Unification of the revised trauma score

BACKGROUND: The Revised Trauma Score (RTS) calculated with Major Outcome Trauma Study weights (MTOS-RTS) is currently the standard physiologic severity score in trauma research and quality control. It is often confused with the Triage-RTS (T-RTS), a version that is easier to calculate but only intended for clinical triage. OBJECTIVES: To compare the accuracy of the MTOS-RTS to the RTS calculated with weights derived from the study population (POP-RTS) and the T-RTS, for predicting mortality in a trauma population. METHODS: The study population consists of 22,388 patients, drawn from the trauma registries of three Level I trauma centers. The predictive accuracy of the MTOS-RTS, POP-RTS, and the T-RTS were compared using measures of discrimination and model fit from logistic regression models. RESULTS: The MTOS-RTS, the POP-RTS, and the T-RTS had the same discrimination (Area under the Receiver Operating Curve [AUC] = 0.841). The POP-RTS and the T-RTS had a slightly better model fit than the MTOS-RTS (AIC = 8010, 8010, and 8067, respectively). The T-RTS had equal discrimination and equal or better model fit than the MTOS-RTS in the whole sample, in each of the three trauma centers and in the population of patients with severe head trauma. The T-RTS was also equivalent to the POP-RTS in all of these population sub-groups. CONCLUSIONS: The T-RTS could replace the MTOS-RTS as the standard physiologic severity score for trauma outcome prediction. The advantages of using the T-RTS over the MTOS-RTS are ease of calculation, the need for only one measure for triage and mortality prediction purposes and universal adaptation to a broad range of trauma populations.     

Statistical validation of the Revised Trauma Score

BACKGROUND: To validate the accuracy of the Revised Trauma Score (RTS) and its components for predicting in-hospital mortality. METHODS: Analyses were based on 22,388 patients from the trauma registries of three urban Level I trauma centers in the province of Quebec, Canada. The accuracy of RTS coded variables for the Glasgow Coma Score (GCSc), Systolic Blood Pressure (SBPc), and Respiratory Rate (RRc) for predicting mortality was evaluated in logistic regression models with measures of discrimination and model fit and compared with Fractional Polynomial (FP) transformations of each component. RESULTS: RTS coded variables were associated with sparse data distributions and did not accurately represent the relation of GCS, SBP, and RR to mortality. FP models were always associated with significantly better discrimination (all p < 0.00001) and model fit. Survival probability estimates generated by the model with FP transformations were significantly different to those generated by the model with RTS-coded variables. CONCLUSIONS: The RTS in its present form does not accurately describe the relation of GCS, SBP, and RR to mortality. FP transformation would improve the accuracy of predicted survival probabilities used for performance evaluation and may improve control of confounding caused by of physiologic severity case mix in trauma research.     

Development of a novel age-specific pediatric trauma score

BACKGROUND/PURPOSE: Trauma scoring systems are needed to provide efficient triage of injured patients and to assess differences in outcomes and quality of care between different trauma centers. Current scoring systems used in pediatric trauma are not age specific, and thus have significant limitations. METHODS: The authors queried the Pennsylvania Trauma Outcome Study for all children 0 to 16 years entered in the database from 1993 to 1996. Age-specific threshold values for systolic blood pressure, pulse, and respiratory rate were established. Using coded scores for these age-specific values and Glasgow Coma Scale, an age-specific pediatric trauma score (ASPTS) was derived. Triage ASPTS (T-ASPTS) consisted of the integer sum of coded scores for the 4 variables, whereas ASPTS was calculated using weighted coefficients derived from logistic regression for each variable. RESULTS: T-ASPTS correlated with mortality rate. Using a threshold score of less than 10, T-ASPTS predicted mortality rate with a sensitivity of 96.97% and a specificity of 88.83%. T-ASPTS predicted mortality rate and percentage of patients with Injury Severity Score greater than 20 with similar sensitivity to the Revised Trauma Score (RTS), but T-ASPTS was more specific. The ASPTS predicted probability of survival more accurately than the RTS. CONCLUSIONS: ASPTS performs favorably as both a triage score and as a tool for predicting probability of survival for outcomes analysis. Further comparisons to existing trauma scores are needed to verify the utility of ASPTS.     

Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study

IntroductionIn India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India.MethodsWe performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality.ResultsA total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality.ConclusionThe routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.     

IS THE REVISED TRAUMA SCORE STILL USEFUL?

The revised trauma score (RTS) has been embraced by the trauma community worldwide. Although originally developed as a triage tool, the use of the RTS has since been expanded to include the prediction of outcome following traumatic injury. Through a critical review of the literature, evidence for use of the RTS is discussed along with the limitations of this commonly used tool. In summary, the RTS is a well-established predictor of mortality in trauma populations, but there is a lack of definitive evidence supporting its use as a primary triage tool and as a predictor of outcomes other than mortality. Difficulty in collecting the components of the RTS creates issues for data validity and the use of the RTS as a research tool. Although the weighted RTS has been developed to improve the prediction capacity of the RTS, studies reporting its use are few and there is debate regarding the applicability of the published coefficients for broad use. Overall, further studies are warranted to clearly establish the usefulness of the RTS as a triage tool in the field, to further evaluate the weighted version of the RTS, and to determine the ability of the RTS to predict functional outcome and quality of life. In particular, future research is needed to address these issues in Australian trauma populations.     

Major pelvic fractures: identification of patients at high risk

The identification of high-risk factors in patients with fractures of the pelvis at the time of presentation would facilitate investigation and management. In a series of 174 consecutive patients with unstable fractures of the pelvic ring, clinical data were used to calculate the injury severity score (ISS), the triage-revised trauma score (T-RTS), and the Glasgow coma scale (GCS). The morphology of the fracture was classified according to the AO system and that of Burgess et al. The data were analysed using univariate and multivariate methods in order to determine which presenting features were identified with high risk.Univariate analysis showed an association between mortality and an ISS over 25, a T-RTS below eight, age over 65 years, systolic blood pressure under 100 mmHg, a GCS of less than 8, blood transfusion of more than ten units in the first 24 hours and colloid infusion of more than six litres in the first 24 hours. Multivariate analysis showed that age, T-RTS and ISS were independent determinants of mortality. A T-RTS of eight or less identified the cohort of patients at greatest risk (65%). The morphology of the fracture was not predictive of mortality. We recommend the use of the T-RTS in the acute situation in order to identify patients at high risk.     

Validation of new trauma triage rules for trauma attending response to the emergency department

INTRODUCTION: The American College of Surgeons Committee on Trauma has suggested triage criteria for the immediate attendance of a trauma surgeon to an injured patient in the emergency department. This study validates the accuracy of these criteria in identifying high-risk trauma patients and assesses the impact of trauma surgeon response time. METHODS: A study group of trauma patients with a systolic blood pressure (SBP) < 90 mm Hg, Glasgow Coma Scale (GCS) score < 8, airway compromise managed with endotracheal intubation (ETI) or surgical airway, or gunshot wound (GSW) to the neck or torso were compared with a control group of patients meeting none of these criteria. Outcome measurements included Injury Severity Score (ISS), duration of hospitalization (length of stay [LOS]), intensive care unit (ICU) days, direct transfer to the ICU or operating room, and mortality. For the study group, trauma surgeon response times, < or = 15 minutes and > 15 minutes, were compared for age, ISS, LOS, ICU days, mortality, and direct transfer to the ICU or operating room. Statistical analysis was performed using the t test and the Yates-corrected chi(2) test (p < 0.05), with odds ratios calculated on the basis of trauma activation criteria and outcome measures. Multiple logistic regression was used to assess the relation between the independent variables SBP, GCS, ETI, and GSW with direct transfer to the ICU or operating room and mortality. RESULTS: A total of 4,910 patients were identified, including 791 study group patients. The mean ISS, LOS, ICU days, and mortality were significantly higher in the study group (p < 0.01). Odds ratios of the study group for direct transfer to the ICU or operating room were 91 and 2 for ETI, 23 and 1.4 for GCS score < 8, 8 and 2.2 for GSW, and 7 and 1.6 for SBP < 90 mm Hg, respectively. The odds ratios for mortality were 39 for ETI, 104 for GCS score < 8, 12 for GSW, and 74 for SBP < 90 mm Hg. Regression analysis demonstrated that GSW, SBP < 90 mm Hg, and ETI predicted ICU admission; GSW, SBP < 90 mm Hg, and ETI predicted operative intervention; and GCS score < 8, SBP < 90 mm Hg, and ETI were associated with mortality. Trauma surgeon response times were available for 658 (83%) of the study group patients. No significant differences were found between the two response groups. CONCLUSION: Trauma patients meeting the triage criteria proposed by the American College of Surgeons Committee on Trauma have more severe injuries, a higher mortality rate, and longer hospital and ICU stays than control patients. SBP < 90 mm Hg, ETI, and GSW are predictive of urgent operating room use and ICU admission. A significantly higher mortality rate is associated with SBP < 90 mm Hg, ETI, and GCS score < 8. Incorporating these criteria into trauma center triage rules to identify high-risk injured patients is warranted. However, trauma surgeon response time < or = 15 minutes was not associated with improved patient outcome, and optimal response time remains uncertain.     

