Clinical Implications of Over- and Under-Triage Using Need for Trauma Intervention and Cribari Indices

BACKGROUND

Need for Trauma Intervention (NFTI) score was proposed to help identify injured trauma patients while minimizing under (UT) and over triage (OT). Using a national database, we aimed to describe UT and OT of NFTI vs standard Cribari method (CM) and hypothesized triage sensitivity remains poor.

METHODS

The 2021 Trauma Quality Improvement Program (TQIP) database was queried. Demographics, mechanism, verification level, interfacility transfer (IF), and level of activation were collected. Patients were stratified by both NFTI [+ vs -] and CM [Injury severity score (ISS) < 15 vs > 15]. UT was defined as NFTI + or ISS >15 without full trauma activation.

RESULTS

1,030,526 patients were identified in TQIP. 84,969 were UT and 97,262 were OT using NFTI while 94,020 were UT and 108,823 were OT using CM. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of NFTI is 49%, 89%, 45%, and 90%, respectively vs 43%, 87%, 39%, and 89% of CM, respectively. Age was higher in the UT group using both scores (52 vs 42, P < .0001 and 54 vs 42, P < .0001, respectively). Using MLR, level 2 and 3 verification, blunt mechanism, female, IF, and older age were associated with UT in both NFTI and CM. Level 1 verification, penetrating mechanism, male, no IF, and younger age were associated with OT.

CONCLUSIONS

Current prehospital triage criteria have poor sensitivity for identifying severely injured trauma patients by both NFTI and CM. UT increases as age of the patient increases. Further studies are needed to improve triage.

Emergency resuscitative thoracotomy in severe trauma: Analysis of the nation-wide registry data in Japan

Aim

Emergency resuscitative thoracotomy is a potentially lifesaving procedure for patients with cardiac pulmonary arrest and profound circulatory failure resulting from a severe injury. However, survival rate post-emergency resuscitative thoracotomy shows considerable variation, with many studies constrained by limited sample sizes and ambiguous criteria for inclusion. Herein, we assessed the outcomes of emergency resuscitative thoracotomy and identified predictors of futility using Japan Trauma Data Bank data.

Methods

Data of patients aged ≥18 years between 2004 and 2019 were analyzed. The primary outcome measure was survival at discharge. Descriptive statistics were used to compare the survivor and nonsurvivor groups. A multivariable logistic regression analysis was conducted to identify predictors of survival in patients undergoing emergency resuscitative thoracotomy while adjusting for confounding factors.

Results

Among patients who underwent emergency resuscitative thoracotomy, 684/5062 (13.5%) survived. Age <65 years (adjusted odds ratio, 1.351; 95% confidence interval, 1.130-1.615; p < 0.001), absence of cardiac pulmonary arrest on emergency department arrival (adjusted odds ratio, 1.694; 95% confidence interval, 1.280-2.243; p < 0.01), Injury Severity Score <16 (adjusted odds ratio, 2.195; 95% confidence interval, 1.611-2.992; p < 0.01), and penetrating injury (adjusted odds ratio, 1.834; 95% confidence interval, 1.384-2.431; p < 0.01) were identified as factors associated with survival at discharge.

Conclusion

The survival rate for emergency resuscitative thoracotomy in Japan stands at approximately 13.5%. Factors contributing to survival include younger age, absence of cardiopulmonary arrest at emergency department arrival, lack of severe trauma, and sustaining penetrating injuries.

Performance of severity indices for admission and mortality of trauma patients in the intensive care unit: a retrospective cohort study

BACKGROUND

Little is known about the performance of severity indices for indicating intensive care and predicting mortality in the Intensive Care Unit (ICU) of trauma patients. This study aimed to compare the performance of severity indices to predict trauma patients' ICU admission and mortality.

METHODS

A retrospective cohort study which analyzed the electronic medical records of trauma patients aged ≥ 18 years, treated at a hospital in Brazil, between 2014 and 2017. Physiological [Revised Trauma Score (RTS), New Trauma Score (NTS) and modified Rapid Emergency Medicine Score (mREMS)], anatomical [Injury Severity Score (ISS) and New Injury Severity Score (NISS)] and mixed indices [Trauma and Injury Severity Score (TRISS), New Trauma and Injury Severity Score (NTRISS), Base-deficit Injury Severity Score (BISS) and Base-deficit and New Injury Severity Score (BNISS)] were compared in analyzing the outcomes (ICU admission and mortality) using the Area Under the Receiver Operating Characteristics Curves (AUC-ROC).

