.785] and 0.731 [0.720–0.741], respectively) and significantly higher than those for rSIM, SI, GCS, T-RTS, and PSP (all p < 0.0001). The AUROC for emergent interventions was highest for rSIG (0.760 [0.753–0.768]) and significantly higher for rSIG than for rSIM, T-RTS, PSP, ABC, or FASILA (all p < 0.0001). rSIG is a simple and effective point-of-care predictor of emergent interventions during initial management of trauma. [ABSTRACT FROM AUTHOR]

Extravasation is an inadvertent injection or leakage of fluid and drugs in the extravascular or subcutaneous space. The extravasation by massive transfused blood results in the elevation of intra-compartmental pressures. Severely increased pressure may lead to acute compartment syndrome (ACS). A 50-year-old man underwent craniectomy for traumatic subdural hemorrhage of the brain. During intraoperative periods, the blood components were transfused by rapid transfusion device and manual pressurized pumping through the central and peripheral lines because of hemorrhagic hypovolemic shock. Approximately 30 minutes after transfusion, we found a hardened right low leg that was obscured by the surgical drape. Immediately, fasciotomy was performed to release all four compartments. The early recognition and treatment of ACS were important factors contributing to anatomical structure salvage and preservation of function. Anesthesia providers should check the site of the insertion of the intravenous catheter, especially while pressurized massive transfusion via the peripheral intravenous catheter.

Abstract An 8‐year‐old 24.6 kg mixed breed dog underwent bronchoscopy for evaluation of a persistent progressive cough. Bronchoscopy documented a markedly thick and irregular, cobblestone appearance of the mucosa. A bronchoscopic biopsy was obtained; immediately after the biopsy, a large amount of hemorrhage poured from the endotracheal tube. Multiple efforts to control the hemorrhage were unsuccessful and the dog suffered a cardiopulmonary arrest and could not be revived. A necropsy was performed, which was significant for pallor, evidence of prior heartworm disease, prominent bronchial arteries, and erosion of the submucosal vessels at the site of the biopsy. The cause of death was hemorrhage associated with transbronchial biopsy of an enlarged bronchial artery associated with heartworm disease. This report describes a rare complication of a routine diagnostic procedure.

Objectives: Early adequate resuscitation of patients with trauma is crucial in preventing shock and early mortality. Thus, we aimed to determine the performance of the inferior vena cava (IVC) volume and other risk factors and scores in predicting massive transfusion and mortality. Methods: We included all patients with trauma who underwent computed tomography (CT) scan of the torso, which included the abdominal area, in our emergency department (ED) from January 2014 to January 2017. We calculated the 3-dimensional IVC volume from the left renal vein to the IVC bifurcation. The primary outcome was the performance of IVC volume in predicting massive transfusion, and the secondary outcome was the performance of IVC volume in predicting 24-hour and 30-day in-hospital mortality. Results: Among the 236 patients with trauma, 7.6% received massive transfusions. The IVC volume and revised trauma score (RTS) were independent predictors of massive transfusion (adjusted odds ratio [OR]: 0.79 vs 1.86, 95% confidence interval [CI], 0.71-0.89 vs 1.4-2.47, respectively). Both parameters showed the good area under the curve (AUC) for the prediction of massive transfusion (adjusted AUC: 0.83 and 0.82, 95% CI, 0.74-0.92 vs 0.72-0.93, respectively). Patients with a large IVC volume (fourth quartile) were less likely to receive massive transfusion than those with a small IVC volume (first quartile, ≥28.29 mL: 0% vs <15.08 mL: 20.3%, OR: 0.13, 95% CI, 0.03-0.66). Conclusions: The volume of IVC measured on CT scan and RTS are independent predictors of massive transfusion in patients with trauma in the ED. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Early initial massive transfusion protocol and blood transfusion can reduce patient mortality, however accurately identifying the risk of massive transfusion (MT) remains a major challenge in severe trauma patient therapy. We retrospectively analyzed clinical data of severe trauma patients with and without MT. Based on analysis results, we established a MT prediction model of clinical and laboratory data by using the decision tree algorithm in patients with multiple trauma. Our results demonstrate that shock index, injury severity score, international normalized ratio, and pelvis fracture were the most significant risk factors of MT. These four indexes were incorporated into the prediction model, and the model was validated by using the testing dataset. Moreover, the sensitivity, specificity, accuracy and area under curve values of prediction model for MT risk prediction were 60%, 92%, 90% and 0.85. Our study provides an easy and understandable classification rules for identifying risk factors associated with MT that may be useful for promoting trauma management. [ABSTRACT FROM AUTHOR]

