Clinical gestalt and the prediction of massive transfusion after trauma

Published:February 04, 2015DOI:



      Early recognition and treatment of trauma patients requiring massive transfusion (MT) has been shown to reduce mortality. While many risk factors predicting MT have been demonstrated, there is no universally accepted method or algorithm to identify these patients. We hypothesised that even among experienced trauma surgeons, the clinical gestalt of identifying patients who will require MT is unreliable.


      Transfusion and mortality outcomes after trauma were observed at 10 U.S. Level-1 trauma centres in patients who survived ≥30 min after admission and received ≥1 unit of RBC within 6 h of arrival. Subjects who received ≥10 units within 24 h of admission were classified as MT patients. Trauma surgeons were asked the clinical gestalt question “Is the patient likely to be massively transfused?” 10 min after the patients arrival. The performance of clinical gestalt to predict MT was assessed using chi-square tests and ROC analysis to compare gestalt to previously described scoring systems.


      Of the 1245 patients enrolled, 966 met inclusion criteria and 221 (23%) patients received MT. 415 (43%) were predicted to have a MT and 551(57%) were predicted to not have MT. Patients predicted to have MT were younger, more often sustained penetrating trauma, had higher ISS scores, higher heart rates, and lower systolic blood pressures (all p < 0.05). Gestalt sensitivity was 65.6% and specificity was 63.8%. PPV and NPV were 34.9% and 86.2% respectively.


