title: Clinical gestalt and the prediction of massive transfusion after trauma.
abstract: BACKGROUND
  Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesised that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable.
  
  
  METHODS
  Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centres in patients who survived ≥ 30 min after admission and received ≥ 1 unit of RBC within 6h of arrival. Subjects who received ≥ 10 units within 24h of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question "Is the patient likely to be massively transfused?" 10 min after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems.
  
  
  RESULTS
  Of the 1245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p<0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively.
  
  
  CONCLUSIONS
  Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier.
authors: Center for Translational Injury Research, University of Texas Health Science Center at Houston, United States; Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States. Electronic address: matthew.j.pommerening@uth.tmc.edu.
authors: Matthew J
authors: MJ
authors: Pommerening
authors: Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, United States. Electronic address: md-goodman@hotmail.com.
authors: Michael D
authors: MD
authors: Goodman
authors: Center for Translational Injury Research, University of Texas Health Science Center at Houston, United States; Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States. Electronic address: john.holcomb@uth.tmc.edu.
authors: John B
authors: JB
authors: Holcomb
authors: Center for Translational Injury Research, University of Texas Health Science Center at Houston, United States; Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States. Electronic address: charles.e.wade@uth.tmc.edu.
authors: Charles E
authors: CE
authors: Wade
authors: Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States; Biostatistics/Epidemiology/Research Design Core, Center for Clinical and Translational Sciences, University of Texas Health Science Center at Houston, United States. Electronic address: erin.e.fox@uth.tmc.edu.
authors: Erin E
authors: EE
authors: Fox
authors: Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States; Biostatistics/Epidemiology/Research Design Core, Center for Clinical and Translational Sciences, University of Texas Health Science Center at Houston, United States. Electronic address: Deborah.J.DelJunco@uth.tmc.edu.
authors: Deborah J
authors: DJ
authors: Del Junco
authors: Division of Trauma and Critical Care, Department of Surgery, Medical College of Wisconsin, United States. Electronic address: kbrasel@mcw.edu.
authors: Karen J
authors: KJ
authors: Brasel
authors: Division of Trauma and Critical Care, Department of Surgery, School of Medicine, University of Washington, United States. Electronic address: ebulger@u.washington.edu.
authors: Eileen M
authors: EM
authors: Bulger
authors: Division of General Surgery, Department of Surgery, School of Medicine, University of California San Francisco, United States. Electronic address: mcohen@sfghsurg.ucsf.edu.
authors: Mitch J
authors: MJ
authors: Cohen
authors: Division of Trauma and General Surgery, Department of Surgery, School of Medicine, University of Pittsburgh, United States. Electronic address: alarconl@upmc.edu.
authors: Louis H
authors: LH
authors: Alarcon
authors: Division of Trauma, Critical Care and Acute Care Surgery, School of Medicine, Oregon Health & Science University, United States. Electronic address: schreibm@ohsu.edu.
authors: Martin A
authors: MA
authors: Schreiber
authors: Division of Trauma, Department of Surgery, School of Medicine, University of Texas Health Science Center at San Antonio, United States. Electronic address: myersjg@uthscsa.edu.
authors: John G
authors: JG
authors: Myers
authors: Division of Burn/Trauma/Critical Care, Department of Surgery, Medical School, University of Texas Southwestern Medical Center at Dallas, United States. Electronic address: Herb.Phelan@UTSouthwestern.edu.
authors: Herb A
authors: HA
authors: Phelan
authors: Division of Trauma/Critical Care, Department of Surgery, College of Medicine, University of Cincinnati, United States.
authors: Peter
authors: P
authors: Muskat
authors: Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States; Division of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center at Houston, United States.
authors: Mohammad
authors: M
authors: Rahbar
authors: Center for Translational Injury Research, University of Texas Health Science Center at Houston, United States; Division of Acute Care Surgery, Department of Surgery, University of Texas Health Science Center at Houston, United States. Electronic address: Bryan.A.Cotton@uth.tmc.edu.
authors: Bryan A
authors: BA
authors: Cotton
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000401:mortality / Q000706:statistics & numerical data*; D058734:Exsanguination / Q000401:mortality / Q000628:therapy*; D005260:Female; D005863:Gestalt Theory; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D015203:Reproducibility of Results; D018570:Risk Assessment; D012720:Severity of Illness Index; D013997:Time Factors; D014193:Trauma Centers / Q000458:organization & administration*; D014947:Wounds and Injuries / Q000150:complications / Q000401:mortality / Q000628:therapy*
keywords: Gestalt; Massive transfusion; Trauma