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Crit Care
Critical Care
1364-8535
1466-609X
BioMed Central London

38762746
4955
10.1186/s13054-024-04955-7
Research
Development and validation of the tic score for early detection of traumatic coagulopathy upon hospital admission: a cohort study
Brac Louis louis.brac@hotmail.fr

1
Levrat Albrice 1
Vacheron Charles-Hervé 23
Bouzat Pierre 4
Delory Tristan 56
David Jean-Stéphane 78
1 Department of Intensive Care, Annecy-Genevois Hospital, Annecy, France
2 https://ror.org/01502ca60 grid.413852.9 0000 0001 2163 3825 Department of Anesthesia and Intensive Care, Groupe Hospitalier Sud, Hospices Civils de Lyon, Pierre Bénite, France
3 grid.413852.9 0000 0001 2163 3825 Biostatistics Health Team, Biometrics and Evolutionary Biology Laboratory, Hospices Civils de Lyon, Lyon, France
4 https://ror.org/02rx3b187 grid.450307.5 Department of Anesthesia and Intensive Care, Grenoble-Alpes University Hospital, Grenoble, France
5 Annecy-Genevois Hospital, Annecy, France
6 grid.462844.8 0000 0001 2308 1657 INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique, Sorbonne Université, Paris, France
7 grid.411430.3 0000 0001 0288 2594 Department of Anesthesia and Intensive Care, Lyon Sud Hospital, Hospices Civils de Lyon, Pierre-Bénite, France
8 grid.7849.2 0000 0001 2150 7757 Research on Healthcare Performance (RESHAPE), INSERM U1290, University Claude Bernard Lyon 1, Lyon, France
18 5 2024
18 5 2024
2024
28 1682 2 2024
14 5 2024
© The Author(s) 2024
2024
https://creativecommons.org/licenses/by/4.0/ Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.
Background

Critically injured patients need rapid and appropriate hemostatic treatment, which requires prompt identification of trauma-induced coagulopathy (TIC) upon hospital admission. We developed and validated the performance of a clinical score based on prehospital resuscitation parameters and vital signs at hospital admission for early diagnosis of TIC.

Methods

The score was derived from a level-1 trauma center registry (training set). It was then validated on data from two other level-1 trauma centers: first on a trauma registry (retrospective validation set), and then on a prospective cohort (prospective validation set). TIC was defined as a PTratio > 1.2 at hospital admission. Prehospital (vital signs and resuscitation care) and admission data (vital signs and laboratory parameters) were collected. We considered parameters independently associated with TIC in the score (binomial logistic regression). We estimated the score’s performance for the prediction of TIC.

Results

A total of 3489 patients were included, and among these a TIC was observed in 22% (95% CI 21–24%) of cases. Five criteria were identified and included in the TIC Score: Glasgow coma scale < 9, Shock Index > 0.9, hemoglobin < 11 g.dL−1, prehospital fluid volume > 1000 ml, and prehospital use of norepinephrine (yes/no). The score, ranging from 0 and 9 points, had good performance for the identification of TIC (AUC: 0.82, 95% CI: 0.81–0.84) without differences between the three sets used. A score value < 2 had a negative predictive value of 93% and was selected to rule-out TIC. Conversely, a score value ≥ 6 had a positive predictive value of 92% and was selected to indicate TIC.

Conclusion

The TIC Score is quick and easy to calculate and can accurately identify patients with TIC upon hospital admission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-024-04955-7.

Keywords

Coagulopathy
Score
Trauma
Prehospital
Prediction
Blood products
issue-copyright-statement© BioMed Central Ltd., part of Springer Nature 2024
==== Body
pmcIntroduction

Severe injuries are a leading cause of death globally, particularly among young people [1]. Uncontrolled bleeding and traumatic brain injury are the primary causes of death in these patients, and trauma-induced coagulopathy (TIC) is frequent in such cases (up to a third of patients) [2]. TIC is associated with impaired outcomes, including an increased likelihood of massive bleeding, multiple organ failure, transfusion, and death in the first hours following hospital admission [3–5]. Early and aggressive resuscitation strategies that aim to directly correct TIC are associated with improved outcomes and decreased blood products administration [6, 7], and therefore the early identification and prompt treatment of TIC are essential [8]. However, in daily practice, the administration of hemostatic resuscitation is often based on clinical judgment, which performs moderately to identify massive hemorrhage [9], leading to unnecessary blood product administration to patients responsible for potential side effects and wasted blood products [10].

TIC is most commonly defined as a PTratio measurement > 1.2 [11]. It is usually measured using conventional coagulation techniques or point-of-care devices [12, 13], including viscoelastic techniques (VET) [14], but they have several limitations and are not available in all hospitals. In addition to point-of-care devices, it has been also suggested to calculate scores upon patient admission for predicting TIC or the need for massive transfusion [15–17]. These scores usually require additional laboratory data such as arterial blood gas measurement, a FAST (focused assessment with sonography in trauma) or a full clinical examination. Perkins et al. have proposed a score based on 14 variables that must be calculated online, and which is strongly associated with TIC [16]. Two other scores, COAST and PACT, have also been proposed [15, 18]. Both can be calculated before hospital admission. The performance of the COAST score is weak as sensitivity is poor; that of the PACT score is better, but it only considers certain elements of pre-hospital resuscitation, such as cardiopulmonary resuscitation or intubation and it requires an online application for calculation [15]. In a previous study, we observed that several parameters, including pre-hospital vital signs (Glasgow coma scale and Shock Index) pre-hospital resuscitation (fluids and vasopressors), as well as parameters measured at admission (Shock Index and point-of-care hemoglobin) were associated with TIC upon admission [19].

