From the School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ont. (Tran, Taljaard, Abdulaziz,); the Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ont. (Taljaard, Abdulaziz, Vaillancourt); the Division of General Surgery, The Ottawa Hospital, Ottawa, Ont. (Tran, Matar, Lampron); the Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, the Netherlands (Steyerberg); the Department of Public Health, Erasmus MC, Rotterdam, the Netherlands (Steyerberg); and the Department of Emergency Medicine, University of Ottawa, Ottawa, Ont. (Vaillancourt).
Can J Surg. 2020 Sep-Oct;63(5):E422-E430. doi: 10.1503/cjs.010619.
Failure to rapidly identify bleeding in trauma patients leads to substantial morbidity and mortality. We aimed to develop and validate a simple bedside score for identifying bleeding patients requiring escalation of care beyond initial resuscitation.
We included patients with major blunt or penetrating trauma, defined as those with an Injury Severity Score greater than 12 or requiring trauma team activation, at The Ottawa Hospital from September 2014 to September 2017. We used logistic regression for derivation. The primary outcome was a composite of the need for massive transfusion, embolization or surgery for hemostasis. We prespecified clinical, laboratory and imaging predictors using findings from our prior systematic review and survey of Canadian traumatologists. We used an AIC-based stepdown procedure based on the Akaike information criterion and regression coefficients to create a 5-variable score for bedside application. We used bootstrap internal validation to assess optimism-corrected performance.
We included 890 patients, of whom 133 required a major intervention. The main model comprised systolic blood pressure, clinical examination findings suggestive of hemorrhage, lactate level, focused assessment with sonography in trauma (FAST) and computed tomographic imaging. The C statistic was 0.95, optimism-corrected to 0.94. A simplified Canadian Bleeding (CAN-BLEED) score was devised. A score cut-off of 2 points yielded sensitivity of 97.7% (95% confidence interval [CI] 93.6 to 99.5) and specificity 73.2% (95% CI 69.9 to 76.3). An alternative version that included mechanism of injury rather than CT had lower discriminative ability (C statistic = 0.89).
A simple yet promising bleeding score is proposed to identify highrisk patients in need of major intervention for traumatic bleeding and determine the appropriateness of early transfer to specialized trauma centres. Further research is needed to evaluate the performance of the score in other settings, define interrater reliability and evaluate the potential for reduction of time to intervention.
未能快速识别创伤患者的出血会导致大量发病率和死亡率。我们旨在开发和验证一种简单的床边评分，以识别需要超越初始复苏进行治疗升级的出血患者。
我们纳入了 2014 年 9 月至 2017 年 9 月在渥太华医院接受主要钝性或穿透性创伤的患者，定义为损伤严重程度评分大于 12 分或需要创伤小组激活的患者。我们使用逻辑回归进行推导。主要结局是大量输血、栓塞或手术止血的需要的复合指标。我们使用来自我们之前的系统评价和加拿大创伤学家调查的临床、实验室和影像学预测因素进行了预设。我们使用基于 AIC 的逐步降阶程序，根据 Akaike 信息准则和回归系数，为床边应用创建了一个 5 变量评分。我们使用自举内部验证来评估校正后的乐观性能。
我们纳入了 890 名患者，其中 133 名需要进行重大干预。主要模型包括收缩压、提示出血的临床检查结果、乳酸水平、创伤超声重点评估（FAST）和计算机断层扫描成像。C 统计量为 0.95，校正后的乐观值为 0.94。设计了简化的加拿大出血（CAN-BLEED）评分。2 分的评分切点具有 97.7%（95%置信区间 [CI] 93.6 至 99.5）的敏感性和 73.2%（95% CI 69.9 至 76.3）的特异性。包含损伤机制而非 CT 的替代版本的判别能力较低（C 统计量=0.89）。
提出了一种简单但有前途的出血评分，以识别需要进行重大干预治疗创伤性出血的高危患者，并确定早期转至专门创伤中心的适当性。需要进一步研究以评估该评分在其他环境中的表现，定义组内可靠性，并评估减少干预时间的潜力。