      Data from this large multicenter trial demonstrates that predicting the need for MT continues to be a challenge. Because of the increased mortality associated with delayed therapy, a more reliable algorithm is needed to identify and treat these severely injured patients earlier.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Injury
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Cotton B.A.
        • Dossett L.A.
        • Au B.K.
        • Nunez T.C.
        • Robertson A.M.
        • Young P.P.
        Room for (performance) improvement: provider-related factors associated with poor outcomes in massive transfusion.
        J Trauma. 2009; 67: 1004-1012
        • Cotton B.A.
        • Au B.K.
        • Nunez T.C.
        • Gunter O.L.
        • Robertson A.M.
        • Young P.P.
        Predefined massive transfusion protocols are associated with a reduction in organ failure and postinjury complications.
        J Trauma. 2009; 66 (discussion 8-9): 41-48
        • Tan J.N.
        • Burke P.A.
        • Agarwal S.K.
        • Mantilla-Rey N.
        • Quillen K.
        A massive transfusion protocol incorporating a higher FFP/RBC ratio is associated with decreased use of recombinant activated factor VII in trauma patients.
        Am J Clin Pathol. 2012; 137: 566-571
        • Khan S.
        • Allard S.
        • Weaver A.
        • Barber C.
        • Davenport R.
        • Brohi K.
        A major haemorrhage protocol improves the delivery of blood component therapy and reduces waste in trauma massive transfusion.
        Injury. 2013; 44: 587-592
        • O’Keeffe T.
        • Refaai M.
        • Tchorz K.
        • Forestner J.E.
        • Sarode R.
        A massive transfusion protocol to decrease blood component use and costs.
        Arch Surg. 2008; 143 (discussion 90-1): 686-690
        • McDaniel L.M.
        • Neal M.D.
        • Sperry J.L.
        • Alarcon L.H.
        • Forsythe R.M.
        • Triulzi D.
        • et al.
        Use of a massive transfusion protocol in nontrauma patients: activate away.
        J Am Coll Surg. 2013; 216: 1103-1109
        • Riskin D.J.
        • Tsai T.C.
        • Riskin L.
        • Hernandez-Boussard T.
        • Purtill M.
        • Maggio P.M.
        • et al.
        Massive transfusion protocols: the role of aggressive resuscitation versus product ratio in mortality reduction.
        J Am Coll Surg. 2009; 209: 198-205
        • Koffka K.
        Principles of gestalt psychology.
        Harcourt, Brace and Company, New York1935
        • Bolte A.
        • Goschke T.
        Intuition in the context of object perception: intuitive gestalt judgments rest on the unconscious activation of semantic representations.
        Cognition. 2008; 108: 608-616
        • Pelli D.G.
        • Majaj N.J.
        • Raizman N.
        • Christian C.J.
        • Kim E.
        • Palomares M.C.
        Grouping in object recognition: the role of a Gestalt law in letter identification.
        Cognit Neuropsychol. 2009; 26: 36-49
        • Ali N.
        • Peebles D.
        The effect of Gestalt laws of perceptual organization on the comprehension of three-variable bar and line graphs.
        Hum Factors. 2013; 55: 183-203
        • Kabrhel C.
        • Camargo Jr., C.A.
        • Goldhaber S.Z.
        Clinical gestalt and the diagnosis of pulmonary embolism: does experience matter.
        Chest. 2005; 127: 1627-1630
        • Cook C.
        Is clinical gestalt good enough?.
        J Manual Manip Ther. 2009; 17: 6-7
        • Koontz N.A.
        • Gunderman R.B.
        Gestalt theory: implications for radiology education.
        AJR Am J Roentgenol. 2008; 190: 1156-1160
        • Klein J.G.
        Five pitfalls in decisions about diagnosis and prescribing.
        BMJ. 2005; 330: 781-783
        • Dubose J.J.
        • Scalea T.M.
        • Holcomb J.B.
        • Shrestha B.
        • Okoye O.
        • Inaba K.
        • et al.
        Open abdominal management after damage-control laparotomy for trauma: a prospective observational American Association for the Surgery of Trauma multicenter study.
        J Trauma Acute Care Surg. 2013; 74 (discussion 1120-2): 113-120
        • Rahbar M.H.
        • Fox E.E.
        • del Junco D.J.
        • Cotton B.A.
        • Podbielski J.M.
        • Matijevic N.
        • et al.
        Coordination and management of multicenter clinical studies in trauma: experience from the PRospective Observational Multicenter Major Trauma Transfusion (PROMMTT) Study.
        Resuscitation. 2012; 83: 459-464
        • Yucel N.
        • Lefering R.
        • Maegele M.
        • Vorweg M.
        • Tjardes T.
        • Ruchholtz S.
        • et al.
        Trauma Associated Severe Hemorrhage (TASH)-Score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma.
        J Trauma. 2006; 60 (discussion 36-7): 1228-1236
        • McLaughlin D.F.
        • Niles S.E.
        • Salinas J.
        • Perkins J.G.
        • Cox E.D.
        • Wade C.E.
        • et al.
        A predictive model for massive transfusion in combat casualty patients.
        J Trauma. 2008; 64 (discussion S): S57-S63
        • Schreiber M.A.
        • Perkins J.
        • Kiraly L.
        • Underwood S.
        • Wade C.
        • Holcomb J.B.
        Early predictors of massive transfusion in combat casualties.
        J Am Coll Surg. 2007; 205: 541-545
        • Nunez T.C.
        • Voskresensky I.V.
        • Dossett L.A.
        • Shinall R.
        • Dutton W.D.
        • Cotton B.A.
        Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption).
        J Trauma. 2009; 66: 346-352
        • Cotton B.A.
        • Dossett L.A.
        • Haut E.R.
        • Shafi S.
        • Nunez T.C.
        • Au B.K.
        • et al.
        Multicenter validation of a simplified score to predict massive transfusion in trauma.
        J Trauma. 2010; 69: S33-S39
        • Penaloza A.
        • Verschuren F.
        • Meyer G.
        • Quentin-Georget S.
        • Soulie C.
        • Thys F.
        • et al.
        Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism.
        Ann Emerg Med. 2013; 62 (e2): 117-124
        • Mitra B.
        • Rainer T.H.
        • Cameron P.A.
        Predicting massive blood transfusion using clinical scores post-trauma.
        Vox Sang. 2012; 102: 324-330
        • Sears B.W.
        • Luchette F.A.
        • Esposito T.J.
        • Dickson E.L.
        • Grant M.
        • Santaniello J.M.
        • et al.
        Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients?.
        J Trauma. 2005; 59 (discussion 30-2): 324-330
        • Dillard E.
        • Luchette F.A.
        • Sears B.W.
        • Norton J.
        • Schermer C.R.
        • Reed 2nd, R.L.
        • et al.
        Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?.
        Am J Emerg Med. 2007; 25: 823-830
        • Goettler C.E.
        • Waibel B.H.
        • Goodwin J.
        • Watkins F.
        • Toschlog E.A.
        • Sagraves S.G.
        • et al.
        Trauma intensive care unit survival: how good is an educated guess?.
        J Trauma. 2010; 68 (discussion 87-8): 1279-1287