The pediatric trauma score as a predictor of injury severity in the injured child

The ability of the Pediatric Trauma Score (PTS) to accurately predict the degree of injury severity of the injured child was assessed by comparing two separate groups of pediatric trauma victims. The first group consisted of 110 patients evaluated at a regional pediatric trauma center whose data was collected and assessed by a single investigator. The second group consisted of a similar matched cohort of 120 patients from the National Pediatric Trauma Registry whose data was collated from multiple participating institutions. In both cases, a linear relationship between PTS and Injury Severity Score (ISS) was documented that was statistically significant to P less than .001. The linear regression coefficients of each group were similar as was the distribution of PTS and ISS. This study documents the validity of the PTS as an initial assessment tool and confirms its reliability as a predictor of injury severity.     

Comparison of the new injury severity score and the injury severity score in multiple trauma patients

Objective： To assess whether these characteristics of less misclassification and greater area under receiver operator characteristic （ROC） curve of the new injury severity score （NISS） are better than the injury severity score （ISS） as applying it to our multiple trauma patients registered into the emergency intensive care unit （EICU）.
Methods： This was a retrospective review of registry data from 2 286 multiple trauma patients consecutively registered into the EICU from January 1,1997 to December 31, 2006 in the Second Affiliated Hospital, Medical School of Zhejiang University in China. Comparisons between ISS and NISS were made using misclassification rates, ROC curve analysis, and the H-L statistics by univariate and multivariate logistic progression model.
Results： Among the 2 286 patients, 176 （7.7%） were excluded because of deaths on arrival or patients less than 16 years of age. The study population therefore comprised 2 1 10 patients. Mean EICU length of stay （LOS） was 7.8 days ± 2.4 days. Compared with the blunt injury group, the penetrating injury group had a higher percentage of male, lower mean EICU LOS and age. The most frequently injured body regions were extremities and head/neck, followed by thorax, face and abdomen in the blunt injury group; whereas, thorax and abdomen were more frequently seen in the penetrating injury group. The minimum misclassification rate for NISS was slightly less than ISS in all groups （4.01% versus 4.49%）. However, NISS had more tendency to misclassify in the penetrating injury group. This, we noted, was attributed mainly to a higher false-positive rate （21.04% versus 15.55% for IS S, t=-3.310, P〈0.001）, resulting in an overall misclassification rate of 23.57% for NISS versus 18.79% for ISS （t=3.290, P〈0.001）. In the whole sample, NISS presented equivalent discrimination （area under ROC curve： NISS=0.938 versus ISS=0.943）. The H-L statistics showed poorer calibration （48.64 versus 32.11, t=3.305, P〈0.001） in     

New injury severity score (NISS) outperforms injury severity score (ISS) in the evaluation of severe blunt trauma patients

Purpose: The injury severity score (ISS) and new injury severity score (NISS) have been widely used in trauma evaluation. However, which scoring system is better in trauma outcome prediction is still disputed. The purpose of this study is to evaluate the value of the two scoring systems in predicting trauma outcomes, including mortality, intensive care unit (ICU) admission and ICU length of stay. Methods: The data were collected retrospectively from three hospitals in Zhejiang province, China. The comparisons of NISS and ISS in predicting outcomes were performed by using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics. Results: A total of 1825 blunt trauma patients were enrolled in our study. Finally, 1243 patients were admitted to ICU, and 215 patients died before discharge. The ISS and NISS were equivalent in predicting mortality (area under ORC curve [AUC]: 0.886 vs. 0.887, p ¼ 0.9113). But for the patients with ISS 25, NISS showed better performance in predicting mortality. NISS was also significantly better than ISS in predicting ICU admission and prolonged ICU length of stay. Conclusion: NISS outperforms ISS in predicting the outcomes for severe blunt trauma and can be an essential supplement of ISS. Considering the convenience of NISS in calculation, it is advantageous to promote NISS in China’s primary hospitals.     

