{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,11,10]],"date-time":"2026-11-10T23:58:51Z","timestamp":1794355131772,"version":"4.9.0"},"reference-count":38,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2024,1,12]],"date-time":"2024-01-12T00:00:00Z","timestamp":1705017600000},"content-version":"unspecified","delay-in-days":11,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Royal College of Surgeons of Edinburgh and Orthopaedic Research UK"},{"name":"Combat Casualty Care Research Program of the US Army Medical Research and Materiel Command","award":["DM180044"],"award-info":[{"award-number":["DM180044"]}]},{"name":"Royal College of Surgeons of England and Rosetrees Trust"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Trauma Surg Acute Care Open"],"accepted":{"date-parts":[[2023,12,24]]},"published-print":{"date-parts":[[2024,1]]},"abstract":"<jats:sec>\n                  <jats:title>Background<\/jats:title>\n                  <jats:p>Hemorrhage is the most common cause of potentially preventable death after injury. Early identification of patients with major hemorrhage (MH) is important as treatments are time-critical. However, diagnosis can be difficult, even for expert clinicians. This study aimed to determine how accurate clinicians are at identifying patients with MH in the prehospital setting. A second aim was to analyze factors associated with missed and overdiagnosis of MH, and the impact on mortality.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Methods<\/jats:title>\n                  <jats:p>Retrospective evaluation of consecutive adult (\u226516 years) patients injured in 2019\u20132020, assessed by expert trauma clinicians in a mature prehospital trauma system, and admitted to a major trauma center (MTC). Clinicians decided to activate the major hemorrhage protocol (MHPA) or not. This decision was compared with whether patients had MH in hospital, defined as the critical admission threshold (CAT+): administration of \u22653 U of red blood cells during any 60-minute period within 24\u2009hours of injury. Multivariate logistical regression analyses were used to analyze factors associated with diagnostic accuracy and mortality.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Results<\/jats:title>\n                  <jats:p>Of the 947 patients included in this study, 138 (14.6%) had MH. MH was correctly diagnosed in 97 of 138 patients (sensitivity 70%) and correctly excluded in 764 of 809 patients (specificity 94%). Factors associated with missed diagnosis were penetrating mechanism (OR 2.4, 95% CI 1.2 to 4.7) and major abdominal injury (OR 4.0; 95% CI 1.7 to 8.7). Factors associated with overdiagnosis were hypotension (OR 0.99; 95% CI 0.98 to 0.99), polytrauma (OR 1.3, 95% CI 1.1 to 1.6), and diagnostic uncertainty (OR 3.7, 95% CI 1.8 to 7.3). When MH was missed in the prehospital setting, the risk of mortality increased threefold, despite being admitted to an MTC.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Conclusion<\/jats:title>\n                  <jats:p>Clinical assessment has only a moderate ability to identify MH in the prehospital setting. A missed diagnosis of MH increased the odds of mortality threefold. Understanding the limitations of clinical assessment and developing solutions to aid identification of MH are warranted.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Level of evidence<\/jats:title>\n                  <jats:p>Level III\u2014Retrospective study with up to two negative criteria.<\/jats:p>\n               <\/jats:sec>\n               <jats:sec>\n                  <jats:title>Study type<\/jats:title>\n                  <jats:p>Original research; diagnostic accuracy study.<\/jats:p>\n               <\/jats:sec>","DOI":"10.1136\/tsaco-2023-001214","type":"journal-article","created":{"date-parts":[[2024,1,12]],"date-time":"2024-01-12T13:06:08Z","timestamp":1705064768000},"page":"e001214","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":23,"title":["Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome"],"prefix":"10.1136","volume":"9","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-8276-0465","authenticated-orcid":false,"given":"Jared M","family":"Wohlgemut","sequence":"first","affiliation":[{"name":"Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK"},{"name":"Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2365-4643","authenticated-orcid":false,"given":"Erhan","family":"Pisirir","sequence":"additional","affiliation":[{"name":"School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7784-6360","authenticated-orcid":false,"given":"Rebecca S","family":"Stoner","sequence":"additional","affiliation":[{"name":"Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK"},{"name":"Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Evangelia","family":"Kyrimi","sequence":"additional","affiliation":[{"name":"School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael","family":"Christian","sequence":"additional","affiliation":[{"name":"London\u2019s Air Ambulance, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Thomas","family":"Hurst","sequence":"additional","affiliation":[{"name":"London\u2019s Air Ambulance, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0212-6363","authenticated-orcid":false,"given":"William","family":"Marsh","sequence":"additional","affiliation":[{"name":"School of Electronic Engineering and Computer Science, Queen Mary University of London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4807-8803","authenticated-orcid":false,"given":"Zane B","family":"Perkins","sequence":"additional","affiliation":[{"name":"Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK"},{"name":"Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Nigel R M","family":"Tai","sequence":"additional","affiliation":[{"name":"Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK"},{"name":"Trauma Service, Royal London Hospital, Barts Health NHS Trust, London, 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