195 – What is the best way to determine acute blood loss and predict operative blood loss in trauma patients with orthopaedic injuries?

195 – What is the best way to determine acute blood loss and predict operative blood loss in trauma patients with orthopaedic injuries?

Justin Kleiner, Paul Tornetta III.

Response/Recommendation: Multiple factors have been studied to assess blood loss prior to presentation, and the prediction of transfusion. Adequate risk stratification involves consideration of the patient’s vital signs, laboratory data, injuries, and medical history.

Strength of Recommendation: Low.

Rationale: Bleeding is a significant source of morbidity and mortality in trauma patients1,2. Adequate resuscitation is an important aspect of management of trauma patients3–5. In patients requiring surgery, under-resuscitation may delay operative treatment, and is associated with increased risk of complications. Many factors indicate an increased risk of substantial bleeding in trauma patients. A patient’s presenting vital signs, temperature, coagulopathic state, severity of injuries, mechanism of injury, as well as their medical comorbidities all contribute to the risk of bleeding in acute trauma. Prehospital care may also have an effect. A variety of scoring systems have been developed to guide clinicians in evaluating this risk4,6–13.

Clinicians routinely use a trauma patient’s presenting blood pressure and tachycardia to evaluate sustained blood loss2,8,14. Shock index, defined as heart rate/systolic blood pressure (HR/SBP), is a validated tool in stratifying blood loss and is simple to calculate in the acute trauma setting. El Menyar et al., found that shock index greater than 0.8 was an independent predictor of transfusion and mortality8. Similarly, Vandromme et al., showed increased transfusion rates in patients with shock index greater than 0.9, and five-fold increase in transfusion rates with shock index greater than 1.114. Cannon et al found higher mortality in patients with a presenting shock index greater than 0.910.

Other scoring systems for prior acute blood loss have been developed that supplement vital signs data with additional presenting laboratory values. ABC score considers SBP < 90, HR > 120, penetrating mechanism, and positive FAST study6,9. Patients with at least two of these are likely to require massive transfusion. However, Schroll et al., found ABC score to have lower sensitivity but greater specificity than shock index for predicting massive transfusion15. Further systems include BATT score, developed to predict hemorrhagic death in trauma, which uses SBP < 100, BP > 100, as well as respiratory rate, GCS score, age, penetrating mechanism, and high-velocity trauma12. HISS score uses presenting labs of glucose, lactate, pH, potassium, and pO2 to predict mortality and ICU stay11.

In addition to a patient’s presenting laboratory values and vital signs, overall injury burden and mechanism of injury contribute to bleeding risk. Rainer et al showed that patients with displaced pelvic fractures had odds ratio of 7.6 for requiring massive transfusion.16 Additionally, they showed that positive FAST score, injury severity score greater than 25, and high energy MVC were associated with transfusion16. Further, the physiologic response to trauma varies by mechanism and has a significant impact on bleeding risk17. Blunt trauma without shock promotes a prothrombotic response due to diffuse tissue damage.18 However, penetrating trauma or trauma with shock may have produced a coagulopathic response associated with increased bleeding risk18. Given the variable effects of trauma on coagulation pathways, viscoelastic assays have been studied to monitor hemostasis in acute trauma2,17. The use of thromboelastography (TEG) is used more widely in Europe than in North America, but more locations are evaluating this methodology19.

Patients requiring surgery are at increased risk of bleeding, and this varies with type of surgery needed. Patients who required hemostatic or endovascular surgery have been shown to require massive transfusion more frequently.20 In femur fracture patients receiving intramedullary nails, perioperative blood loss has been estimated at about 1200cc using dilutional methods.21 In acetabular fracture fixation, reported blood loss can be more than 2,000 cc’s depending on the pattern and approach, with approximately 40% requiring transfusion.22–24  Even lower extremity surgery without a tourniquet can result in over 1,000cc’s of loss 25

Medical history must also be considered when evaluating bleeding risk in trauma patients. Taking a personal and family history of bleeding is recommended in all preoperative patients. 26Medication history should routinely be reviewed, as patients on anticoagulation are also at higher risk of bleeding after trauma. Williams et al report anticoagulation and INR > 1.5 were independent risk factors for mortality in trauma patients. 5

Appropriate risk stratification for bleeding in trauma patients requires a multi-factorial approach. Multiple scoring systems exist to evaluate vital signs and laboratory data. In particular, hypotension and tachycardia on presentation consistently prove to be important factors in predicting significant blood loss. In addition to these tools, physicians should also consider overall injury burden, mechanism of injury, and patient medical history to appropriately stratify bleeding risk.


