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Multicenter Study
. 2018 May 5;22(1):113.
doi: 10.1186/s13054-018-2026-9.

Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma

Sophie Rym Hamada  1   2 , Anne Rosa  3 , Tobias Gauss  4 , Jean-Philippe Desclefs  5 , Mathieu Raux  6 , Anatole Harrois  7 , Arnaud Follin  8 , Fabrice Cook  9 , Mathieu Boutonnet  10 ; Traumabase® Group; Arie Attias, Sylvain Ausset, Mathieu Boutonnet, Gilles Dhonneur, Jacques Duranteau, Olivier Langeron, Catherine Paugam-Burtz, Romain Pirracchio, Guillaume de St Maurice, Bernard Vigué, Alexandra Rouquette  11   12 , Jacques Duranteau  7
Affiliations
Multicenter Study

Development and validation of a pre-hospital "Red Flag" alert for activation of intra-hospital haemorrhage control response in blunt trauma

Sophie Rym Hamada et al. Crit Care. .

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.

Keywords: Anticipation; Organization; Protocol; Severe haemorrhage; Severe trauma.

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Conflict of interest statement

Ethics approval and consent to participate

The data come from the Traumabase®. This registry obtained approval from the Advisory Committee for Information Processing in Health Research (CCTIRS, 11.305bis) and from the National Commission on Informatics and Liberties (CNIL, 911461), and the analysis meets the requirement of the local and national ethics committee (Comité de Protection des Personnes, Paris VI).

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart of the study. SH severe haemorrhage
Fig. 2
Fig. 2
Calibration plot of the model in the validation cohort: agreement between observed and predicted proportion of severe haemorrhage (SH) by the model
Fig. 3
Fig. 3
a Red Flag alert. b Contingency mosaic according to threshold of activation. FN false negative, FP false positive, Hb haemoglobin MBP mean arterial blood pressure, OTI Oro-tracheal intubation, SI Shock Index, TN true negative, TP true positive
See this image and copyright information in PMC

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