The aim of the present study was to create and validate a straightforward screening tool, called the Trauma Induced Coagulopathy (TIC) Score, to rapidly identify patients with a PTratio > 1.2.

Material and methods

Study design and data collection

To build the score, we used data from the registries of three regional trauma centers (Lyon-Sud university hospital, Grenoble university hospital, and Annecy Genevois hospital). We retrieved the demographic and injury characteristics for each patient, including the Injury Severity Score (ISS), prehospital and admission vital signs, prehospital resuscitation including fluids volume, tranexamic acid and vasopressor, and survival at hospital discharge. Point-of-care hemoglobin (HemoCue® France, Bailly-Romainvilliers, France) was measured at admission. TIC was defined as a PTratio > 1.2 [2, 3]. We excluded patients who were treated with anticoagulants, received fresh frozen plasma or platelet concentrates during the prehospital phase. Additionally, we excluded patients without hemostasis analysis at admission. The study was approved by the ethics committee of the French Society of Anesthesia and Intensive Care (00010254-2021-217), and it was registered under the number (Commission Nationale Informatique et Liberté, MR004-2205982). Information about the registry was provided to all patients (or their next of kin), and written informed consent was not required. This study follows the TRIPOD Statement for prediction model studies [20].

The score was derived from the first set of data (training set) obtained from the trauma registry in Lyon. We then validated the predictive values of the TIC Score retrospectively on a trauma registry (retrospective validation set) common to Grenoble and Annecy trauma centers. Finally, we validated the performance of the TIC Score, in a third set, on data prospectively collected in two trauma centers (Grenoble university hospital and Genevois-Annecy hospital), that were required for computing individual score value.

Patient care

In France, all patients are cared for and triaged during the prehospital phase by a physician who may be an anesthesiologist or an emergency medicine physician (‘SAMU system’) [21, 22]. After careful evaluation of injury severity (clinical examination and vital signs, FAST examination, point-of-care hemoglobin), the prehospital physician implements all the necessary care including resuscitation techniques (mechanical ventilation, blood transfusion, general anesthesia, vasopressor and fluid resuscitation, analgesia, etc.) and direct the patient to the most appropriate facility. Fluid resuscitation usually includes crystalloids such as saline or a balanced solution (Ringer's lactate). Administration of norepinephrine is suggested if, despite fluid resuscitation, systolic blood pressure remains below 80–90 mmHg or in the case of severe head trauma, if systolic blood pressure remains below 110–120 mmHg. The three trauma centers have similar practices in the anesthesiologist-led trauma resuscitation unit. This includes blood testing strategy and algorithmic-based decision-making process for delivering blood products. A viscoelastic assay is used to diagnose a TIC and to guide administration of blood products in the three trauma centers.

The TIC score

Training set

We developed the score using data from a training cohort retrieved from a prospective registry supervised by the regional emergency network ‘RESUVAL’. We included from the registry severely injured patients admitted to the Lyon Sud university hospital, a level-1 trauma center, between January 1, 2011, and December 31, 2019, who met at least one of the following criteria: (1) received at least one blood product or coagulation factor concentrate during the first 24 h following hospital admission; (2) had a ROTEM (Werfen, le Pré St Gervais, France) or conventional laboratory tests to measure hemostasis; (3) were admitted to a critical care unit.

Factors independently associated with a PTratio > 1.2 at admission were identified, using bi-directional stepwise logistic binomial regression, among the following: sex, type of injury (factor, blunt versus penetrating), Glasgow coma scale at first medical evaluation (numeric value, between 3 and 15), prehospital and admission systolic blood pressure (numeric value, in mmHg), heart rate (numeric value, in bpm) and Shock index (numeric value, heart rate/systolic blood pressure), admission point-of-care hemoglobin level (numeric value, in g.dL−1), prehospital resuscitation using fluid therapy (factor, yes/no), and prehospital use of norepinephrine (factor, yes/no). Each numeric variable was categorized using the median, or the most relevant cut-off. Associations were reported as odds ratio (OR) with 95% confidence intervals (CI). We derived the score form from the final model’s coefficients (β) of the factors that were significantly associated with the outcome in the regression analysis, using a previously described methodology [23].

Retrospective validation set

To ensure the generalizability of the score, we first validated the TIC Score using data from a regional trauma registry in which data are prospectively collected, including all adult patients admitted with a severe injury according to regional triage rules, and admitted to one of two level-1 trauma centers (Grenoble university hospital, and Annecy Genevois hospital, France—the ‘TRENAU’ registry) between January 1, 2018 and December 31, 2020 [22].

Prospective validation set

To control for the level of missingness for the variables of interest and optimize methodological reliability, we constituted a prospective validation cohort of all consecutive patients admitted with severe injury to the same two trauma centers (Grenoble university hospital, and Annecy Genevois hospital, France—the ‘TRENAU’ registry) between February 1 and May 31, 2022. Data collected in this cohort were crosschecked by independent examiners.

Statistical analysis

We used median and interquartile range [IQR] to describe numeric variables, and number and percentage (%) for nominal variables. Differences between groups were estimated using the Wilcoxon rank-sum test for quantitative variables, and the Chi-squared test or Fisher’s exact test for qualitative variables.

Score performances

For each of these datasets, we calculated the performance of the score to predict a coagulopathy (PTratio > 1.2), including sensitivity and specificity, negative and positive predictive values, as well as the discrimination (receiver operating characteristic curve) and the calibration (calibration plot and Brier score). We also calculated the predicted probability of coagulopathy associated with each score value.

As INR is used by some in place of PTratio, we also checked that substituting INR for PTratio did not alter the results; in addition the performance of the TIC Score to predict fibrinogen < 1.5 g.L−1.