Injury specific factors

  1. Presenting vitals/labs
    1. Shock index- El Menyar 2018 (HR/SBP > 0.8) independent predictor of transfusion and mortality
    1. HISS score uses presenting labs of glucose, lactate, pH, potassium, pO2 to predict mortality and ICU stay (Bhat 2020)
  2. Overall injury burden/injury severity score:
    1. Rainer 2011- displaced pelvic fracture, positive FAST, increased ISS increase risk of needing massive transfusion.
    1. Ageron 2021 BATT score to predict hemmoragic death: Age, GCS, mechanism, vitals. Peltan 2016 PACT score similar variables.
  3. Mechanism of injury
    1. Blunt trauma without shock may have increased risk of thrombosis due to tissue injury, whereas trauma with shock may have increased risk of bleeding. Further, TBI is associated with delayed clot formation. (Duque 2019).
    1. Higher energy injury (MVC) associated with greater risk of MTP (Charbit 2016)
    1. Can consider viscoelastic assays, however not widely used at this time.
  4. Planned surgery
    1. Spyropoulous 2019 major surgery >2% blood loss (joint replacement, major ortho surgery, operation >45 mins). Lower risk with arthroscopy, hand or foot surgeries.
    1. Patients who required hemostatic or endovascular surgery more likely to needing massive transfusion (Charbit 2016)

Patient-specific factors

  1. Bleeding related comorbidities
    1. Chee et al recommend medical/family history of bleeding in all preoperative patients
  2. Medications- patients on anticoagulation
    1. Williams et al report anticoagulation and INR > 1.5 independent risk factor for mortality
  3. Additional medical comorbidities (Capacity to compensate for blood loss/increased risk)
    1. Age: BATT score shows correlation between increased age and hemorrhagic death (Ageron 2021)


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2.         Maegele M. The European Perspective on the Management of Acute Major Hemorrhage and Coagulopathy after Trauma: Summary of the 2019 Updated European Guideline. J Clin Med. 2021;10(2):362. doi:10.3390/jcm10020362

3.         Tran A, Matar M, Lampron J, Steyerberg E, Taljaard M, Vaillancourt C. Early identification of patients requiring massive transfusion, embolization or hemostatic surgery for traumatic hemorrhage: A systematic review and meta-analysis. J Trauma Acute Care Surg. 2018;84(3):505-516. doi:10.1097/TA.0000000000001760

4.         Cornero SG, Maegele M, Lefering R, et al. Predictive Factors for Massive Transfusion in Trauma: A Novel Clinical Score from an Italian Trauma Center and German Trauma Registry. J Clin Med. 2020;9(10):3235. doi:10.3390/jcm9103235

5.         Williams TM, Sadjadi J, Harken AH, Victorino GP. The Necessity to Assess Anticoagulation Status in Elderly Injured Patients. J Trauma – Inj Infect Crit Care. 2008;65(4):772-776. doi:10.1097/TA.0b013e3181877ff7

6.         Nunez TC, Voskresensky I V., Dossett LA, Shinall R, Dutton WD, Cotton BA. Early prediction of massive transfusion in trauma: Simple as ABC (Assessment of Blood Consumption)? J Trauma – Inj Infect Crit Care. 2009;66(2):346-352. doi:10.1097/TA.0b013e3181961c35

7.         Peltan ID, Rowhani-Rahbar A, Vande Vusse LK, et al. Development and validation of a prehospital prediction model for acute traumatic coagulopathy. Crit Care. 2016;20(1):1-10. doi:10.1186/s13054-016-1541-9

8.         El-Menyar A, Goyal P, Tilley E, Latifi R. The clinical utility of shock index to predict the need for blood transfusion and outcomes in trauma. J Surg Res. 2018;227:52-59. doi:10.1016/j.jss.2018.02.013

9.         Cantle PM, Cotton BA. Prediction of Massive Transfusion in Trauma. Crit Care Clin. 2017;33(1):71-84. doi:10.1016/j.ccc.2016.08.002

10.       Cannon CM, Braxton CC, Kling-Smith M, Mahnken JD, Carlton E, Moncure M. Utility of the shock index in predicting mortality in traumatically injured patients. J Trauma – Inj Infect Crit Care. 2009;67(6):1426-1430. doi:10.1097/TA.0b013e3181bbf728