两种损伤严重程度评分对腹部闭合性损伤病人死亡率预测价值的对比分析

目的探讨新损伤严重程度评分(new injury severity score,NISS)与损伤严重程度评分(injury severity score,ISS)对腹部损伤病人预后预测价值的差异。方法自2010年1月至2015年5月,按照连续采样的方法收集就诊的腹部损伤病人的临床资料,根据病人是否死亡将所有病人分为死亡组和生存组。比较组间病人年龄、性别、入院时脉搏、收缩压、NISS、ISS以及受伤机制的差异,多元回归分析法判定腹部损伤病人死亡的相关危险因素,并绘制相关危险因素预测病人死亡的ROC曲线,以比较两种评价体系对病人预后预测价值的差异,并确定相关危险因素预测病人死亡的临界值。结果组间病人入院情况相比,生存组病人入院时平均脉搏相对较慢,收缩压相对较高,ISS、NISS评分相对较低,就病人致伤因素分布情况来看,死亡组病人交通事故伤病人比例相对较高,以上组间相比差异均有统计学意义(P均0.05)。病人死亡危险因素的多元回归分析结果显示,病人入院时收缩压、ISS、NISS评分是腹部损伤病人死亡的独立危险因素(OR值均1.0,P值均0.05)。ISS、NISS预测病人死亡的对比分析结果显示,NISS[曲线下面积(AUC)=0.96,95%置信区间(CI):0.57~1.93,P0.001]预测病人死亡风险的AUC较ISS(AUC=0.75,95%CI:0.92~1.00,P=0.003)相对较大,准确性相对较高,在NISS=14时,其预测腹部损伤病人死亡的敏感性和特异性分别为90.2%和88.6%。结论 ISS、NISS两种评分体系均是腹部闭合性损伤病人死亡风险的独立危险因素,但在病人死亡风险预测上,NISS评分的预测价值相对较大,值得临床进一步研究证实。     

Obesity is an independent risk factor of mortality in severely injured blunt trauma patients

HYPOTHESIS: Obesity is associated with increased morbidity and mortality in critically injured blunt trauma patients. DESIGN: Case-control study of all critically injured blunt trauma patients between January 2002 and December 2002. SETTING: Academic level I trauma center at a county referral hospital. PATIENTS: Two hundred forty-two consecutive patients admitted to the intensive care unit following blunt trauma. Patients were divided into 2 groups by body mass index. The obese group was defined as having a body mass index of 30 kg/m2 or higher, and the nonobese group was defined as having a body mass index lower than 30 kg/m2. MAIN OUTCOME MEASURES: Univariate and multivariate analyses were performed to identify risk factors for mortality. Complications and length of stay were also evaluated. RESULTS: Of the 242 patients, 63 (26%) were obese, and 179 (74%) were nonobese. The obese and nonobese groups were similar with regard to age (mean +/- SD, 49 +/- 18 years vs 45 +/- 22 years), male sex (63% vs 72%), Glasgow Coma Scale score (mean +/- SD, 11 +/- 5 vs 11 +/- 5), and injury severity score (mean +/- SD, 21 +/- 13 vs 20 +/- 14). The obese group had a higher body mass index (mean +/- SD, 35 +/- 7 vs 24 +/- 3; P<.001). Mechanisms of injury and injury patterns were similar between groups. The obese group had a higher incidence of multiple organ failure (13% vs 3%; P =.02) and mortality (32% vs 16%; P=.008). Obesity was an independent predictor of mortality with an adjusted odds ratio of 5.7 (95% confidence interval, 1.9-19.6; P=.003). CONCLUSIONS: Critically injured obese trauma patients have similar demographics and injury patterns as nonobese patients. Obesity is an independent predictor of mortality following severe blunt trauma.     

Abdominal vascular trauma in 760 severely injured patients

Purpose

The relevance of abdominal vascular injuries in polytraumatic patients within a large collective has not yet been thoroughly analyzed. This study aimed at assessing the prevalence of traumatic injuries in relation to outcome and currently established treatment options.

Methods

51,425 patients from the Trauma Registry of the German Society of Trauma Surgery (TR DGU) (1993–2009) were analyzed retrospectively. All patients who had an Injury Severity Score (ISS) of ≥16, were directly admitted to a trauma center and subsequently received treatment for at least three days, were ≥16 years old, and had an abdominal injury (AIS_abdomen ≥2) were included. Patients with abdominal trauma (AIS_abdomen ≥2) were compared with patients with additional vascular trauma (AIS_vascular 2–5).

Results

10,530 (20.5 %) of the 51,425 patients had documented abdominal injury. 760 (7.2 %) of the patients with abdominal injury additionally showed abdominal vascular injury (AIS_abdomen ≥2, AIS_vascular 2–5) and were analyzed based on the classification of the American Association for the Surgery of Trauma (AAST) organ severity score (AAST vascular injury grade: II, 2.4 %; III, 2.7 %; IV, 1.8 %; V, 0.2 %. Patients with high-grade abdominal vascular injury (grades IV and V) showed a significant increase in mortality (IV, 44.6 %; V, 60 %) and consequently a decrease in the need for surgical intervention (IV, 67.4 %; V, 64 %).

Conclusions

The results presented here show the prevalence and outcome of abdominal vascular injuries in a large collective within the TR DGU for the first time. Based on the current literature and these findings, a treatment algorithm has been developed.     

