title: Defining when to initiate massive transfusion: a validation study of individual massive transfusion triggers in PROMMTT patients.
abstract: BACKGROUND
  Early predictors of massive transfusion (MT) would prevent undertriage of patients likely to require MT. This study validates triggers using the Prospective Observational Multicenter Major Trauma Transfusion (PROMMTT) study.
  
  
  METHODS
  All enrolled patients in PROMMTT were analyzed. The initial emergency department value for each trigger (international normalized ratio [INR], systolic blood pressure, hemoglobin, base deficit, positive result for Focused Assessment for the Sonography of Trauma examination, heart rate, temperature, and penetrating injury mechanism) was compared for patients receiving MT (≥ 10 U of packed red blood cells in 24 hours) versus no MT. Adjusted odds ratios (ORs) for MT are reported using multiple logistic regression. If all triggers were known, a Massive Transfusion Score (MTS) was created, with 1 point assigned for each met trigger.
  
  
  RESULTS
  A total of 1,245 patients were prospectively enrolled with 297 receiving an MT. Data were available for all triggers in 66% of the patients including 67% of the MTs (199 of 297). INR was known in 87% (1,081 of 1,245). All triggers except penetrating injury mechanism and heart rate were valid individual predictors of MT, with INR as the most predictive (adjusted OR, 2.5; 95% confidence interval, 1.7-3.7). For those with all triggers known, a positive INR trigger was seen in 49% receiving MT. Patients with an MTS of less than 2 were unlikely to receive MT (negative predictive value, 89%). If any two triggers were present (MTS ≥ 2), sensitivity for predicting MT was 85%. MT was present in 33% with an MTS of 2 greater compared with 11% of those with MTS of less than 2 (OR, 3.9; 95% confidence interval, 2.6-5.8; p < 0.0005).
  
  
  CONCLUSIONS
  Parameters that can be obtained early in the initial emergency department evaluation are valid predictors for determining the likelihood of MT.
  
  
  METHODS
  Diagnostic, level II.
authors.affiliation: Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, San Francisco, California 94110, USA. callcutr@sfghsurg.ncsf.edu
authors.forename: Rachael A
authors.initials: RA
authors.lastname: Callcut
authors.forename: Bryan A
authors.initials: BA
authors.lastname: Cotton
authors.forename: Peter
authors.initials: P
authors.lastname: Muskat
authors.forename: Erin E
authors.initials: EE
authors.lastname: Fox
authors.forename: Charles E
authors.initials: CE
authors.lastname: Wade
authors.forename: John B
authors.initials: JB
authors.lastname: Holcomb
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Rahbar
authors.forename: Mitchell J
authors.initials: MJ
authors.lastname: Cohen
authors.forename: M Margaret
authors.initials: MM
authors.lastname: Knudson
authors.forename: Karen J
authors.initials: KJ
authors.lastname: Brasel
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Deborah J
authors.initials: DJ
authors.lastname: Del Junco
authors.forename: John G
authors.initials: JG
authors.lastname: Myers
authors.forename: Louis H
authors.initials: LH
authors.lastname: Alarcon
authors.forename: Bryce R H
authors.initials: BR
authors.lastname: Robinson
mesh_terms: D001803:Blood Transfusion; D004636:Emergency Service, Hospital; D006470:Hemorrhage / Q000628:therapy*; D017052:Hospital Mortality; D006801:Humans