For the training set and the first validation set, we used Multivariate Imputation by Chained Equations (MICE) to handle missing information. In the second validation set, we did not impute for missing data. We performed a sensitivity analysis by estimating the performance of the score on the merged datasets including all patients with complete data. All tests were two-tailed, and significance set at 5%. All analyses were performed using the R software for statistical computing, version 3.4.3 (R foundation for statistical computing, Vienna, Austria).

Results

In total, 3,489 trauma patients were included in the study: 984 (28%) in the training set, 2275 (65%) in the historical validation set, and 230 (7%) in the prospective validation set (Fig. 1). Overall, the rate of TIC was 22% (95% CI 21–24%). Patients were severely injured (median [IQR] ISS 17 [9–26]), and their injury was overwhelmingly blunt trauma (93%, Table 1). The characteristics of each set are described in Table 1.Fig. 1 Flowchart of the study. Exclusion criteria: Patients < 18 years old, receiving anticoagulant therapy, prehospital administration of fresh frozen plasma/fibrinogen concentrate

Table 1 Baseline demographics and vital signs. Data are median [interquartile range] or n (%)

Characteristics	Training Set	Retrospective validation set	Prospective validation set	Data available	
N	984	2275	230	3489	
Demographics and injury characteristics	
Age	41 [25–57]	40 [28–56]	37 [25–56]	3455 (99)	
Male sex	748 (76)	1805 (79)	164 (73)	3489 (100)	
Penetrating injury	62 (6)	169 (7)	13 (6)	3489 (100)	
ISS	25 [17–33]	13 [9–25]	16 [9–25]	3484 (100)	
ISS categories	
 < 16	172 (18)	1340 (59)	109 (47)		
16–24	306 (31)	377 (17)	66 (29)		
25–48	445 (45)	526 (23)	44 (19)		
49–75	61 (6)	28 (1)	19 (8)		
Prehospital characteristics	
Shock Index > 0.9	245 (25)	300 (18)	40 (18)	3274 (94)	
GCS < 9	290 (30)	326 (15)	34 (15)	3429 (98)	
TXA administration	497 (52)	528 (37)	149 (66)	2625 (75)	
Norepinephrine use	201 (20)	111 (5)	34 (15)	3488 (100)	
Prehospital RBC	41 (4)	13 (1)	4 (2)	3489 (100)	
Admission characteristics	
Shock index, continuous	0.7 [0.6–0.9]	0.7 [0.6–0.8]	0.7 [0.6–0.8]	3274 (94)	
Shock Index > 0.9	295 (25)	295 (13)	40 (18)	3274 (94)	
Laboratory tests	
POC Hgb	125 [108–139]	139 [129–151]	137 [135–150]	3444 (99)	
POC Hgb < 11 (g.dL−1)	252 (26)	237 (10)	36 (16)	3444 (99)	
PTratio	1.1 [1.0–1.3]	1.1 [1.0–1.2]	1.1 [1.0–1.2]	3476 (100)	
PTratio > 1.2	320 (34)	412 (18)	51 (22)	3476 (100)	
Hemoglobin (g.dL−1)	126 [110–140]	139 [129–151]	137 [123–149]	3460 (99)	
Fibrinogen (g.L−1)	2.1 [1.7–2.6]	2.7 [2.2–3.2]	2.5 [2.1–2.9]	3370 (96)	
Platelet (109.L−1)	213 [179–259]	238 [200–279]	241 [198–290]	3453 (99)	
Data are median [interquartile range] or n (%)

GCS Glasgow coma scale; TXA tranexamic acid; RBC red blood cell; POC point-of-care; PTratio prothrombin time ratio; Hgb hemoglobin

The TIC score

From regression analysis, and among the 984 patients in the training set, factors associated with a coagulopathy upon trauma center admission were: prehospital GCS < 9; admission point-of-care hemoglobin level < 11 g/dL; admission Shock Index value > 0.9; prehospital fluid therapy above 1000 ml; and prehospital norepinephrine (Table 2). These variables were included in the computation of the TIC Score, for which values ranged from 0 to 9. The score coefficients and score points are presented in Table 2.Table 2 Factors associated with coagulopathy, and variables retained in the score in multivariate regression analysis

TIC Score variables	Coefficient	Odds ratio (95% CI)	Corresponding Score points	
Point-of-care hemoglobin level < 11 (g.dL−1)	1.47	4.37 (3.06–6.23)	3	
Shock Index > 0.9	1.13	3.10 (2.19–4.40)	2	
GCS < 9	0.98	2.67 (1.87–3.82)	2	
Prehospital Fluid resuscitation > 1000 ml	0.82	2.24 (1.16–2.68)	1	
Prehospital norepinephrine	0.56	2.27 (1.60–3.23)	1	
Total			9	
Intercept of construction model: −2.30 [−2.57 to −2.04], p < 0.001

We defined a score value < 2 as the threshold for a low probability of coagulopathy, and a score value ≥ 6 as the one for a high probability of coagulopathy. Score values between 2 and 5 indicate possible coagulopathy (Table 3). Among the 3075 patients with complete data across different datasets, 1967 (64%) had a score < 2900 (29%) had a score between 2 and 5, and 208 (7%) had a score ≥ 6. Fibrinogen, PTratio and platelet count by score category, are presented in Supplementary Fig. S1. Across all datasets, the score yielded an area under the curve (AUC) of 0.82 (95% CI 0.81–0.84) to predict TIC (Fig. 2A). The calibration was 0.115 according to the Brier score, without significant differences across sets (Fig. 2B). Details of the performance and calibration of the TIC Score on the training and validation sets are presented in Table 3.Table 3 Performance and calibration of the TIC score on training and validation sets