Salvage versus amputation: Utility of mangled extremity severity score in severely injured lower limbs

Background:

The purpose of the present study was to evaluate the clinical utility of Mangled extremity severity score (MESS) in severely injured lower limbs.

Materials and Methods:

Retrospectively 25 and prospectively 36 lower limbs in 58 patients with high-energy injuries were evaluated with the use of MESS, to assist in the decision-making process for the care of patients with such injuries. Difference between the mean MESS scores for amputated and salvaged limbs was analyzed.

Results:

In the retrospective study 4.65 (4.65 ± 1.32) was the mean score for the salvaged limbs and 8.80 (8.8 ± 1.4) for the amputated limbs. In the prospective study 4.53 (4.53 ± 2.44) was the mean score for the salvaged limbs and 8.83 (8.83 ± 2.34) for the amputated limbs. There was a significant difference in the mean scores for salvaged and amputated limbs. Retrospective 21 (84%) and prospective 29 (80.5%) limbs remained in the salvage pathway six months after the injury.

Conclusion:

MESS could predict amputation of severely injured lower limbs, having score of equal or more than 7 with 91% sensitivity and 98% specificity. There was a significant difference in the mean MESS scores in the prospective study (n=36), 4.53 (4.53 ± 2.44) in thirty salvaged limbs (83.33%) and 8.83 (8.83 ± 2.34) in six amputated limbs (16.66%) with a P-value 0.002 (P-value < 0.01). Similarly there was a significant difference in the mean MESS score in the retrospective study (n=25), 4.65 (4.65 ± 1.32) in twenty salvaged limbs (80%) and 8.80 (8.8 ± 1.4) in five amputated limbs (20%) with a P-value 0.00005 (P-value < 0.01). MESS is a simple and relatively easy and readily available scoring system which can help the surgeon to decide the fate of the lower extremity with a high-energy injury.     

Intestinal necroses in severely injured patients without abdominal trauma

Bowel necrosis in the critical trauma patient without abdominal involvement or preexisting vascular disease is a known but rare complication. During 1977-1986 we observed 31 cases in 2530 patients. Symptoms were unspecific, and since most of the patients were artificially ventilated, pain and tenderness were of little diagnostic value. Twenty-three patients presented with paralytic ileus, fifteen with diarrhea, and four with melena. In eleven patients diagnosis was made clinically, and in twenty patients at autopsy. Twenty-three patients died from septic shock, six from cerebral complications, and one from myocardial infarction. Risk factors for bowel necrosis were fluid restriction, hypotension, hypoxemia, venous congestion, vasoconstrictive drugs, paralytic ileus, and constipation.     

Accuracy and relationship of mechanisms of injury, trauma score, and injury severity score in identifying major trauma

The accuracy of mechanism of injury criteria and trauma scores as triage criteria for identifying major trauma patients has been determined from the experience at one trauma center treating 2,500 patients over a 2 year period. Death of the other occupant of the same vehicle as the patient and patient extrication taking longer than 20 minutes were determined to be sufficiently accurate triage criteria. Trauma scores of 14 or less were more accurate than trauma scores of 12 or less.     

Head injury in the severely injured: long-term follow-up in 157 patients

Ninety-two patients with head injury in the context of multiple injury were followed up 5 years after injury. Severe disability in this group of patients was nearly always due to brain/spinal cord injury, rather than musculoskeletal injury. A substantial number of patients with mild or moderate head injuries had significant persisting disability 5 years after injury.     

The injury severity score in pregnant trauma patients: predicting placental abruption and fetal death

BACKGROUND: The Injury Severity Score (ISS) is the national standard for injury severity assessment but has been rarely validated in the pregnant population. METHODS: We evaluated 294 pregnant women who were hospitalized for injury in Washington State from 1989 to 1997. We used ICDMAP-90 computer software to assign an ISS to all women. We identified injured pregnant women who experienced a placental abruption or a fetal death using the Washington State delivery hospitalization data and the birth certificate or fetal death records. We evaluated the accuracy of the ISS in predicting these adverse outcomes using sensitivity analysis. RESULTS: We found that the ISS was not accurate in predicting placental abruption and fetal death. We also found that relatively minor injuries were associated with adverse pregnancy outcomes. CONCLUSION: A more comprehensive injury assessment tool is needed to accurately predict adverse outcomes in the pregnant trauma population.     