The principal triggers for intervention in the setting of pediatric blunt solid organ injury (BSOI) are declining hemoglobin values and hemodynamic instability. The clinical management of BSOI is, however, complex. We therefore hypothesized that state-of-art machine learning (computer-based) algorithms could be leveraged to discover new combinations of clinical variables that might herald the need for an escalation in care. We developed algorithms to predict the need for massive transfusion (MT), failure of non-operative management (NOM), mortality, and successful non-operative management without intervention, all within 4 hours of emergency department (ED) presentation. Children (≤ 18 years) who sustained a BSOI (liver, spleen, and/or kidney) between 2009 and 2018 were identified in the trauma registry at a pediatric level 1 trauma center. Deep learning models were developed using clinical values [vital signs, shock index-pediatric adjusted (SIPA), organ injured, and blood products received], laboratory results [hemoglobin, base deficit, INR, lactate, thromboelastography (TEG)], and imaging findings [focused assessment with sonography in trauma (FAST) and grade of injury on computed tomography scan] from pre-hospital to ED settings for prediction of MT, failure of NOM, mortality, and successful NOM without intervention. Sensitivity, specificity, accuracy, and area under the receiver operating characteristic curve (AUC) were used to evaluate each model's performance. A total of 477 patients were included, of which 5.7% required MT (27/477), 7.2% failed NOM (34/477), 4.4% died (21/477), and 89.1% had successful NOM (425/477). The accuracy of the models in the validation set was as follows: MT (90.5%), failure of NOM (83.8%), mortality (91.9%), and successful NOM without intervention (90.3%). Serial vital signs, the grade of organ injury, hemoglobin, and positive FAST had low correlations with outcomes. Deep learning-based models using a combination of clinical, laboratory and radiographic features can predict the need for emergent intervention (MT, angioembolization, or operative management) and mortality with high accuracy and sensitivity using data available in the first 4 hours of admission. Further research is needed to externally validate and determine the feasibility of prospectively applying this framework to improve care and outcomes. III Retrospective comparative study (Prognosis/Care Management). [ABSTRACT FROM AUTHOR]

Background: Systolic blood pressure (SBP) and shock index (SI) are accurate indicators of hemodynamic instability and the need for transfusion in trauma patients. We aimed to determine whether the utility and cutoff point for SBP and SI are affected by age and antihypertensives. Methods: This was a retrospective observational study of a level 1 trauma center between January 2017 and December 2018. We analyzed the utility and cutoff points of SBP and SI for predicting massive transfusion (MT) and 30-day mortality according to patients' age and whether they were taking antihypertensives. A multivariable logistic regression analysis was conducted to estimate the association of age and antihypertensives on primary and secondary outcomes. Results: We analyzed 4681 trauma cases. There were 1949 patients aged 65 years or older (41.6%), and 1375 hypertensive patients (29.4%). MT was given to 137 patients (2.9%). The 30-day mortality rate was 6.3% (n = 294). In geriatric trauma patients taking antihypertensives, a prehospital SBP less than 110 mmHg was the cutoff value for predicting MT in multivariate logistic regression analyses; packed red blood cell transfusion volume decreased abruptly based on prehospital SBP of 110 mmHg. Emergency Department SI greater than 1.0 was the cutoff value for predicting MT in patients who were older than 65 years and were not taking antihypertensives. Conclusions: The triage of trauma patients is based on the identification of clinical features readily identifiable by first responders. However, age and medications may also affect the accurate evaluation. In initial trauma management, we must apply SBP and SI differently depending on age, whether a patient is taking antihypertensives, and the time at which the indicators are measured. [ABSTRACT FROM AUTHOR]

