A comparison of clinical prediction scores for massive traumatic hemorrhage

Accurate early identification of bleeding trauma patients remains challenging. Several clinical prediction tools-including the Assessment of Blood Consumption (ABC) score, Trauma-Associated Severe Hemorrhage (TASH) score, and shock index (SI)-have been developed to guide transfusion decisions, but their performance across clinically meaningful outcomes remains uncertain.

We conducted a retrospective cohort study of trauma patients with massive hemorrhage protocol (MHP) activation at a university-affiliated, regional referral trauma center in Ontario, Canada, from July 2019 to September 2022. We included patients aged ≥ 16 years who presented within 3 h of injury. We evaluated the ABC score, TASH score, and SI for predicting massive transfusion (≥ 10 PRBCs in 24 h or ≥ 5 PRBCs in 4 h), the critical administration threshold (CAT; ≥3 PRBCs in 1 h), need for hemostatic intervention, and hemorrhage-related mortality. Score performance was assessed using area under the ROC curve (AUC), sensitivity, and specificity.

Among 331 patients, 10.6% received ≥ 10 PRBCs, 20.8% met the 5-unit threshold, 30.8% met CAT, 27.8% required hemostatic intervention, and 4.2% died from hemorrhage during the index admission. The TASH score had the highest AUCs (0.72-0.82) but poor sensitivity. The ABC score showed moderate, threshold-dependent performance (AUCs 0.66-0.76). The shock index (≥ 1.0) showed fair discrimination for major transfusion thresholds (AUC ~ 0.74) but was less predictive for hemostatic intervention (AUC 0.60).

The ABC, TASH, and SI scores performed poorly to moderately across key bleeding outcomes. These findings highlight the need for improved tools aligned with real-time, clinically actionable endpoints in trauma resuscitation.