Physiologic,demographic and mechanistic factors predicting New Injury Severity Score (NISS) in motor vehicle accident victims

Background

Current literature on motor vehicle accidents (MVAs) has few reports regarding field factors that predict the degree of injury. Also, studies of mechanistic factors rarely consider concurrent predictive effects of on-scene patient physiology. The New Injury Severity Score (NISS) has previously been found to correlate with mortality, need for ICU admission, length of hospital stay, and functional recovery after trauma. To potentially increase future precision of trauma triage, we assessed how the NISS is associated with physiologic, demographic and mechanistic variables from the accident site.

Methods

Using mixed-model linear regression analyses, we explored the association between NISS and pre-hospital Glasgow Coma Scale (GCS) score, Revised Trauma Score (RTS) categories of respiratory rate (RR) and systolic blood pressure (SBP), gender, age, subject position in the vehicle, seatbelt use, airbag deployment, and the estimated squared change in vehicle velocity on impact ((Δv)²). Missing values were handled with multiple imputation.

Results

We included 190 accidents with 353 dead or injured subjects (mean NISS 17, median NISS 8, IQR 1–27). For the 307 subjects in front-impact MVAs, the mean increase in NISS was −2.58 per GCS point, −2.52 per RR category level, −2.77 per SBP category level, −1.08 for male gender, 0.18 per year of age, 4.98 for driver vs. rear passengers, 4.83 for no seatbelt use, 13.52 for indeterminable seatbelt use, 5.07 for no airbag deployment, and 0.0003 per (km/h)² velocity change (all p < 0.002).

Conclusion

This study in victims of MVAs demonstrated that injury severity (NISS) was concurrently and independently predicted by poor pre-hospital physiologic status, increasing age and female gender, and several mechanistic measures of localised and generalised trauma energy. Our findings underscore the need for precise information from the site of trauma, to reduce undertriage, target diagnostic efforts, and anticipate need for high-level care and rehabilitative resources.     

Prehospital triage and survival of major trauma patients in a Dutch regional trauma system: relevance of trauma registry

Background and aims Since 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients.Patients and methods Major trauma patients (n=511) (June 2001–December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases.Results The T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS≤10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p<0.001). No significant difference emerged between the mortality rates of both groups. The Ws {−0.46 calculated on the US model [95% confidence interval (CI) ranging from −1.99 to 1.07]} [0.60 calculated on the UK model (95% CI ranging from −1.25 to 2.44)] did not differ significantly from zero.Conclusion The trauma center managed most of the major trauma patients in the trauma system but the triage criteria need to be reconsidered. The level of care of the regional trauma system was shown to measure up to US and UK benchmarks.     