Score	Training set	Validation set	Prospective set	Total population	
Probability	PPV	NPV	Probability	PPV	NPV	Probability	PPV	NPV	Probability	PPV	NPV	
0	9.1	44.7	90.4	7.3	45.1	93.1	2.9	64.5	98.0	7.8	45.9	93.1	
1	14.7	49	89.4	15.0	45.7	92.7	9.4	67.8	98.1	14.2	48.2	92.5	
2	23.0	58.4	85.1	28.3	70.0	88.7	26.7	82.1	93.8	24.4	64.2	88.4	
3	33.0	70.5	83.5	46.9	78.2	86.9	56.1	96.4	91.4	38.8	74.8	86.5	
4	47.0	76.1	81.1	66.4	84.3	85.8	81.7	95.8	89.5	55.3	79.8	85.1	
5	60.5	82.4	77.5	81.5	96.3	83.8	94.0	94.4	86.8	70.8	86.5	82.5	
6	72.5	89.1	74.6	90.8	97.4	83.2	98.2	92.3	84.7	82.6	92.0	81.1	
7	82.0	91.7	70.5	95.7	100	82.5	99.5	100	83.5	90.3	94.9	79.3	
8	88.7	96.2	69.2	98.0	100	82.0	99.9	100	81.9	94.8	96.7	78.6	
9	93.1	100	67.5	99.1	100	–	100	100	80.0	93.3	100	77.9	
AUC (95% CI)	0.82 (0.79–0.85)	0.80 (0.77–0.82)	0.93 (0.89–0.96)	0.83 (0.81–0.84)	
PPV positive predictive value; NPV negative predictive value. Calibration for total population (Brier: 0.115). AUC (area under the curve); 95% CI: 95% confidence interval

Fig. 2 TIC Score receiving operating curve and calibration plot for predicting PTratio > 1.2, by dataset and overall. Panel A: ROC curve. Plot of the TIC Score sensitivity by specificity for predicting PTratio > 1.2, by dataset; Panel B: Calibration Plot. Plot of observed probabilities by the probabilities predicted by the TIC Score for observing a PTratio > 1.2, and dataset. Lines are smoothed using coefficients from linear regression: blue line indicates Training Set, Sky blue line indicates retrospective Set, red line indicates prospective set and purple line indicates All Cohorts

We explored if the INR could be used to define TIC instead of PTratio to establish the scoring system. The AUC of the score to predict a TIC defined as an INR > 1.2 instead of PTratio > 1.2, was 0.80 (95% CI 0.79–0.82), which was not significantly different from the AUC calculated with the PTratio (p = 0.097).

We also observed that the TIC Score well predicted fibrinogen < 1.5 g.L−1 (AUC: 0.88, 95% CI: 0.86 to 0.90) and a threshold ≥ 6 had a 97% specificity (Supplementary Fig.  S2).

Outcomes and blood products administration

Overall, mortality was 10.0% (95% CI: 8.9% to 11.1%) at hospital discharge. We observed a close relationship between the TIC Score and the administration of blood products, massive transfusion rate, mortality at 24 h and at hospital discharge (Fig. 3).Fig. 3 Outcome according to score values. Bars correspond to frequency of event (percentage) by score value (ranging from 0 to 9). The 95% CI are displayed for each point using error bars in lightgrey

Discussion

We have developed a simple and ready-to-use screening tool for the early detection of TIC. The TIC Score has good statistical performance; a TIC Score < 2 indicating patients with a low probability of TIC, and a TIC Score ≥ 6 identifying patients with a high probability of TIC.

Trauma patients require hemostatic goal-directed therapy that relies on early and accurate diagnosis of TIC to provide optimal blood support [6, 8, 14, 24]. Laboratory tests used to guide hemostatic therapy can be either conventional coagulation tests or viscoelastic assays [8]. Viscoelastic assays allow timely management of trauma by providing a 30–60-min gain over conventional coagulation tests [14]. A randomized controlled trial of patients requiring massive transfusion showed improved survival at 28 days for those allocated to receive a massive transfusion protocol guided by viscoelastic testing compared with conventional coagulation testing [6]. However, these results were not replicated in the ITACTIC randomized controlled trial [25], probably due to a bias towards a population at very low risk of trauma-induced coagulopathy [26]. These data highlight the need for a screening tool able to accurately detect the presence of a TIC upon patient admission. The TIC Score will allow the selection of patients with a high probability of trauma-induced coagulopathy, i.e. those who could benefit the most from early initiation of active therapies, including fibrinogen (TIC Score ≥ 6). It is for these patients that the use of VETs could be most interesting and relevant. Conversely, for patients with a low probability of coagulopathy (TIC Score < 2, 64% of cases) the administration of blood products will be avoided and also the many associated side effects (TRALI, infection, venous thrombosis, etc.).

Other scores have been developed for the prediction of massive blood transfusion (ABC, TASH, TICCS), or to assess the presence of a coagulopathy (PACT, TICCS, COAST) [16, 17, 27–29]. However, although these scores can predict massive transfusion or coagulopathy, they were not developed to implement a goal-directed therapy algorithm [29, 30]. Only the Bayesian score has been specifically developed to identify a PTratio > 1.2, with similar performance to the TIC Score described herein [31], but it is not suitable for the early management of severely injured patients because of its complexity (14 variables including 3 laboratory variables) that precludes its timely calculation at the admission to the trauma center. Other scores have a low sensitivity for predicting coagulopathy (21% for TICCS and 17% for COAST), resulting in a high likelihood of false negatives and in the risk of missing opportunities for early detection and correction of TIC [29, 32]. It has been emphasized that in the absence of external and prospective validation of these scores, their reliability is too low to promote their use in daily practice [30, 33].