Background: Massive transfusion protocols (MTP) are a routine component of any major trauma center's armamentarium in the management of exsanguinating hemorrhages. Little is known about the potential complications of those that survive a MTP. We sought to determine the incidence of venous thromboembolism (VTE) following MTP. We hypothesized that MTP would be associated with a higher risk of VTE when compared with a risk-adjusted control population without MTP.Methods: The Pennsylvania Trauma Outcome Study database was retrospectively queried from 2015 to 2018 for trauma patients who developed VTE and survived until discharge at accredited trauma centers in Pennsylvania. Patient demographics, injury severity, and clinical outcomes were compared to assess differences in VTE development between MTP and non-MTP patients. A multivariate logistic regression model assessed the adjusted impact of MTP on VTE development.Results: 176 010 patients survived until discharge, meeting inclusion criteria. Of those, 1667 developed a VTE (pulmonary embolism [PE]: 662 [0.4%]; deep vein thrombosis [DVT]: 1142 [0.6%]; PE and DVT: 137 [0.1%]). 1268 patients (0.7%) received MTP and, of this subset of patients, 171 (13.5%) developed a VTE during admission. In adjusted analysis, patients who had a MTP and survived until discharge had a higher odds of developing a VTE (adjusted odds ratio: 2.62; 95% CI: 2.13-3.24; P < .001).Discussion: MTP is a harbinger for higher risk of VTE in those patients who survive. This may, in part, be related to the overcorrection of coagulation deficits encountered in the hemorrhagic event. A high index of suspicion for the development of VTE as well as aggressive VTE prophylaxis is warranted in those patients who survive MTP. [ABSTRACT FROM AUTHOR]

Expanding neck hematoma with progressive airway obstruction is a life-threatening airway emergency. Patients are at risk of cranio-cerebral circulation compromise leading to perioperative cerebrovascular accidents. Furthermore, precipitous fall of blood pressure following neck hematoma exploration mandate the activation of protocols for massive transfusion. We describe the successful anaesthetic management of an extremely rare case of spontaneous rupture of a vertebral artery pseudoaneurysm. [ABSTRACT FROM AUTHOR]

Background and objective Studies assessing the incidence of venous thromboembolic (VTE) events in the setting of massive balanced transfusions and/or tranexamic acid (TXA) infusion have yielded varied outcomes. In light of this, we conducted this study to examine the incidence of VTEs in trauma patients requiring blood products, and to identify the risk factors for VTE and mortality in this population. Methods We performed a retrospective analysis of trauma patients admitted to our level 1 trauma center from January 2013 to September 2023. Clinical characteristics were compared between patients who developed VTE and those who did not. A regression analysis of potential variables associated with the development of VTEs and mortality was performed. Results Among 1305 patients (mean age: 42.4 ± 18.8 years) receiving blood products within the initial 24 hours, 4.3% (56 patients) developed a VTE. Patients with VTE experienced prolonged ICU and hospital stays and ventilation duration (p<0.001). They were also noted to have delayed initiation of VTE prophylaxis (104.2 vs. 50.3 hours, p<.001). Prolonged ventilation >7 days was the sole significant factor associated with VTE in multivariate regression analysis [odds ratio (OR): 6.2, p=0.004]. Early TXA administration (within four hours) showed a higher association with VTE than TXA within 24 hours (OR: 2.1, p=0.07 vs. OR 1.6, p=0.22). Massive transfusion was found to increase VTE risk (OR: 2.65, p<0.001). Severe head and neck (OR: 6.0, p=0.002) and chest (OR: 3.8, p=0.01) injuries were key predictors of mortality, while TXA was not significantly associated with mortality in the multivariate model. Conclusions Our study revealed an elevated risk of VTE in patients requiring massive transfusion protocol (MTP, ≥6 units). Early TXA administration was neither associated with increased VTE risk in MTP patients nor increased mortality risk. Strategies directed at reducing the risk of VTE in massively transfused patients while maintaining the survival benefits of balanced resuscitation and TXA need to be devised., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Halalmeh et al.)