Victims of fall from height. Study of 287 patients and determination of clinical prognostic factors

INTRODUCTION: Fall from height is a common cause of severe blunt urban trauma but this mechanism of trauma is poorly documented. OBJECTIVE: To describe initial clinical parameters, injuries and outcome in patients victims of falls from height and to determinate clinical prognostic factors. STUDY DESIGN: Retrospective study from January 1998 to May 1999 and prospective study from June 1999 to September 2000. Inclusions: patients older than 12 year-old victims of falls with height of more than 3 m. PATIENTS ET METHODS: Studied parameters: demographic data, fall circumstances, prehospital clinical evaluation (Glasgow coma scale (GCS), Arterial Blood Pressure (ABP), Heart Rhythm (ER) and revised trauma score (RTS) initial and patients outcome. RESULTS: Two hundred and eighty seven patients were included during 32.5 months; 33% were women and 67% men. Mean age: 37 +/- 16 years. Median height of fall: three stairs (3-4). Final mortality: 34% including 22% death on site with or without resuscitation, 5% before hospitalization, 8% during the first day and 2% later. Independent prognostic factors were GCS (OR = 0.40; IC: 0.25 - 0.65; P = 0.0002), initial ABP (OR = 0.94; IC: 0.90 - 0.98; P = 0.008) and RTS (OR = 2.93; 1.19-7.24; P = 0.02). CONCLUSION: Immediate mortality after fall from heights is high and remains low after day 3. GCS, ABP and RTS are independent prognostic factors.     

Prognostic value of trauma scores in pediatric patients with multiple injuries

BACKGROUND: For the quantification of multiple injuries in children, a range of different trauma scores are available, the actual prognostic value of which has, however, not so far been investigated and compared in a group of patients. METHODS: In 261 polytraumatized children and adolescents, 11 trauma scores (Abbreviated Injury Scale [AIS], Injury Severity Score [ISS], Glasgow Coma Scale [GCS], Acute Trauma Index [ATI], Shock Index [SI], Trauma Score [TS], Revised Trauma Score [RTS], Modified Injury Severity Score [MISS], Trauma and Injury Severity Score [TRISS]-Scan, Hannover Polytrauma Score [HPTS], and Pediatric Trauma Score [PTS]) were calculated, and their prognostic relevance in terms of survival, duration of intensive care treatment, hospital stay, and long-term outcome analyzed. RESULTS: With a specificity of 80%, physiologic scores (TS, RTS, GCS, ATI) showed a greater accuracy (79-86% vs. 73-79%) with regard to survival prediction than did the anatomic scores (AIS, HPTS, ISS, PTS); combined forms of these two types of score (TRISS-Scan, MISS) did not provide any additional information (76-80%). Overall, the TRISS-Scan was the score that showed the highest correlation with duration of treatment and long-term outcome. Trauma scores specially conceived for use with children (PTS, MISS) failed to show any superiority vis-à-vis trauma scores in general. CONCLUSION: With regard to prognostic quality and ease of use in the practical setting, TS and the TRISS-Scan are recommended for polytrauma in children and adolescents. Special pediatric scores are not necessary.     

Analysis on care outcome of patients with polytrauma and coma

Objective ： To make further improvement of outcome of patients with polytrauma and coma. Methods： The data of 3 361 patients （2 378 males and 983 females, aged from 5-95 years, 38. 2 years on average） with severe polytrauma and coma admitted to Chongqing Emergency Medical Center （Level I Trauma Center ）, Chongqing, China, from November 1978 to December 2004 were analyzed retrospectively in this study. Results： The overall survival rate and mortality were 93.2%（3 133/3 361 ）and 6.8%（228/3 361 ）, respectively. The mortalities in patients with coma duration 〈 1 hour and combined with neural dysfunction and in patients with coma duration ≥ 1 hour and combined with or without neural dysfunction were signifieantly higher than that of those with coma duration 〈 1 hour but without neural dysfunction [39.5%（136/344）vs 3.0%（92/3 017）, P 〈0.01]. There existed significant differences in GCS, ISS, and revised trauma score （RTS） between the death group and the survival group （P 〈 0. 01 ）. RTS was in good correspondence with patient＇ s pathophysiological status and outcome in patients with multiple trauma and coma for different groups of systolic blood pressure （SBP）. The mortality in patients with SBP 〈90 nun Hg was significantiy higher than that of those with SBP ≥ 90 mm Hg [ 33. 3 % （68/204） vs5.1%（160/3 157）, P 〈0.01]. The mortality in polytranma patients combined with serious head injury （AIS≥3） was8.2%, among which, 76.5% died from lung complications. The morbidity rate of lung complications and mortality rate increased in patients with head injury complicated with chest or abdomen injury （23.9%, 61.1% vs 27.3 %, 50.0 % ）. The mortality reached up to 61.9 % in patients complicated with severe head, chest and abdomen injuries simultaneously. Conclusions： It plays a key role to establish a fast and effective trauma care system and prompt and definite surgical procedures and to strengthen the management of complications for improving the survival rate of patients with severe palytrauma and coma.     