RESULTS

From the 747 trauma patients analyzed (52.5% female; mean age 51.5 years; 36.1% falls), 106 (14.2%) were admitted to the ICU and 6 (0.8%) died in the unit. The ISS (AUC 0.919) and NISS (AUC 0.916) had better predictive capacity for ICU admission of trauma patients. The NISS (AUC 0.949), TRISS (AUC 0.909), NTRISS (AUC 0.967), BISS (AUC 0.902) and BNISS (AUC 0.976) showed excellent performance in predicting ICU mortality.

CONCLUSIONS

Anatomical indices showed excellent predictive ability for admission of trauma patients to the ICU. The NISS and the mixed indices had the best performances regarding mortality in the ICU.

Associated Risk Factors and Impact in Clinical Outcomes of Multiorgan Failure in Patients with TBI

BACKGROUND

Individual extracerebral organ dysfunction is common after severe traumatic brain injury (TBI) and impacts outcomes. However, multiorgan failure (MOF) has received less attention in patients with isolated TBI. Our objective was to analyze the risk factors associated with the development of MOF and its impact in clinical outcomes in patients with TBI.

METHODS

This was an observational, prospective, multicenter study using data from a nationwide registry that currently includes 52 intensive care units (ICUs) in Spain (RETRAUCI). Isolated significant TBI was defined as Abbreviated Injury Scale (AIS) ≥ 3 in the head area with no AIS ≥ 3 in any other anatomical area. Multiorgan failure was defined using the Sequential-related Organ Failure Assessment as the alteration of two or more organs with a score of ≥ 3. We analyzed the contribution of MOF to crude and adjusted mortality (age and AIS head) by using logistic regression analysis. A multiple logistic regression analysis was performed to analyze the risk factors associated with the development of MOF in patients with isolated TBI.

RESULTS

A total of 9790 patients with trauma were admitted to the participating ICUs. Of them, 2964 (30.2%) had AIS head ≥ 3 and no AIS ≥ 3 in any other anatomical area, and these patients constituted the study cohort. Mean age was 54.7 (19.5) years, 76% of patients were men, and ground-level falls were the main mechanism of injury (49.1%). In-hospital mortality was 22.2%. Up to 185 patients with TBI (6.2%) developed MOF during their ICU stay. Crude and adjusted (age and AIS head) mortality was higher in patients who developed MOF (odds ratio 6.28 [95% confidence interval 4.58-8.60] and odds ratio 5.20 [95% confidence interval 3.53-7.45]), respectively. The logistic regression analysis showed that age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring were significantly associated with MOF development.

CONCLUSIONS

MOF occurred in 6.2% of patients with TBI admitted to the ICU and was associated with increased mortality. MOF was associated with age, hemodynamic instability, the need of packed red blood cells concentrates in the initial 24 h, the severity of brain injury, and the need for invasive neuromonitoring.

Validation of the Conventional Trauma and Injury Severity Score and a Newly Developed Survival Predictive Model in Pediatric Patients with Blunt Trauma: A Nationwide Observation Study

To date, there is no clinically useful prediction model that is suitable for Japanese pediatric trauma patients. Herein, this study aimed to developed a model for predicting the survival of Japanese pediatric patients with blunt trauma and compare its validity with that of the conventional TRISS model. Patients registered in the Japan Trauma Data Bank were grouped into a derivation cohort (2009-2013) and validation cohort (2014-2018). Logistic regression analysis was performed using the derivation dataset to establish prediction models using age, injury severity, and physiology. The validity of the modified model was evaluated by the area under the receiver operating characteristic curve (AUC). Among 11 predictor models, Model 1 and Model 11 had the best performance (AUC = 0.980). The AUC of all models was lower in patients with survival probability Ps < 0.5 than in patients with Ps ≥ 0.5. The AUC of all models was lower in neonates/infants than in other age categories. Model 11 also had the best performance (AUC = 0.762 and 0.909, respectively) in patients with Ps < 0.5 and neonates/infants. The predictive ability of the newly modified models was not superior to that of the current TRISS model. Our results may be useful to develop a highly accurate prediction model based on the new predictive variables and cutoff values associated with the survival mortality of injured Japanese pediatric patients who are younger and more severely injured by using a nationwide dataset with fewer missing data and added valuables, which can be used to evaluate the age-related physiological and anatomical severity of injured patients.