While PTratio and INR values may not be directly interchangeable due to variations in thromboplastin sensitivity, the consistent performance of the TIC Score regardless of the parameter used suggests its robustness in characterizing coagulopathy. This flexibility enhances the applicability and usability of the TIC Score across different healthcare settings and practices.

Finally, we propose a simple triage algorithm (Fig. 4) that strikes a balance between sensitivity and specificity, and could enable, in a straightforward manner, a more targeted and specific use of VETs and, where appropriate, blood products.Fig. 4 Suggested triage algorithm using the TIC Score. This algorithm proposes à patient management strategy found on clinical features and TIC Score values. FFP fresh frozen plasma; RBC red blood cell

Study strengths

The multicenter design in highly experienced level-1 trauma centers, with a large sample size mixing data from trauma registries with prospective evaluations, supports the robustness and reliability of interpretation. The TIC Score is operational and pragmatic, with variables systematically and immediately available upon admission to the trauma center. Several key factors justify the extrapolation of the results across centers: the wide range of trauma types and severity of injury as well as the various geographical areas (rural, mountainous and urban). Finally, we also observed that INR can be used as an alternative to the PTratio, thus increasing the possibilities of using the TIC Score.

Study limitations

The registry data used to develop the TIC Score had missingness (~ 12%). However, in the prospective dataset the level of missingness was very low, and the performance of the score remained similar. The performance of the score was also consistent in the analysis including all patients with complete data. However, patients presented mainly with blunt trauma, and only 7% with penetrating trauma, as is usually the case in France [34, 35]. This is well below that observed in American trauma centers, where ballistic trauma is more commonly observed [34]. Another limitation is that the study was conducted in a trauma system where patients are cared by a physician and then received extensive prehospital resuscitation, including fluid resuscitation and vasopressors, intubation and mechanical ventilation, chest tube, and, if available, blood products. The results presented herein may therefore not be transposable to systems where patients do not benefit from intensive prehospital resuscitation and where priority is given to rapid transport. A final limitation may arise from the fact that norepinephrine administration and the Shock Index co-exist in the score, and that there may be interactions between the 2. This is a parameter to be taken into account, but several years ago we showed that the Shock Index measured during the patient's initial pre-hospital assessment was associated in multivariate analysis with the occurrence of coagulopathy or massive transfusion, after adjustment on several parameters including norepinephrine administration [19].

Conclusion

The TIC Score is an easy to calculate score for the early diagnosis of TIC at admission. It may help for the selection of patients in need of viscoelastic testing or a hemostatic treatment. A score < 2 rules out a TIC whereas a score ≥ 6 indicates a TIC.

Supplementary Information

Supplementary file 1 (JPG 1471 kb)

Supplementary file 2 (JPG 453 kb)

Supplementary file 3 (DOCX 12 kb)

Acknowledgements

We express our gratitude to the medical and nursing staff of the Departments of Anesthesia and Intensive Care Medicine of the 3 participating Hospital; without whose assistance this study would not have been possible. To the medical and nursing staff of the 3 department of Anesthesia and Intensive care.

Author contributions

JSD, AL, CVH, TD and LBP conceived the study, analyzed the data, and wrote the manuscript. CHV and TD did statistical analysis. LBP collected data. PB critical reviewed the article. All authors read and approved the final manuscript.

Funding

None.

Availability of data and materials

On demand to the authors.

Declarations

Ethics approval and consent to participate

The study was approved by the Ethics Committee of the French Society of Anesthesia and Intensive Care (Number IRB 00010254-2021-217), which was registered with the French authorities under the number MR004-2205982. Information about the registry was provided to all patients (or their next of kin), and written informed consent was not required.

Consent for publication

Written informed consent was not required, and all patients (or their next of kin) were provided with information about the registry.

Competing interests

JSD and PB did lectures and consulting for LFB (Les Ullis, France).

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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References