11.       Bhat A, Podstawczyk D, Walther BK, et al. Toward a hemorrhagic trauma severity score: Fusing five physiological biomarkers. J Transl Med. 2020;18(1):1-17. doi:10.1186/s12967-020-02516-4

12.       Ageron FX, Coats TJ, Darioli V, Roberts I. Validation of the BATT score for prehospital risk stratification of traumatic haemorrhagic death: usefulness for tranexamic acid treatment criteria. Scand J Trauma Resusc Emerg Med. 2021;29(1):1-9. doi:10.1186/s13049-020-00827-5

13.       Yücel N, Lefering R, Maegele M, et al. Trauma Associated Severe Hemorrhage (TASH)-score: Probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma – Inj Infect Crit Care. 2006;60(6):1228-1236. doi:10.1097/01.ta.0000220386.84012.bf

14.       Vandromme MJ, Griffin RL, Kerby JD, McGwin G, Rue LW, Weinberg JA. Identifying risk for massive transfusion in the relatively normotensive patient: Utility of the prehospital shock index. J Trauma – Inj Infect Crit Care. 2011;70(2):384-390. doi:10.1097/TA.0b013e3182095a0a

15.       Schroll R, Swift D, Tatum D, et al. Accuracy of shock index versus ABC score to predict need for massive transfusion in trauma patients. Injury. 2018;49(1):15-19. doi:10.1016/j.injury.2017.09.015

16.       Rainer TH, Ho AMH, Yeung JHH, et al. Early risk stratification of patients with major trauma requiring massive blood transfusion. Resuscitation. 2011;82(6):724-729. doi:10.1016/j.resuscitation.2011.02.016

17.       Maegele M, Spinella PC, Schöchl H. The acute coagulopathy of trauma: Mechanisms and tools for risk Stratification. Shock. 2012;38(5):450-458. doi:10.1097/SHK.0b013e31826dbd23

18.       Duque P, Mora L, Levy JH, Schöchl H. Pathophysiological response to trauma-induced coagulopathy: A comprehensive review. Anesth Analg. 2020;XXX(Xxx):654-664. doi:10.1213/ANE.0000000000004478

19.       George MJ, Aroom KR, Wade CE, Cox CS, Gill BS. A Novel Platelet Function Assay for Trauma. J Surg Res. 2020;246:605-613. doi:10.1016/j.jss.2019.09.052

20.       Charbit J, Lakhal K, Deras P, et al. Influence of surgical bleeding on the relationship between admission coagulopathy and risk of massive transfusion: lesson from 704 severe trauma patients. Vox Sang. 2016;111(2):151-160. doi:10.1111/vox.12401

21.       Lieurance R, Benjamin JB, Rappaport WD. Blood loss and transfusion in patients with isolated femur fractures. J Orthop Trauma. 1992;6(2):175-179. doi:10.1097/00005131-199206000-00007

22.       Lack WD, Crist BD, Seymour RB, Harvin W, Karunakar MA. Effect of Tranexamic Acid on Transfusion: A Randomized Clinical Trial in Acetabular Fracture Surgery. J Orthop Trauma. 2017;31(10):526-530. doi:10.1097/BOT.0000000000000968

23.       Bigsby E, Acharya MR, Ward AJ, Chesser TJS. The Use of Blood Cell Salvage in Acetabular Fracture Internal Fixation Surgery. J Orthop Trauma. 2013;27(10):e230-e233. doi:10.1097/BOT.0b013e3182877684

24.       Wadhwa H, Chen MJ, Tigchelaar SS, Bellino MJ, Bishop JA, Gardner MJ. Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery. Injury. 2021;52(7):1783-1787. doi:10.1016/j.injury.2021.03.059

25.       Shank J, Swords M, Kramer P, Benirschke S. Is Delayed Open Reduction Internal Fixation of Calcaneal Fractures Effective? In: Orthopedic Trauma Association Annual Meeting. ; 2002.

26.       Chee YL, Crawford JC, Watson HG, Greaves M. Guidelines on the assessment of bleeding risk prior to surgery or invasive procedures: British Committee for Standards in Haematology. Br J Haematol. 2008;140(5):496-504. doi:10.1111/j.1365-2141.2007.06968.x

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