Comparing logistic models based on modified GCS motor component with other prognostic tools in prediction of mortality: results of study in 7226 trauma patients

A simple reproducible and sensitive prognostic trauma tool is still needed. In this article we have introduced modified GCS motor response (MGMR) and evaluated the performance of logistic models based on this variable. The records of 8452 trauma patients admitted to major hospitals of Tehran from 1999 to 2000 were analysed. 7226 records with known outcome were included in our study. Logistic models based on outcome (death versus survival) as a dependent variable and Injury Severity Score (ISS), Revised Trauma Score (RTS), Glasgow Coma Scale (GCS), GCS motor component (GMR) and MGMR (following command [=2], movement but not following [=1] command and without movement [=0]) were compared based on their accuracy and area under the Receiver Operating Characteristic (ROC) curve. The accuracy of the Trauma and Injury Severity Score (TRISS), RTS, GCS, GMR and MGMR models were almost the same. Considering both the area under the ROC curve and accuracy, the age included MGMR model was also comparable with other age included models (RTS+age, GCS+age, GMR+age). We concluded that although in some situations we need more sophisticated models, should our results be reproducible in other populations, MGMR (with or without age added) model may be of considerable practical value.     

Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: A multicentre prospective cohort study

BackgroundGlasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting.MethodWe analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality.ResultsA total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS.ConclusionThis study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.     

Changes in the outcomes of severe trauma patients from 15-year experience in a Western European trauma ICU of Emilia Romagna region (1996–2010). A population cross-sectional survey study

Background

Our experience in trauma center management increased over time and improved with development of better logistics, optimization of structural and technical resources. In addition recent Government policy in safety regulations for road traffic accident (RTA) prevention, such compulsory helmet use (2000) and seatbelt restraint (2003) were issued with aim of decreasing mortality rate for trauma.

Introduction

The evaluation of their influence on mortality during the last 15 years can lead to further improvements.

Methods

In our level I trauma center, 60,247 trauma admissions have been recorded between 1996 and 2010, with 2183 deaths (overall mortality 3.6 %). A total of 2,935 trauma patients with ISS >16 have been admitted to Trauma ICU and recorded in a prospectively collected database (1996–2010). Blunt trauma occurred in 97.1 % of the cases, whilst only 2.5 % were penetrating. A retrospective review of the outcomes was carried out, including mortality, cause of death, morbidity and length of stay (LOS) in the intensive care unit (ICU), with stratification of the outcome changes through the years. Age, sex, mechanism, glasgow coma scale (GCS), systolic blood pressure (SBP), respiratory rate (RR), revised trauma score (RTS), injury severity score (ISS), pH, base excess (BE), as well as therapeutic interventions (i.e., angioembolization and number of blood units transfused in the first 24 h), were included in univariate and multivariate analyses by logistic regression of mortality predictive value.

Results

Overall mortality through the whole period was 17.2 %, and major respiratory morbidity in the ICU was 23.3 %. A significant increase of trauma admissions has been observed (before and after 2001, p?<?0.01). Mean GCS (10.2) increased during the period (test trend p?<?0.05). Mean age, ISS (24.83) and mechanism did not change significantly, whereas mortality rate decreased showing two marked drops, from 25.8 % in 1996, to 18.3 % in 2000 and again down to 10.3 % in 2004 (test trend p?<?0.01). Traumatic brain injury (TBI) accounted for 58.4 % of the causes of death; hemorrhagic shock was the death cause in 28.4 % and multiple organ failure (MOF)/sepsis in 13.2 % of the patients. However, the distribution of causes of death changed during the period showing a reduction of TBI-related and increase of MOF/sepsis (CTR test trend p?<?0.05). Significant predictors of mortality in the whole group were year of admission (p?<?0.05), age, hemorrhagic shock and SBP at admission, ISS and GCS, pH and BE (all p?<?0.01). In the subgroup of patients that underwent emergency surgery, the same factors confirmed their prognostic value and remained significant as well as the adjunctive parameter of total amount of blood units transfused (p?<?0.05). Surgical time (mean 71 min) showed a significant trend towards reduction but did not show significant association with mortality (p?=?0.06).