Evaluations of statistical methods for outlier detection when benchmarking in clinical registries: a systematic review

OBJECTIVES

Benchmarking is common in clinical registries to support the improvement of health outcomes by identifying underperforming clinician or health service providers. Despite the rise in clinical registries and interest in publicly reporting benchmarking results, appropriate methods for benchmarking and outlier detection within clinical registries are not well established, and the current application of methods is inconsistent. The aim of this review was to determine the current statistical methods of outlier detection that have been evaluated in the context of clinical registry benchmarking.

DESIGN

A systematic search for studies evaluating the performance of methods to detect outliers when benchmarking in clinical registries was conducted in five databases: EMBASE, ProQuest, Scopus, Web of Science and Google Scholar. A modified healthcare modelling evaluation tool was used to assess quality; data extracted from each study were summarised and presented in a narrative synthesis.

RESULTS

Nineteen studies evaluating a variety of statistical methods in 20 clinical registries were included. The majority of studies conducted application studies comparing outliers without statistical performance assessment (79%), while only few studies used simulations to conduct more rigorous evaluations (21%). A common comparison was between random effects and fixed effects regression, which provided mixed results. Registry population coverage, provider case volume minimum and missing data handling were all poorly reported.

CONCLUSIONS

The optimal methods for detecting outliers when benchmarking clinical registry data remains unclear, and the use of different models may provide vastly different results. Further research is needed to address the unresolved methodological considerations and evaluate methods across a range of registry conditions.

PROSPERO REGISTRATION NUMBER

CRD42022296520.

Understanding the burden of injury in children from conflict: an analysis of radiological imaging from a Role 3 hospital in Afghanistan in 2011

INTRODUCTION

There is a need for quality medical care for children injured in conflict, but a description of injuries and injury burden from blast and ballistic mechanisms is lacking. The radiology records of children imaged during the war in Afghanistan represent a valuable source of information about the patterns of paediatric conflict injuries.

METHODS

The UK military radiological database was searched for all paediatric presentations to Camp Bastion during 2011. Reports and original images were reviewed to determine location and severity of injuries sustained. Additional information was obtained from imaging request forms and the Joint Theatre Trauma Register, a database of those treated at UK medical facilities in Iraq and Afghanistan.

RESULTS

Radiology was available for 219 children. 71% underwent CT scanning. 46% suffered blast injury, 22% gunshot wounds (GSWs), and 32% disease and non-battle injuries (DNBIs). 3% had penetrating head injury, 11% penetrating abdominal trauma and 8% lower limb amputation, rates far exceeding those found in civilian practice. Compared with those with DNBI, those with blast or GSW were more likely to have serious (Abbreviated Injury Score, AIS, ≥3) injuries (median no. AIS ≥3 injuries were 1 for blast, 1 for GSW and 0 for DNBI, p<0.05) and children exposed to blast were more likely to have multiple body regions with serious injuries (OR for multiple AIS ≥3 injuries for blast vs DNBI=5.811 CI [1.877 to 17.993], p<0.05).

CONCLUSIONS

Paediatric conflict injuries are severe, and clinicians used only to civilian practice may be unprepared for the nature and severity of injuries inflicted on children in conflict. Whole-body CT for those with conflict-related injuries, especially blast, is hugely valuable. We recommend that CT is used for paediatric assessment in blast and ballistic incidents and that national imaging guidelines amend the threshold for doing so.