External validation of a modified trauma and injury severity score model in major trauma injury

BackgroundThe establishment of an accurate prognostic model in major trauma patients is important mainly because this group of patients will benefit the most. Clinical prediction models must be validated internally and externally on a regular basis to ensure the prediction is accurate and current. This study aims to externally validate two prediction models, the Trauma and Injury Severity Score model developed using the Major Trauma Outcome Study in North America (MTOS-TRISS model), and the NTrD-TRISS model, which is a refined MTOS-TRISS model with coefficients derived from the Malaysian National Trauma Database (NTrD), by regarding mortality as the outcome measurement.MethodThis retrospective study included patients with major trauma injuries reported to a trauma centre of Hospital Sultanah Aminah over a 6-year period from 2011 and 2017. Model validation was examined using the measures of discrimination and calibration. Discrimination was assessed using the area under the receiver operating characteristic curve (AUC) and 95% confidence interval (CI). The Hosmer-Lemeshow (H-L) goodness-of-fit test was used to examine calibration capabilities. The predictive validity of both MTOS-TRISS and NTrD-TRISS models were further evaluated by incorporating parameters such as the New Injury Severity Scale and the Injury Severity Score.ResultsTotal patients of 3788 (3434 blunt and 354 penetrating injuries) with average age of 37 years (standard deviation of 16 years) were included in this study. All MTOS-TRISS and NTrD-TRISS models examined in this study showed adequate discriminative ability with AUCs ranged from 0.86 to 0.89 for patients with blunt trauma mechanism and 0.89 to 0.99 for patients with penetrating trauma mechanism. The H-L goodness-of-fit test indicated the NTrD-TRISS model calibrated as good as the MTOS-TRISS model for patients with blunt trauma mechanism.ConclusionFor patients with blunt trauma mechanism, both the MTOS-TRISS and NTrD-TRISS models showed good discrimination and calibration performances. Discrimination performance for the NTrD-TRISS model was revealed to be as good as the MTOS-TRISS model specifically for patients with penetrating trauma mechanism. Overall, this validation study has ascertained the discrimination and calibration performances of the NTrD-TRISS model to be as good as the MTOS-TRISS model particularly for patients with blunt trauma mechanism.     

Radiation exposure from diagnostic imaging in severely injured trauma patients

BACKGROUND: Trauma patients often require multiple imaging tests, including computed tomography (CT) scans. CT scanning, however, is associated with high-radiation doses. The purpose of this study was to measure the radiation doses trauma patients receive from diagnostic imaging. METHODS: A prospective cohort study was conducted from June 1, 2004 to March 31, 2005 at a Level I trauma center in Toronto, Canada. All trauma patients who arrived directly from the scene of injury and who survived to discharge were included. Three dosimeters were placed on each patient (neck, chest, and groin) before radiologic examination. Dosimeters were removed before discharge. Surface doses in millisieverts (mSv) at the neck, chest, and groin were measured. Total effective dose, thyroid, breast, and red bone marrow organ doses were then calculated. RESULTS: Trauma patients received a mean effective dose of 22.7 mSv. The standard "linear no threshold" (LNT) model used to extrapolate from effects observed at higher dose levels suggests that this would result in approximately 190 additional cancer deaths in a population of 100,000 individuals so exposed. In addition, the thyroid received a mean dose of 58.5 mSv. Therefore, 4.4 additional fatal thyroid cancers would be expected per 100,000 persons. In all, 22% of all patients had a thyroid dose of over 100 mSv (mean, 156.3 mSv), meaning 11.7 additional fatal thyroid cancers per 100,000 persons would result in this subgroup. CONCLUSION: Trauma patients are exposed to significant radiation doses from diagnostic imaging, resulting in a small but measurable excess cancer risk. This small individual risk may become a greater public health issue as more CT examinations are performed. Unnecessary CT scans should be avoided.     

Thoracolumbar injury classification and severity score: a new paradigm for the treatment of thoracolumbar spine trauma

Background Contemporary understanding of the biomechanics, natural history, and methods of treating thoracolumbar spine injuries continues to evolve. Current classification schemes of these injuries, however, can be either too simplified or overly complex for clinical use. Methods The Spine Trauma Group was given a survey to identify similarities in treatment algorithms for common thoracolumbar injuries, as well as to identify characteristics of injury that played a key role in the decision-making process. Results Based on the survey, the Spine Trauma Group has developed a classification system and an injury severity score (thoracolumbar injury classification and severity score, or TLICS), which may facilitate communication between physicians and serve as a guideline for treating these injuries. The classification system is based on the morphology of the injury, integrity of the posterior ligamentous complex, and neurological status of the patient. Points are assigned for each category, and the final total points suggest a possible treatment option. Conclusions The usefulness of this new system will have to be proven in future studies investigating inter- and intraobserver reliability, as well as long-term outcome studies for operative and nonoperative treatment methods. Presented at the 78th Annual Meeting of the Japanese Orthopaedic Association, Yokohama, Japan, May 14, 2005