1. Harikrishnan S Jeemon P Mini GK Thankappan KR Sylaja PGBD GBD 2017 causes of Death Collaborators Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the global burden of disease study 2017 Lancet 2018 392 10159 1736 1788 10.1016/S0140-6736(18)32203-7 30496103
Harikrishnan S, Jeemon P, Mini GK, Thankappan KR, Sylaja PGBD, GBD 2017 causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: a systematic analysis for the global burden of disease study 2017. Lancet. 2018;392(10159):1736–88.30496103 10.1016/S0140-6736(18)32203-7
2. Davenport R Curry N Manson J De'Ath H Coates A Rourke C Pearse R Stanworth S Brohi K Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2 J Trauma 2011 70 1 90 95 21217486
Davenport R, Curry N, Manson J, De’Ath H, Coates A, Rourke C, Pearse R, Stanworth S, Brohi K. Hemostatic effects of fresh frozen plasma may be maximal at red cell ratios of 1:2. J Trauma. 2011;70(1):90–5.21217486
3. Frith D Goslings JC Gaarder C Maegele M Cohen MJ Allard S Johansson PI Stanworth S Thiemermann C Brohi K Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations J Thromb Haemost 2010 8 9 1919 1925 10.1111/j.1538-7836.2010.03945.x 20553376
Frith D, Goslings JC, Gaarder C, Maegele M, Cohen MJ, Allard S, Johansson PI, Stanworth S, Thiemermann C, Brohi K. Definition and drivers of acute traumatic coagulopathy: clinical and experimental investigations. J Thromb Haemost. 2010;8(9):1919–25.20553376 10.1111/j.1538-7836.2010.03945.x
4. MacLeod JB Lynn M McKenney MG Cohn SM Murtha M Early coagulopathy predicts mortality in trauma J Trauma 2003 55 39 44 10.1097/01.TA.0000075338.21177.EF 12855879
MacLeod JB, Lynn M, McKenney MG, Cohn SM, Murtha M. Early coagulopathy predicts mortality in trauma. J Trauma. 2003;55:39–44.12855879 10.1097/01.TA.0000075338.21177.EF
5. Maegele M Lefering R Yucel N Tjardes T Rixen D Paffrath T Simanski C Neugebauer E Bouillon B (DGU). TAPotGTS: early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients Injury 2007 38 298 304 10.1016/j.injury.2006.10.003 17214989
Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, Simanski C, Neugebauer E, Bouillon B. (DGU). TAPotGTS: early coagulopathy in multiple injury: an analysis from the German Trauma Registry on 8724 patients. Injury. 2007;38:298–304.17214989 10.1016/j.injury.2006.10.003
6. Gonzalez E Moore EE Moore HB Chapman MP Chin TL Ghasabyan A Wohlauer MV Barnett CC Bensard DD Biffl WL Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays Ann Surg 2016 263 6 1051 1059 10.1097/SLA.0000000000001608 26720428
Gonzalez E, Moore EE, Moore HB, Chapman MP, Chin TL, Ghasabyan A, Wohlauer MV, Barnett CC, Bensard DD, Biffl WL, et al. Goal-directed hemostatic resuscitation of trauma-induced coagulopathy: a pragmatic randomized clinical trial comparing a viscoelastic assay to conventional coagulation assays. Ann Surg. 2016;263(6):1051–9.26720428 10.1097/SLA.0000000000001608
7. David JS James A Orion M Selves A Bonnet M Glasman P Vacheron CH Raux M Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study Crit Care 2023 27 1 141 10.1186/s13054-023-04421-w 37055832
David JS, James A, Orion M, Selves A, Bonnet M, Glasman P, Vacheron CH, Raux M. Thromboelastometry-guided haemostatic resuscitation in severely injured patients: a propensity score-matched study. Crit Care. 2023;27(1):141.37055832 10.1186/s13054-023-04421-w
8. Rossaint R Afshari A Bouillon B Cerny V Cimpoesu D Curry N Duranteau J Filipescu D Grottke O Gronlykke L The European guideline on management of major bleeding and coagulopathy following trauma Crit Care 2023 27 1 80 10.1186/s13054-023-04327-7 36859355
Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Gronlykke L, et al. The European guideline on management of major bleeding and coagulopathy following trauma. Crit Care. 2023;27(1):80.36859355 10.1186/s13054-023-04327-7
9. Wohlgemut JM Pisirir E Stoner RS Kyrimi E Christian M Hurst T Marsh W Perkins ZB Tai NRM Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome Trauma Surg Acute Care Open 2024 9 1 e001214 10.1136/tsaco-2023-001214 38274019
Wohlgemut JM, Pisirir E, Stoner RS, Kyrimi E, Christian M, Hurst T, Marsh W, Perkins ZB, Tai NRM. Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome. Trauma Surg Acute Care Open. 2024;9(1):e001214.38274019 10.1136/tsaco-2023-001214
10. Watson GA Sperry JL Rosengart MR Minei JP Harbrecht BG Moore EE Cuschieri J Maier RV Billiar TR Peitzman AB Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome J Trauma 2009 67 2 221 227 19667872
Watson GA, Sperry JL, Rosengart MR, Minei JP, Harbrecht BG, Moore EE, Cuschieri J, Maier RV, Billiar TR, Peitzman AB. Fresh frozen plasma is independently associated with a higher risk of multiple organ failure and acute respiratory distress syndrome. J Trauma. 2009;67(2):221–7.19667872
11. Davenport R Manson J De'Ath H Platton S Coates A Allard S Hart D Pearse R Pasi KJ MacCallum P Functional definition and characterization of acute traumatic coagulopathy Crit Care Med 2011 39 12 2652 2658 10.1097/CCM.0b013e3182281af5 21765358
Davenport R, Manson J, De’Ath H, Platton S, Coates A, Allard S, Hart D, Pearse R, Pasi KJ, MacCallum P, et al. Functional definition and characterization of acute traumatic coagulopathy. Crit Care Med. 2011;39(12):2652–8.21765358 10.1097/CCM.0b013e3182281af5
12. Mistral T Boue Y Bosson JL Manhes P Greze J Brun J Albaladejo P Payen JF Bouzat P Performance of point-of-care international normalized ratio measurement to diagnose trauma-induced coagulopathy Scand J Trauma Resusc Emerg Med 2017 25 1 59 10.1186/s13049-017-0404-y 28637514