Artificial intelligence and machine learning for hemorrhagic trauma care

Artificial intelligence (AI), a branch of machine learning (ML) has been increasingly employed in the research of trauma in various aspects. Hemorrhage is the most common cause of trauma-related death. To better elucidate the current role of AI and contribute to future development of ML in trauma care, we conducted a review focused on the use of ML in the diagnosis or treatment strategy of traumatic hemorrhage. A literature search was carried out on PubMed and Google scholar. Titles and abstracts were screened and, if deemed appropriate, the full articles were reviewed. We included 89 studies in the review. These studies could be grouped into five areas: (1) prediction of outcomes; (2) risk assessment and injury severity for triage; (3) prediction of transfusions; (4) detection of hemorrhage; and (5) prediction of coagulopathy. Performance analysis of ML in comparison with current standards for trauma care showed that most studies demonstrated the benefits of ML models. However, most studies were retrospective, focused on prediction of mortality, and development of patient outcome scoring systems. Few studies performed model assessment via test datasets obtained from different sources. Prediction models for transfusions and coagulopathy have been developed, but none is in widespread use. AI-enabled ML-driven technology is becoming integral part of the whole course of trauma care. Comparison and application of ML algorithms using different datasets from initial training, testing and validation in prospective and randomized controlled trials are warranted for provision of decision support for individualized patient care as far forward as possible.

Usefulness of resuscitative endovascular balloon occlusion of the aorta compared to aortic cross-clamping in severely injured trauma patients: Analysis from the Japan Trauma Data Bank

Aim

To compare in-hospital mortality of severely injured trauma patients who underwent resuscitative endovascular balloon occlusion of the aorta (REBOA) or aortic cross-clamping (ACC).

Methods

In this multicenter, retrospective cohort study using data from a nationwide trauma registry of tertiary emergency medical centers in Japan (n = 280), trauma patients who underwent aortic occlusion at the emergency department from 2004 to 2019 were divided into two groups according to the treatment they received: patients treated with ACC and patients who underwent placement of a REBOA catheter. Multiple imputations were used to handle the missing data. In-hospital mortality of the patients who underwent REBOA or ACC was compared using a mixed-effect logistic regression analysis and a propensity score-matching analysis, in which the confounders, including baseline patient demographics and severity, were adjusted.

Results

Of 1,670 patients (1,137 with REBOA and 533 with ACC), 66% were male. The median age was 56 years, and the mortality rate was 55.2% in the REBOA group and 81.6% in the ACC group. The mixed-effect model regression analysis showed a significantly lower odds ratio for in-hospital mortality rate in the REBOA group (odds ratio 0.17; 95% confidence interval, 0.12-0.26). A similar odds ratio was observed in the propensity score matching analysis (odds ratio 0.27; 95% confidence interval, 0.18-0.40).

Conclusion

Compared with ACC, REBOA use was associated with decreased mortality in severely injured trauma patients.

Traumatic Brain Injury and Acute Kidney Injury-Outcomes and Associated Risk Factors

Our objective was to analyze the contribution of acute kidney injury (AKI) to the mortality of isolated TBI patients and its associated risk factors. Observational, prospective and multicenter registry (RETRAUCI) methods were used, from March 2015 to December 2019. Isolated TBI was defined as abbreviated injury scale (AIS) ≥ 3 head with no additional score ≥ 3. A comparison of groups was conducted using the Wilcoxon test, chi-square test or Fisher's exact test, as appropriate. A multiple logistic regression analysis was conducted to analyze associated risk factors in the development of AKI. For the result, overall, 2964 (30.2%) had AIS head ≥ 3 with no other area with AIS ≥ 3. The mean age was 54.7 (SD 19.5) years, 76% were men, and the ground-level falls was 49.1%. The mean ISS was 18.4 (SD 8). The in-hospital mortality was 22.2%. Up to 310 patients (10.6%) developed AKI, which was associated with increased mortality (39% vs. 17%, adjusted OR 2.2). Associated risk factors (odds ratio (OR) (95% confidence interval)) were age (OR 1.02 (1.01-1.02)), hemodynamic instability (OR 2.87 to OR 5.83 (1.79-13.1)), rhabdomyolysis (OR 2.94 (1.69-5.11)), trauma-associated coagulopathy (OR 1.67 (1.05-2.66)) and transfusion of packed red-blood-cell concentrates (OR 1.76 (1.12-2.76)). In conclusion, AKI occurred in 10.6% of isolated TBI patients and was associated with increased mortality.