Conclusion

Mortality of severe trauma decreased significantly during the last 15 years as well as mean GCS improved whereas mean ISS remained stable. The new safety regulations positively influenced incidence and severity of TBI and seemed to improve the outcomes. ISS seems to be a better predictor of outcome than RTS.     

胸部闭合伤的损伤严重度评估及临床意义

目的：探讨胸部闭合伤的临床特点及其损伤严重度评估的临床意义。方法：分析456例胸部闭合伤的致伤因素和死亡率,并按有无合并伤（分为单纯胸伤组,合并伤组）和结局（分为生存组,死亡组）分组进行创伤评分,分别比较不同组间的损伤严重程度。结果：致伤原因为交通伤发生率最高（60．97％）,其次为高处坠落伤（13．82％）。456例中288例合并其它部位损伤,占63．16％,死亡18例,死亡率3．95％,单纯胸伤组的格拉斯哥昏迷指(GCS),睡正创伤评分（RTS）和生存概率（Ps)较高,损伤严重评分（ISS）低于合并伤组,胸部简明损伤定级（AIS）评分两组间差别无显著性意义,死亡组和生存组比较,前者生理评分低,解剖评分高,生存概率亦低。结论：胸部闭合伤常合并全身多发伤,伤情判断困难,合理使用创伤评分有助于判断损伤严重度,指导临床救治。     

Time of hypotension and discharge outcome in children with severe traumatic brain injury

We performed a retrospective study at a level I pediatric trauma center of patients admitted between 1998 and 2005 to determine the time after severe pediatric traumatic brain injury (TBI) that hypotension (systolic blood pressure [SBP] of <5th percentile) is most strongly associated with poor outcome. One hundred forty-six patients of <18 years of age with TBI, head Abbreviated Injury Score (AIS) of >or=3, and PICU admission Glasgow Coma Scale (GCS) score of <9 formed the analytic sample. Available SBP readings through the first 72 h after severe TBI were collected. SBP of <5th percentile was defined as hypotension. Discharge Glasgow Outcome Scale (GOS) score of <4 defined poor outcome. Of 146, 59 (40%) patients had discharge GOS of <4 and 12% died. The adjusted risk of poor outcome associated with hypotension stabilized by 8 h (adjusted risk ratio [RR] 1.7; 95% confidence interval [CI] 1.1-2.6) after injury. The risk of poor outcome peaked with hypotension occurring within the first 6 h after injury (RR 2.0, 95% CI 1.3-3.3). Poor discharge GOS was predicted by hypotension occurring during the first 6 h after injury. SBP data beyond the first 6 h did not improve our ability to predict poor discharge GOS. The first 6 h after severe pediatric TBI may represent a critical time period for either predicting or improving outcome.     

A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting

Introduction: An assessment of physiological status is a key step in the early assessment of trauma patients with implications for triage, investigation and management. This has traditionally been done using vital signs. Previous work from large European trauma datasets has suggested that base deficit (BD) predicts clinically important outcomes better than vital signs (VS). A BD derived classification of haemorrhagic shock appeared superior to one based on VS derived from ATLS criteria in a population of predominantly blunt trauma patients. The initial aim of this study was to see if this observation would be reproduced in penetrating trauma patients. The power of each individual variable (BD, heart rate (HR), systolic blood pressure (SBP), shock index(SI) (HR/SBP) and Glasgow Coma Score (GCS)) to predict mortality was then also compared.Methods: A retrospective analysis of adult trauma patients presenting to the Pietermaritzburg Metropolitan Trauma Service was performed. Patients were classified into four “shock” groups using VS or BD and the outcomes compared.Receiver Operator Characteristic (ROC) curves were then generated to compare the predictive power for mortality of each individual variable.Results: 1863 patients were identified. The overall mortality rate was 2.1%. When classified by BD, HR rose and SBP fell as the “shock class” increased but not to the degree suggested by the ATLS classification. The BD classification of haemorrhagic shock appeared to predict mortality better than that based on the ATLS criteria. Mortality increased from 0.2% (Class 1) to 19.7% (Class 4) based on the 4 level BD classification. Mortality increased from 0.3% (Class 1) to 12.6% (Class 4) when classified based by VS.Area under the receiver operator characteristic (AUROC) curve analysis of the individual variables demonstrated that BD predicted mortality significantly better than HR, GCS, SBP and SI. AUROC curve (95% Confidence Interval (CI)) for BD was 0.90 (0.85-0.95) compared to HR 0.67(0.56-0.77), GCS 0.70(0.62-0.79), SBP 0.75(0.65-0.85) and SI 0.77(0.68–0.86).Conclusion: BD appears superior to vital signs in the immediate physiological assessment of penetrating trauma patients. The use of BD to assess physiological status may help refine their early triage, investigation and management.     