Mistral T, Boue Y, Bosson JL, Manhes P, Greze J, Brun J, Albaladejo P, Payen JF, Bouzat P. Performance of point-of-care international normalized ratio measurement to diagnose trauma-induced coagulopathy. Scand J Trauma Resusc Emerg Med. 2017;25(1):59.28637514 10.1186/s13049-017-0404-y
13. David JS Levrat A Inaba K Macabeo C Rugeri L Fontaine O Cheron A Piriou V Utility of a point-of-care device for rapid determination of prothrombin time in trauma patients: a preliminary study J Trauma Acute Care Surg 2012 72 3 703 707 10.1097/TA.0b013e31822c884d 22491557
David JS, Levrat A, Inaba K, Macabeo C, Rugeri L, Fontaine O, Cheron A, Piriou V. Utility of a point-of-care device for rapid determination of prothrombin time in trauma patients: a preliminary study. J Trauma Acute Care Surg. 2012;72(3):703–7.22491557 10.1097/TA.0b013e31822c884d
14. Zipperle J Schmitt FCF Schochl H Point-of-care, goal-directed management of bleeding in trauma patients Curr Opin Crit Care 2023 29 6 702 712 10.1097/MCC.0000000000001107 37861185
Zipperle J, Schmitt FCF, Schochl H. Point-of-care, goal-directed management of bleeding in trauma patients. Curr Opin Crit Care. 2023;29(6):702–12.37861185 10.1097/MCC.0000000000001107
15. Peltan ID Rowhani-Rahbar A Vande Vusse LK Caldwell E Rea TD Maier RV Watkins TR Development and validation of a prehospital prediction model for acute traumatic coagulopathy Crit Care 2016 20 1 371 10.1186/s13054-016-1541-9 27846895
Peltan ID, Rowhani-Rahbar A, Vande Vusse LK, Caldwell E, Rea TD, Maier RV, Watkins TR. Development and validation of a prehospital prediction model for acute traumatic coagulopathy. Crit Care. 2016;20(1):371.27846895 10.1186/s13054-016-1541-9
16. Perkins ZB Yet B Marsden M Glasgow S Marsh W Davenport R Brohi K Tai NRM Early identification of trauma-induced coagulopathy: development and validation of a multivariable risk prediction model Ann Surg 2021 274 6 e1119 e1128 10.1097/SLA.0000000000003771 31972649
Perkins ZB, Yet B, Marsden M, Glasgow S, Marsh W, Davenport R, Brohi K, Tai NRM. Early identification of trauma-induced coagulopathy: development and validation of a multivariable risk prediction model. Ann Surg. 2021;274(6):e1119–28.31972649 10.1097/SLA.0000000000003771
17. Nunez TC Voskresensky IV Dossett LA Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma 2009 66 346 352 19204506
Nunez TC, Voskresensky IV, Dossett LA, et al. Early prediction of massive transfusion in trauma: simple as ABC (assessment of blood consumption)? J Trauma. 2009;66:346–52.19204506
18. Mitra B Cameron PA Mori A Maini A Fitzgerald M Paul E Street A Early prediction of acute traumatic coagulopathy Resuscitation 2011 82 9 1208 1213 10.1016/j.resuscitation.2011.04.007 21600687
Mitra B, Cameron PA, Mori A, Maini A, Fitzgerald M, Paul E, Street A. Early prediction of acute traumatic coagulopathy. Resuscitation. 2011;82(9):1208–13.21600687 10.1016/j.resuscitation.2011.04.007
19. David JS Voiglio EJ Cesareo E Vassal O Decullier E Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients Vox Sang 2017 112 557 566 10.1111/vox.12545 28612932
David JS, Voiglio EJ, Cesareo E, Vassal O, Decullier E, et al. Prehospital parameters can help to predict coagulopathy and massive transfusion in trauma patients. Vox Sang. 2017;112:557–66.28612932 10.1111/vox.12545
20. Collins GS Reitsma JB Altman DG Moons KG Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement BMJ 2015 350 g7594 10.1136/bmj.g7594 25569120
Collins GS, Reitsma JB, Altman DG, Moons KG. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): the TRIPOD statement. BMJ. 2015;350:g7594.25569120 10.1136/bmj.g7594
21. David JS Bouzat P Raux M Evolution and organisation of trauma systems Anaesth Crit Care Pain Med 2019 38 2 161 167 10.1016/j.accpm.2018.01.006 29476943
David JS, Bouzat P, Raux M. Evolution and organisation of trauma systems. Anaesth Crit Care Pain Med. 2019;38(2):161–7.29476943 10.1016/j.accpm.2018.01.006
22. Bouzat P Ageron FX Brun J Levrat A Berthet M Rancurel E Thouret JM Thony F Arvieux C Payen JF A regional trauma system to optimize the pre-hospital triage of trauma patients Crit Care 2015 19 111 10.1186/s13054-015-0835-7 25887150
Bouzat P, Ageron FX, Brun J, Levrat A, Berthet M, Rancurel E, Thouret JM, Thony F, Arvieux C, Payen JF, et al. A regional trauma system to optimize the pre-hospital triage of trauma patients. Crit Care. 2015;19:111.25887150 10.1186/s13054-015-0835-7
23. Mehta HB Mehta V Girman CJ Adhikari D Johnson ML Regression coefficient-based scoring system should be used to assign weights to the risk index J Clin Epidemiol 2016 79 22 28 10.1016/j.jclinepi.2016.03.031 27181564
Mehta HB, Mehta V, Girman CJ, Adhikari D, Johnson ML. Regression coefficient-based scoring system should be used to assign weights to the risk index. J Clin Epidemiol. 2016;79:22–8.27181564 10.1016/j.jclinepi.2016.03.031
24. Nardi G Agostini V Rondinelli B Russo E Bastianini B Bini G Bulgarelli S Cingolani E Donato A Gambale G Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs Crit Care 2015 19 83 10.1186/s13054-015-0817-9 25880548
Nardi G, Agostini V, Rondinelli B, Russo E, Bastianini B, Bini G, Bulgarelli S, Cingolani E, Donato A, Gambale G, et al. Trauma-induced coagulopathy: impact of the early coagulation support protocol on blood product consumption, mortality and costs. Crit Care. 2015;19:83.25880548 10.1186/s13054-015-0817-9