Interobserver agreement for the Chest Wall Injury Society taxonomy of rib fractures using computed tomography images

BACKGROUND

In 2020, a universal nomenclature for rib fractures was proposed by the international Chest Wall Injury Society taxonomy collaboration. The purpose of this study is to validate this taxonomy. We hypothesized that there would be at least moderate agreement, regardless of the observers' background.

METHODS

An international group of independent observers evaluated axial, coronal, and sagittal computed tomography images on an online platform from 11 rib fractures for location (anterior, lateral, or posterior), type (simple, wedge, or complex), and displacement (undisplaced, offset, or displaced) of rib fractures. The multirater κ and Gwet's first agreement coefficient (AC1) were calculated to estimate agreement among the observers.

RESULTS

A total of 90 observers participated, with 76 complete responses (84%). Strong agreement was found for the classification of fracture location ( κ = 0.83 [95% confidence interval (CI) 0.69-0.97]; AC1, 0.84 [95% CI, 0.81-0.88]), moderate for fracture type ( κ = 0.46 [95% CI, 0.32-0.59]; AC1, 0.50 [95% CI, 0.45-0.55]), and fair for rib fracture displacement ( κ = 0.38 [95% CI, 0.21-0.54], AC1, 0.38 [95% CI, 0.34-0.42]).

CONCLUSION

Agreement on rib fracture location was strong and moderate for fracture type. Agreement on displacement was lower than expected. Evaluating strategies such as comprehensive education, additional imaging techniques, or further specification of the definitions will be needed to increase agreement on the classification of rib fracture type and displacement as defined by the Chest Wall Injury Society taxonomy.

LEVEL OF EVIDENCE

Diagnostic Test or Criteria; Level IV.

A descriptive study of trauma patients transported by helicopter emergency medical services to a level one trauma centre

•

Helicopter Emergency Medical Service (HEMS) remains an important option in Africa to address long distance transfers.

•

There is insufficient evidence to assess the impact of HEMS on outcomes in the setting of Trauma in a LMIC

•

Further evidence-based research is needed to evaluate Helicopter Emergency Medical Service in a LMIC as far as its impact on significantly shortening the time of transfer to definitive care for patients with time-sensitive medical or surgical conditions.

•

Evidence-based research should evaluate the impact of HEMS in a LMIC regarding its role in providing specialized medical expertise or equipment to patients before and/or during transport, especially patients who are in inaccessible or obscure environments.

Background

KwaZulu-Natal, the largest land mass province that is densely populated in SA has vast distances to referral centres and time to definitive treatment is key in trauma care. Helicopter Emergency Medical Service (HEMS) is still an invaluable prehospital asset for the transport of time sensitive trauma. This study reviews the impact of HEMS in the management of trauma at Inkosi Albert Luthuli hospital (IALCH) which is the only public accredited level one trauma centre in the province.

Methods

A retrospective descriptive study of polytrauma patients transported by HEMS in KZN to IALCH over a three-year period from 01 January 2014 to 31 December 2016. Data was collected around patient demographics, transfer details and patient outcomes.

Results

Over the three-year period, 117 HEMS transfers were reviewed, with the majority being male (90.6%). Just 26% of HEMS transfers were direct from the scene, with the balance being interhospital transfers largely from distant regional hospitals around the province. Some 60% of injuries were caused by vehicle crashes, and 31% by intentional injury. Mortality was 30% which is reflective of the high severity of injury of the cohort. The injury severity scores (ISS) (median 26 overall) of those who died was higher (median 38) (P-= .0002), and there were more interventions before and during transfer such as thoracostomy, ventilation and immobilization. Overall, 88% required admission to ICU at IACLH.

Conclusions

HEMS in the KwaZulu Natal province was mainly used for long-distance transfer of major trauma patients which is an appropriate use of this essential service, given the single major trauma centre in the province. The majority of patients that were transported by HEMS had severe injury, which was also associated with increased mortality outcomes. Rational use of this essential but expensive resource will require clear policy around the role of HEMS and call out criteria in each setting.

Psychometric analysis of the Glasgow Coma Scale and its sub-scale scores in a national retrospective cohort of patients with traumatic injuries

Objectives

To determine the psychometric validity, using Rasch analysis, of summing the three constituent parts of the Glasgow Coma Scale (GCS).

Design

National (registry-based) retrospective study.

Setting

England and Wales.

