Development and validation of a pre-hospital “Red Flag” alert for activation of intra-hospital haemorrhage control response in blunt trauma
Sophie Rym Hamada,
Anne Rosa,
Tobias Gauss,
Jean-Philippe Desclefs,
Mathieu Raux,
Anatole Harrois,
Arnaud Follin,
Fabrice Cook,
Mathieu Boutonnet,
the Traumabase® Group,
Arie Attias,
Sylvain Ausset,
Gilles Dhonneur,
Olivier Langeron,
Catherine Paugam-Burtz,
Romain Pirracchio,
Bruno Riou,
Guillaume de St Maurice,
Bernard Vigué,
Alexandra Rouquette,
Jacques Duranteau
Affiliations
Sophie Rym Hamada
Université Paris Sud, Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud
Anne Rosa
Université Paris Sud, Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris (AP-HP), Béclère Hôpitaux Universitaires Paris Sud
Tobias Gauss
Hôpitaux Universitaires Paris Nord Val de Seine, Department of Anesthesiology and Critical Care, AP-HP, Beaujon
Jean-Philippe Desclefs
Centre Hospitalier Sud-Francilien, SAMU 91 Emergency Department
Mathieu Raux
Sorbonne Université and Department of Anesthesiology and Critical Care, AP-HP, Hôpitaux Universitaires Pitié-Salpêtrière
Anatole Harrois
Université Paris Sud, Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud
Arnaud Follin
Université Paris Descartes, Department of Anesthesiology and Critical Care, AP-HP, Hôpital Européen Georges Pompidou—Hôpitaux Universitaires Paris Ouest
Fabrice Cook
Université Paris Est, Department of Anesthesiology and Critical Care, APHP, Hôpital Henri Mondor
Mathieu Boutonnet
Department of Anesthesiology and Critical Care, Percy Military Teaching Hospital
the Traumabase® Group
Arie Attias
Sylvain Ausset
Gilles Dhonneur
Olivier Langeron
Catherine Paugam-Burtz
Romain Pirracchio
Bruno Riou
Guillaume de St Maurice
Bernard Vigué
Alexandra Rouquette
CESP, INSERM, Université Paris-Sud, UVSQ, Université Paris-Saclay, Paris
Jacques Duranteau
Université Paris Sud, Department of Anesthesiology and Critical Care, AP-HP, Bicêtre Hôpitaux Universitaires Paris Sud
Abstract Background Haemorrhagic shock is the leading cause of early preventable death in severe trauma. Delayed treatment is a recognized prognostic factor that can be prevented by efficient organization of care. This study aimed to develop and validate Red Flag, a binary alert identifying blunt trauma patients with high risk of severe haemorrhage (SH), to be used by the pre-hospital trauma team in order to trigger an adequate intra-hospital standardized haemorrhage control response: massive transfusion protocol and/or immediate haemostatic procedures. Methods A multicentre retrospective study of prospectively collected data from a trauma registry (Traumabase®) was performed. SH was defined as: packed red blood cell (RBC) transfusion in the trauma room, or transfusion ≥ 4 RBC in the first 6 h, or lactate ≥ 5 mmol/L, or immediate haemostatic surgery, or interventional radiology and/or death of haemorrhagic shock. Pre-hospital characteristics were selected using a multiple logistic regression model in a derivation cohort to develop a Red Flag binary alert whose performances were confirmed in a validation cohort. Results Among the 3675 patients of the derivation cohort, 672 (18%) had SH. The final prediction model included five pre-hospital variables: Shock Index ≥ 1, mean arterial blood pressure ≤ 70 mmHg, point of care haemoglobin ≤ 13 g/dl, unstable pelvis and pre-hospital intubation. The Red Flag alert was triggered by the presence of any combination of at least two criteria. Its predictive performances were sensitivity 75% (72–79%), specificity 79% (77–80%) and area under the receiver operating characteristic curve 0.83 (0.81–0.84) in the derivation cohort, and were not significantly different in the independent validation cohort of 2999 patients. Conclusion The Red Flag alert developed and validated in this study has high performance to accurately predict or exclude SH.