25. Baksaas-Aasen K Gall LS Stensballe J Juffermans NP Curry N Maegele M Brooks A Rourke C Gillespie S Murphy J Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial Intens Care Med 2021 47 1 49 59 10.1007/s00134-020-06266-1
Baksaas-Aasen K, Gall LS, Stensballe J, Juffermans NP, Curry N, Maegele M, Brooks A, Rourke C, Gillespie S, Murphy J, et al. Viscoelastic haemostatic assay augmented protocols for major trauma haemorrhage (ITACTIC): a randomized, controlled trial. Intens Care Med. 2021;47(1):49–59.10.1007/s00134-020-06266-1
26. Abraham P Pasquier P Rimmele T David JS Trauma patients do not benefit from a viscoelastic haemostatic assay-guided protocol, but why? Intens Care Med 2021 47 6 726 727 10.1007/s00134-021-06396-0
Abraham P, Pasquier P, Rimmele T, David JS. Trauma patients do not benefit from a viscoelastic haemostatic assay-guided protocol, but why? Intens Care Med. 2021;47(6):726–7.10.1007/s00134-021-06396-0
27. Tonglet ML Early prediction of ongoing hemorrhage in severe trauma: presentation of the existing scoring systems Arch Trauma Res 2016 5 4 e33377 10.5812/atr.33377 28144603
Tonglet ML. Early prediction of ongoing hemorrhage in severe trauma: presentation of the existing scoring systems. Arch Trauma Res. 2016;5(4):e33377.28144603 10.5812/atr.33377
28. Maegele M Lefering R Wafaisade A Theodorou P Wutzler S Fischer P Bouillon B Paffrath T Trauma Registry of Deutsche Gesellschaft fur U: Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury Vox Sang 2011 100 2 231 238 10.1111/j.1423-0410.2010.01387.x 20735809
Maegele M, Lefering R, Wafaisade A, Theodorou P, Wutzler S, Fischer P, Bouillon B, Paffrath T. Trauma Registry of Deutsche Gesellschaft fur U: Revalidation and update of the TASH-Score: a scoring system to predict the probability for massive transfusion as a surrogate for life-threatening haemorrhage after severe injury. Vox Sang. 2011;100(2):231–8.20735809 10.1111/j.1423-0410.2010.01387.x
29. Thorn S Lefering R Maegele M Gruen RL Mitra B Early prediction of acute traumatic coagulopathy: a validation of the COAST score using the German Trauma Registry Eur J Trauma Emerg Surg 2021 47 2 333 341 10.1007/s00068-019-01142-0 31037353
Thorn S, Lefering R, Maegele M, Gruen RL, Mitra B. Early prediction of acute traumatic coagulopathy: a validation of the COAST score using the German Trauma Registry. Eur J Trauma Emerg Surg. 2021;47(2):333–41.31037353 10.1007/s00068-019-01142-0
30. Thorn S Guting H Maegele M Gruen RL Mitra B Early identification of acute traumatic coagulopathy using clinical prediction tools: a systematic review Medicina 2019 55 10 653 10.3390/medicina55100653 31569443
Thorn S, Guting H, Maegele M, Gruen RL, Mitra B. Early identification of acute traumatic coagulopathy using clinical prediction tools: a systematic review. Medicina. 2019;55(10):653.31569443 10.3390/medicina55100653
31. Yet B Perkins Z Fenton N Tai N Marsh W Not just data: a method for improving prediction with knowledge J Biomed Inform 2014 48 28 37 10.1016/j.jbi.2013.10.012 24189161
Yet B, Perkins Z, Fenton N, Tai N, Marsh W. Not just data: a method for improving prediction with knowledge. J Biomed Inform. 2014;48:28–37.24189161 10.1016/j.jbi.2013.10.012
32. Tonglet ML Minon JM Seidel L Poplavsky JL Vergnion M Prehospital identification of trauma patients with early acute coagulopathy and massive bleeding: results of a prospective non-interventional clinical trial evaluating the Trauma Induced Coagulopathy Clinical Score (TICCS) Crit Care 2014 18 6 648 10.1186/s13054-014-0648-0 25425230
Tonglet ML, Minon JM, Seidel L, Poplavsky JL, Vergnion M. Prehospital identification of trauma patients with early acute coagulopathy and massive bleeding: results of a prospective non-interventional clinical trial evaluating the Trauma Induced Coagulopathy Clinical Score (TICCS). Crit Care. 2014;18(6):648.25425230 10.1186/s13054-014-0648-0
33. Maegele M Spinella PC Schochl H The acute coagulopathy of trauma: mechanisms and tools for risk stratification Shock 2012 38 5 450 458 10.1097/SHK.0b013e31826dbd23 23042192
Maegele M, Spinella PC, Schochl H. The acute coagulopathy of trauma: mechanisms and tools for risk stratification. Shock. 2012;38(5):450–8.23042192 10.1097/SHK.0b013e31826dbd23
34. Haider AH David JS Zafar SN Gueugniaud PY Efron DT Floccard B MacKenzie EJ Voiglio E Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States Ann Surg 2013 258 1 178 183 10.1097/SLA.0b013e31828226b6 23478519
Haider AH, David JS, Zafar SN, Gueugniaud PY, Efron DT, Floccard B, MacKenzie EJ, Voiglio E. Comparative effectiveness of inhospital trauma resuscitation at a French trauma center and matched patients treated in the United States. Ann Surg. 2013;258(1):178–83.23478519 10.1097/SLA.0b013e31828226b6
35. Descamps C Hamada S Hanouz JL Vardon-Bounes F James A Garrigue D Abback P Cardinale M Dubreuil G Chatelon J Gunshot and stab wounds in France: descriptive study from a national trauma registry Eur J Trauma Emerg Surg 2022 48 5 3821 3829 10.1007/s00068-021-01742-9 34232339
Descamps C, Hamada S, Hanouz JL, Vardon-Bounes F, James A, Garrigue D, Abback P, Cardinale M, Dubreuil G, Chatelon J, et al. Gunshot and stab wounds in France: descriptive study from a national trauma registry. Eur J Trauma Emerg Surg. 2022;48(5):3821–9.34232339 10.1007/s00068-021-01742-9
