Prehospital shock index and pulse pressure/heart rate ratio to predict massive transfusion after severe trauma: Retrospective analysis of a large regional trauma database.

Background: Early and accurate detection of severe hemorrhage is critical for a timely trigger of massive transfusion (MT). Hemodynamic indices combining heart rate and either systolic (shock index, SI) or pulse pressure (pulse pressure/heart rate ratio, PP/HR) have been shown to track blood loss during hemorrhage. The present study assessed the accuracy of prehospital SI and PP/HR to predict subsequent MT, using the grey zone approach. Methods: Retrospective analysis (January 1st 2009 - December 31th 2011) of a prospectively-developed trauma registry (TRENAU), in which the triage scheme combines patient severity and hospital facilities. Thresholds for MT were either defined as classical (>=10 red blood cell units [RBCs] within the first 24 hours [MT1]) or critical (>=3 RBCs within the first hour [MT2]). The receiver operating characteristic (ROC) curves and grey zones were defined for SI and PP/HR to predict MT1 and MT2 and faced with initial triage scheme. Results: The TRENAU registry included 3689 trauma patients, of which 2557 had complete chart recovery and 176 (6.9%) required MT. In the whole population, PP/HR and SI moderately and similarly predicted MT1 (AUC [95%CI]: 0.77 [0.70-0.84] and 0.80 [0.74-0.87], respectively, p=0.064) and MT2 (0.71 [0.67-0.76] and 0.72 [0.68-0.77], respectively, p=0.48). The proportions of patients in the grey zone for PP/HR and SI were 61% vs. 40%, respectively to predict MT1 (p

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