Physician knowledge of the Glasgow Coma Scale

Appropriate triage is critical to optimizing outcome from battle related injuries. The Glasgow Coma Scale (GCS) is the primary means by which combat casualties, who have suffered head injury, are triaged. For the GCS to be reliable in this critical role, it must be applied accurately. To determine the level of knowledge of the GCS among military physicians with exposure and/or training in the scale we administered a prospective, voluntary, and anonymous survey to physicians of all levels of training at military medical centers with significant patient referral base. The main outcome measures were correct identification of title and categories of the GCS along with appropriate scoring of each category. Overall performance on the survey was marginal. Many were able to identify what "GCS" stands for, but far fewer were able to identify the titles of the specific categories, let alone identify the specific scoring of each category. When evaluated based on medical specialties, those in surgical specialties outperformed those in the medical specialties. When comparing the different levels of training, residents and fellows performed better than attending staff or interns. Finally, those with Advanced Trauma Life Support (ATLS) certification performed significantly better than those without the training. Physician knowledge of the GCS, as demonstrated in this study, is poor, even in a population of individuals with specific training in the use of the scale. It is concluded that, to optimize outcome from combat related head injury, methods for improving accurate quantitation of neurologic state need to be explored.     

Exploring injury severity measures and in-hospital mortality: A multi-hospital study in Kenya

IntroductionLow- and middle-income countries (LMICs) have a disproportionately high burden of injuries. Most injury severity measures were developed in high-income settings and there have been limited studies on their application and validity in low-resource settings. In this study, we compared the performance of seven injury severity measures: estimated Injury Severity Score (eISS), Glasgow Coma Score (GCS), Mechanism, GCS, Age, Pressure score (MGAP), GCS, Age, Pressure score (GAP), Revised Trauma Score (RTS), Trauma and Injury Severity Score (TRISS) and Kampala Trauma Score (KTS), in predicting in-hospital mortality in a multi-hospital cohort of adult patients in Kenya.MethodsThis study was performed using data from trauma registries implemented in four public hospitals in Kenya. Estimated ISS, MGAP, GAP, RTS, TRISS and KTS were computed according to algorithms described in the literature. All seven measures were compared for discrimination by computing area under curve (AUC) for the receiver operating characteristics (ROC), model fit information using Akaike information criterion (AIC), and model calibration curves. Sensitivity analysis was conducted to include all trauma patients during the study period who had missing information on any of the injury severity measure(s) through multiple imputations.ResultsA total of 16,548 patients were included in the study. Complete data analysis included 14,762 (90.2%) patients for the seven injury severity measures. TRISS (complete case AUC: 0.889, 95% CI: 0.866–0.907) and KTS (complete case AUC: 0.873, 95% CI: 0.852–0.892) demonstrated similarly better discrimination measured by AUC on in-hospital deaths overall in both complete case analysis and multiple imputations. Estimated ISS had lower AUC (0.764, 95% CI: 0.736–0.787) than some injury severity measures. Calibration plots showed eISS and RTS had lower calibration than models from other injury severity measures.ConclusionsThis multi-hospital study in Kenya found statistical significant higher performance of KTS and TRISS than other injury severity measures. The KTS, is however, an easier score to compute as compared to the TRISS and has stable good performance across several hospital settings and robust to missing values. It is therefore a practical and robust option for use in low-resource settings, and is applicable to settings similar to Kenya.