Introduction: Calcium is required for coagulation, cardiac output, and peripheral vascular resistance. Between 85% and 94% of trauma patients treated with massive blood transfusion develop hypocalcemia. 1 The aim of this study is to evaluate the relationship between increased intravenous calcium administration during massive transfusion and improved survival of trauma patients., Methods: We performed a retrospective analysis of trauma patients who received massive transfusion over a 2-y period. Doses of elemental calcium administered per unit of blood product transfused were calculated by calcium to blood product ratio (CBR). Chi-square test evaluated association between coagulopathy and 30-d mortality. Two-sample t-test evaluated association between CBR and coagulopathy. Bivariate regression analysis evaluated association between CBR and blood products transfused per patient. Multivariable logistic regression analysis, controlling for age, sex, coagulopathy, and Injury Severity Score evaluated the association between CBR and mortality., Results: The study included 77 patients. Coagulopathy was associated with increased 30-d mortality (P < 0.05). Patients who survived had higher CBR than those who died (P < 0.05). CBR was associated with a significant reduction in total blood products transfused per patient (P < 0.05). CBR was not associated with coagulopathy (P = 0.24). Multivariable logistic regression analysis demonstrated that Injury Severity Score ≥16, coagulopathy and decreased CBR were significant predictors of mortality (P < 0.05). CBR above 50 mg was a predictor of survival (P < 0.05)., Conclusions: Higher doses of calcium given per blood product transfused were associated with improved 30-d survival and decreased blood product transfusions., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Shock Index (SI) has been used to predict the need for massive transfusion (MT) and emergency surgical procedures (ESP) in civilian trauma. We hypothesize that SI can reliably identify combat trauma patients that will require MT and ESP when applied to the resource-constrained, combat environment. A retrospective review was performed within the Department of Defense Trauma Registry (2008-2016). SI was calculated using heart rate and systolic blood pressure on arrival to the initial facility with surgical capabilities. A threshold value of 0.8 was used to stratify patients into two groups (Group I, SI < 0.8; and Group II, SI ≥ 0.8). The need for MT, ESP, and mortality was compared. Regression analyses were conducted to determine the independent association of SI with MT and ESP. A total of 4008 patients were included. The mean age of the patients was 25.5 y, and the majority were predominately male (98%). Mechanisms of injury were blunt and blast injury (62%), penetrating injury (36.7%), and burn injury (0.5%). Overall, 77% of patients (n = 3070) were stratified to Group I, and 23% of patients (n = 938) were stratified to Group II, by SI. Group II patients had a significantly greater need for MT (8.4% versus 0.4%) and ESP (30.7% versus 6.5%), both P < 0.001. Regression analysis controlling for age, gender, Injury Severity Score, and Glasgow Coma Score confirmed that SI ≥ 0.8 was an independent risk factor for both MT and need for ESPs (P < 0.001). SI is a significant predictor of the need for MT and ESPs in the military trauma population, representing a simple and potentially potent tool for triage and prediction of resource consumption in the resource-limited, austere setting. [ABSTRACT FROM AUTHOR]

Abstract Background The relationship between fibrinogen concentration and traumatic death has been poorly explored after severe trauma. Existing studies analysed this relationship in unselected trauma population, often considering fibrinogen concentration as a categorical variable. The aim of our study was to model the relationship between fibrinogen concentration and in-hospital mortality in severe trauma patients requiring massive transfusion using fibrinogen on admission as a continuous variable. Methods We designed a retrospective observational study based on prospectively collected data from 2009 to 2015 in seven French level-I trauma centres. All consecutive patients requiring a transfusion of at least 10 packed red blood cells (RBC) within 24 h were included. To assess the relationship between in-hospital death and fibrinogen concentration on admission, we performed generalized linear and additive models with death as a dependent variable. We also assessed the relationship between fibrinogen concentration below 1.5 g.L− 1 and potential predictors. Results Within the study period, 366 patients were included. A non-linear relationship was found between fibrinogen concentration and death. Graphical modelling of this relationship depicted a negative association between fibrinogen levels and death below a fibrinogen concentration of 1.5 g.L− 1. Predictors of low fibrinogen concentration (

Objective: To determine if there exists an upper limit for amount of blood transfused in trauma patients before it reaches a point of futility.Methods: A prospective cohort study was conducted on 131 patients who received massive blood transfusion (MBT), defined as 10 U or higher of PRBCs received in the initial 24 hours. Data collected from a Level II trauma center registry were used to analyze reports of adult patients from July 2014 to 2017. Cohorts were divided by amount of blood received - 0 to 9 U, 10-19 U, 20 to 29 U, 30-39 U, 40 U or higher - odds ratio for mortality and p-values for mean Injury Severity Score and overall hospital length of stay were calculated for each group.Results: Odds ratios for massive blood transfusion groups from 10 units to 39 units each contained the null value, while our 40 units and above group did not (OR 12.52, 95% CI 1.3-117.7).Conclusion: Although this study is limited by its sample size, these results suggests that 40 units of PRBCs may be a threshold at which survival rates begin to decrease significantly.