Patients

All individuals who sustained a traumatic injury and were: admitted for more than three days; required critical care resources; transferred for specialist management; or who died from their injuries.

Main outcomes and measures

Demographic information (i.e., age at time of injury, and sex), item sub-scores of the first available GCS (either completed by the attending paramedics or on arrival to hospital), injury severity as denoted by the Injury Severity Scale (ISS), and outcome (survival to hospital discharge or 30-days post-injury, whichever is earliest).

Results

321,203 cases between 2008 and 2017. 55.9% were male, the median age was 62.7 years (IQR 44.2–80.8), the median ISS was 9 (IQR 9 to 17), and 6.6% were deceased at 30 days. The reliability statistics suggest that when the extreme scores (i.e. 3 and 15) are accounted for, that there is only sufficient consistency to support the separation of injuries into 3 broad categories, e.g. mild, moderate and severe. As extreme scores don’t impact Rasch item calibrations, subsequent analysis was restricted to the 48,417 non-extreme unique cases. Overall fit to the Rasch model was poor across all analyses (p < 0.0001). Through a combination of empirical evidence and clinical reasoning, item response categories were collapsed to provide a post-hoc scoring amendment. Whilst the modifications improved the function of the individual items, there is little evidence to support them meaningfully contributing to a total score that can be interpreted on an interval scale.

Conclusion and relevance

The GCS does not perform in a psychometrically robust manner in a national retrospective cohort of individuals who have experienced a traumatic injury, even after post-hoc correction.

Multiregion Trauma Center Follow-Up Protocol for Transferred Trauma Patients

BACKGROUND

Trauma centers routinely utilize the Injury Severity Score for performance improvement. Yet, transferring facilities do not always have access to patients' final Injury Severity Score.

OBJECTIVE

The purpose of this project was to develop and implement a multiregion Injury Severity Score follow-up feedback protocol for transferring facilities to receive standardized information on patient treatment and the ability to calculate an accurate follow-up Injury Severity Score of transferred patients.

METHODS

This project included 25 Adult and Pediatric Level I, II, and III trauma centers within three regional trauma systems in a Midwestern state. This project included trauma centers that used one of the two different trauma registry software systems as a solution to develop and implement a protocol for follow-up feedback for transferred trauma patients. A template was created to capture data posttransfer to calculate a final Injury Severity Score.

RESULTS

The feedback protocol was well received by participating regions. Implementation revealed the impact of variable trauma registry software on the ability to create multi-institution feedback programs.

CONCLUSION

Trauma systems can implement similar strategies to ensure transferring trauma centers routinely receive standardized, timely patient feedback.

Validation of the Japan Coma Scale for the prediction of mortality in children: analysis of a nationwide trauma database

Objective

The Japan Coma Scale (JCS) is widely used in clinical practice to evaluate levels of consciousness in Japan. There have been several studies on the usefulness of JCS in adults. However, its usefulness in evaluating children has not been reported. Therefore, this study aimed to assess the usefulness of the JCS for the prediction of mortality in children.

Methods

This is a multicenter cohort study which used data from a national trauma registry (Japan Trauma Data Bank). This study included patients under 16 years of age who were treated between 2004 and 2015.

The primary outcome measure was in-hospital mortality. Two models were used to examine each item of the Glasgow Coma Scale (GCS) and the JCS. Model A included the discrete levels of each index. In model B, data regarding age, sex, vital signs on arrival to hospital, the Injury Severity Score, and blunt trauma were added to each index. The effectivity of the JCS score was then evaluated using the area under the curve (AUC) for discrimination, a calibration plot, and the Hosmer-Lemeshow test for calibration.

Results

A total of 9045 patients were identified. The AUCs of the GCS and JCS were 0.929 (95% confidence interval (CI) 0.904 to 0.954) and 0.930 (95% CI 0.906 to 0.954) in model A and 0.975 (95% CI 0.963 to 0.987) and 0.974 (95% CI 0.963 to 0.985) in model B, respectively. The results of the Hosmer-Lemeshow test were 0.00 (p=1.00) and 0.00 (p=1.00) in model A and 4.14 (p=0.84) and 8.55 (p=0.38) in model B for the GCS and JCS, respectively.

