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J Trauma Acute Care Surg. 2016 Oct;81(4):713-22. doi: 10.1097/TA.0000000000001191.

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

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From the Hôpitaux Universitaires de Strasbourg, Pôle d'Anesthésie-Réanimation SAMU-SMUR, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale; and Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), EA 3072, Institut de Physiologie, Faculté de Médecine, Strasbourg, France (J.P., E.N.); Centre Hospitalier Annecy Genevois, Pôle Urgences-SAMU, Pôle Santé Publique-Réseau Nord Alpin des Urgences, Annecy, France (F.-X.A.); Centre Hospitalier Universitaire de Grenoble, Hôpital Michallon, Pôle d'Anesthésie Réanimation, Grenoble, France (C.F., J.-F.P., P.B.); AP-HP, Hôpitaux Universitaires Paris-Sud, Hôpital de Bicêtre, Département de Physiologie-Université Paris Sud, INSERM U999, Le Kremlin-Bicêtre, France (D.C.); AP-HP, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Service d'Anesthésie-Réanimation, Le Kremlin-Bicêtre; and Laboratoire d'Etude de la Microcirculation, "Bio-CANVAS: Biomarqueurs in CardiaNeuroVascular Diseases" UMRS 942, Paris, France (J.D.); Centre Hospitalier Albertville Moutiers, Service des Urgences-SMUR, Albertville, France (L.C.); Université Grenoble Alpes, Grenoble Institut des Neurosciences, and INSERM U836, Chemin Fortuné Ferrini, Grenoble F-38042, France (J.-F.P, P.B.).



Early and accurate detection of severe hemorrhage is critical for a timely trigger of massive transfusion (MT). Hemodynamic indices combining heart rate (HR) and either systolic (shock index [SI]) or pulse pressure (PP) (PP/HR ratio) have been shown to track blood loss during hemorrhage. The present study assessed the accuracy of prehospital SI and PP/HR ratio to predict subsequent MT, using the gray-zone approach.


This was a retrospective analysis (January 1, 2009, to December 31, 2011) of a prospectively developed trauma registry (TRENAU), in which the triage scheme combines patient severity and hospital facilities. Thresholds for MT were defined as either classic (≥10 red blood cell units within the first 24 hours [MT1]) or critical (≥3 red blood cells within the first hour [MT2]). The receiver operating characteristic curves and gray zones were defined for SI and PP/HR ratio to predict MT1 and MT2 and faced with initial triage scheme.


The TRENAU registry included 3,689 trauma patients, of which 2,557 had complete chart recovery and 176 (6.9%) required MT. In the whole population, PP/HR ratio and SI moderately and similarly predicted MT1 (area under the receiver operating characteristic curve, 0.77 [95% confidence interval {CI}, 0.70-0.84] and 0.80 [95% CI, 0.74-0.87], respectively, p = 0.064) and MT2 (0.71 [95% CI, 0.67-0.76] and 0.72 [95% CI, 0.68-0.77], respectively, p = 0.48). The proportions of patients in the gray zone for PP/HR ratio and SI were 61% versus 40%, respectively, to predict MT1 (p < 0.001) and 62% versus 71%, respectively, to predict MT2 (p < 0.001). In the least severe patient, both indices had fair accuracy to predict MT1 (0.91 [95% CI, 0.82-1.00] vs. 0.87 [95% CI, 0.79-1.00]; p = 0.638), and PP/HR ratio outperformed SI to predict MT2 (0.72 [95% CI, 0.59-0.84] vs. 0.54 [95% CI, 0.33-0.74]; p < 0.015).


In an unselected trauma population, prehospital SI and PP/HR ratio were moderately accurate in predicting MT. In the seemingly least severe patients, an improvement of prehospital undertriage for MT may be gained by using the PP/HR ratio.


Epidemiolgic study, level III.

[Indexed for MEDLINE]

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