A 53-year-old female was admitted to the emergency department with an exsanguinating bleed from the rectum which was of unclear origin. In what could be considered an ultramassive transfusion, 60 units packed red blood cells, 23 units fresh frozen plasma, 20 units platelets, 6 units cryoprecipitate, 30 L of crystalloids, 2 L of colloids, and 4 g of tranexamic acid were transfused over the course of 7 h. An arterio-enteric fistula was diagnosed and treated by an interventional radiologist. The patient recovered rapidly thereafter without any major neurologic, pulmonary, cardiac, or hematologic complications.

Background: Post-traumatic hemorrhage is still the leading cause of potentially preventable death in patients with severe trauma. Traumatic-induced coagulopathy has been described as a risk factor for significant hemorrhage and mortality in this population. Fibrin monomers (FMs) are a direct marker of thrombin action, and thus reflect coagulation activation. This study sought to determine the association of FMs levels at admission with significant hemorrhage and 28-day mortality after a severe trauma.Methods: We conducted a retrospective, observational study including all severe trauma patients admitted in a level-1 trauma center between January 2012 and December 2017. Patients with severe traumatic brain injury or previous anticoagulant / antiaggregant therapies were excluded. FMs measurements and standard coagulation test were taken at admission. Significant hemorrhage was defined as a hemorrhage requiring the transfusion of ≥ 4 Red Blood Cells units during the first 6 h. Multivariable analysis was applied to identify predictors of significant hemorrhage and a simple logistic regression analysis was applied to identify an association between FMs and 28-day mortality.Results: Overall, 299 patients were included. A total of 47 (16%) experienced a significant hemorrhage. The ROC curve demonstrated that FMs had a poor accuracy to predict the occurrence of significant hemorrhage with an AUC of 0.65 (0.57-0.74). The best threshold at 92.45 µg/ml had excellent sensitivity (87%) and negative predictive value (95%), but was not independently associated with significant hemorrhage (OR = 1.5; 95%CI (0.5-4.2)). The 28-day mortality rate was 5%. In simple logistic regression analysis, FMs values ≥109.5 µg/ml were significantly associated with 28-day mortality (unadjusted OR = 13.2; 95%CI (1.7-102)).Conclusions: FMs levels at admission are not associated with the occurrence of a significant hemorrhage in patients with severe trauma. However, the excellent sensitivity and NPV of FMs could help to identify patients with a low risk of severe bleeding during hospital care. In addition, FMs levels ≥109.5 µg/ml might be predictive of 28-day mortality. [ABSTRACT FROM AUTHOR]

Background: Intraoperative massive transfusion (MT) is common during liver transplantation (LT). A predictive model of MT has the potential to improve use of blood bank resources. Study Design and Methods: Development and validation cohorts were identified among deceased‐donor LT recipients from 2010 to 2016. A multivariable model of MT generated from the development cohort was validated with the validation cohort and refined using both cohorts. The combined cohort also validated the previously reported McCluskey risk index (McRI). A simple modified risk index (ModRI) was then created from the combined cohort. Finally, a method to translate model predictions to a population‐specific blood allocation strategy was described and demonstrated for the study population. Results: Of the 403 patients, 60 (29.6%) in the development and 51 (25.5%) in the validation cohort met the definition for MT. The ModRI, derived from variables incorporated into multivariable model, ranged from 0 to 5, where 1 point each was assigned for hemoglobin level of less than 10 g/dL, platelet count of less than 100 × 109/dL, thromboelastography R interval of more than 6 minutes, simultaneous liver and kidney transplant and retransplantation, and a ModRI of more than 2 defined recipients at risk for MT. The multivariable model, McRI, and ModRI demonstrated good discrimination (c statistic [95% CI], 0.77 [0.70‐0.84]; 0.69 [0.62‐0.76]; and 0.72 [0.65‐0.79], respectively, after correction for optimism). For blood allocation of 6 or 15 units of red blood cells (RBCs) based on risk of MT, the ModRI would prevent unnecessary crossmatching of 300 units of RBCs/100 transplants. Conclusions: Risk indices of MT in LT can be effective for risk stratification and reducing unnecessary blood bank resource utilization. [ABSTRACT FROM AUTHOR]

Transfusion of whole blood rather than blood components is gaining popularity. It is easy to use, with one transfusion product to administer rather than 3, and is held at one storage temperature. It only contains anticoagulant-preservative solution, while components contain various storage solutions, which in theory may induce dilution coagulopathy. In this review, the quality of platelets in stored whole blood is summarized. In cold-stored whole blood, the platelet count declines by 1% to 2% per day. The responsiveness to various agonists declines during the storage time, but this appears to have a limited impact on clotting time or on clot strength as measured with thromboelastography. Animal studies have confirmed that platelets from stored whole blood participate equally well in clot formation. The recovery of platelets in stored whole blood is acceptable during at least 15 days of storage. The survival of platelets after transfusion is only 1 day, but this is likely to be sufficient for the intended patient group requiring massive transfusions, as the platelets are rapidly consumed in the wound area. In addition to the logistic benefits, there are drawbacks, most importantly having a sufficiently large inventory with an acceptable outdating rate, particularly since massive transfusions are rare, while requiring a lot of whole blood. The positive experience of the United States military with whole blood transfusion is often brought forward for introduction in the civilian blood bank, but patients with trauma are only a small fraction of the civilian population requiring massive transfusions. It needs to be determined whether in the resourceful environment of the hospital, these patients benefit from whole blood transfusions. Optimization of whole blood storage, with focus on platelet quality, needs to be performed to allow extension of the storage time beyond 15 days to a point where the number of units in inventory and outdating can be balanced. • Platelets in stored whole blood gradually lose their response to specific agonists, but the overall ability to form a clot remains intact. • The recovery of platelets in stored whole blood remains acceptable up to 15 days; survival is about 1 day, which is likely adequate for the intended patient group. • With focus on maintenance of platelet quality, more research is needed to prolong the storage time of whole blood to allow inventory building and to reduce outdating. [ABSTRACT FROM AUTHOR]

Background: In massive bleeding trauma patients, the use of massive transfusion protocol (MTP) has been shown to improve the outcome. However, the triggers for MTP activation vary among institutions. One of the most commonly used scoring systems to predict massive transfusion (MT) is the assessment of blood consumption (ABC) score. The authors' institution has used a simple clinical criterion, the Class-4 Hemorrhage Unresponsive to Lactated Ringer's (CHULA criteria), as a trigger for MTP activation. Objective: To identify the accuracy of CHULA criteria for MTP activation in trauma patients. Materials and Methods: Between April 2013 and April 2016, the authors retrospectively collected the data of trauma patients receiving blood transfusion in the first 24 hours at King Chulalongkorn Memorial Hospital, including demographic data, trauma scores, amount of blood transfusion, and mortality. The detail of CHULA criteria included 1) a patient with clinical signs of Class-4 hemorrhage, 2) not responding to one to two liters of Lactated Ringer's bolus, and 3) had suspected ongoing bleeding. MT was defined as 1) packed red blood cells (PRC) transfusion of equal to or greater than 10 units in 24 hours, or 2) PRC transfusion of more than four units in the first hour. The accuracy of CHULA criteria for MTP activation was analyzed. Comparison between CHULA criteria and ABC score (of equal to or greater than 2) was also performed. Results: Three hundred fifty-eight patients were included in the present study, 292 males and 66 females. The mechanisms of injury were 68% blunt and 32% penetrating, with an average injury severity score of 21. MTP was activated by CHULA criteria in 100 patients and 73 received MT. Of the 258 patients who did not meet CHULA criteria, five received MT. As a trigger for MT activation, CHULA criteria had sensitivity, specificity, and accuracy of 93.6%, 90.4%, and 91%, respectively; while ABC score had sensitivity, specificity, and accuracy of 62.8%, 78.9%, and 75.4%, respectively. Conclusion: CHULA criteria can predict MT in trauma patients with 91% accuracy. When compared with ABC score, CHULA criteria were not inferior to ABC score in predicting MT. [ABSTRACT FROM AUTHOR]

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