Conclusions

We demonstrated that the JCS is as valid as the GCS for predicting mortality. The findings of this study indicate that the JCS is a useful and relevant tool for pediatric trauma care and future research.

Risk Factors Associated with Mortality in Severe Chest Trauma Patients Admitted to the ICU

Our objective was to determine outcomes of severe chest trauma admitted to the ICU and the risk factors associated with mortality. An observational, prospective, and multicenter registry of trauma patients admitted to the participating ICUs (March 2015-December 2019) was utilized to collect the patient data that were analyzed. Severe chest trauma was defined as an Abbreviated Injury Scale (AIS) value of ≥3 in the thoracic area. Logistic regression analysis was used to evaluate the contribution of severe chest trauma to crude and adjusted ORs for mortality and to analyze the risk factors associated with mortality. Overall, 3821 patients (39%) presented severe chest trauma. The sample's characteristics were as follows: a mean age of 49.88 (19.21) years, male (77.6%), blunt trauma (93.9%), a mean ISS of 19.9 (11.6). Crude and adjusted (for age and ISS) ORs for mortality in severe chest trauma were 0.78 (0.68-0.89) and 0.43 (0.37-0.50) (p < 0.001), respectively. In-hospital mortality in the severe chest trauma patients without significant traumatic brain injury (TBI) was 5.63% and was 25.71% with associated significant TBI (p < 0.001). Age, the severity of injury (NISS and AIS-head), hemodynamic instability, prehospital intubation, acute kidney injury, and multiorgan failure were risk factors associated with mortality. The contribution of severe chest injury to the mortality of trauma patients admitted to the ICU was very low. Risk factors associated with mortality were identified.

External validation of International Classification of Injury Severity Score to predict mortality in a Greek adult trauma population

INTRODUCTION

The International Classification of diseases- based Injury Severity Score (ICISS) obtained by empirically derived diagnosis-specific survival probabilities (DSPs) is the best-known risk-adjustment measure to predict mortality. Recently, a new set of pooled DSPs has been proposed by the International Collaborative Effort on Injury Statistics but it remains to be externally validated in other cohorts. The aim of this study was to externally validate the ICISS using international DSPs and compare its prognostic performance with local DSPs derived from Greek adult trauma population.

MATERIALS AND METHODS

This retrospective single-center cohort study enrolled adult trauma patients (≥ 16 years) hospitalized between January 2015 and December 2019 and temporally divided into derivation (n = 21,614) and validation cohorts (n = 14,889). Two different ICISS values were calculated for each patient using two different sets of DSPs: international (ICISSint) and local (ICISSgr). The primary outcome was in-hospital mortality. Models' prediction was performed using discrimination and calibration statistics.

RESULTS

ICISSint displayed good discrimination in derivation (AUC = 0.836 CI 95% 0.819-0.852) and validation cohort (AUC = 0.817 CI 95% 0.797-0.836). Calibration using visual analysis showed accurate prediction at patients with low mortality risk, especially below 30%. ICISSgr yielded better discrimination (AUC = 0.834 CI 95% 0.814-0.854 vs 0.817 CI 95% 0.797-0.836, p ˂ .05) and marginally improved overall accuracy (Brier score = 0.0216 vs 0.0223) compared with the ICISSint in the validation cohort. Incorporation of age and sex in both models enhanced further their performance as reflected by superior discrimination (p ˂ .05) and closer calibration curve to the identity line in the validation cohort.

CONCLUSION

This study supports the use of international DSPs for the ICISS to predict mortality in contemporary trauma patients and provides evidence regarding the potential benefit of applying local DSPs. Further research is warranted to confirm our findings and recommend the widespread use of ICISS as a valid measure that is easily obtained from administrative data based on ICD-10 codes.

Healthcare-associated Infections in Pediatric Patients in Neurotrauma Intensive Care Unit: A Retrospective Analysis

Background

Healthcare-associated infections (HAIs) can impact the outcome following traumatic brain injury (TBI) in children. We undertook a retrospective observational study to see the incidence, risk factors, and microbiological profile for HAIs in pediatric TBI. We also studied the impact of baseline patient characteristics, HAIs on patient outcome, and antibiotic resistance of different types of bacteria.

Materials and methods

Data on pediatric TBI patients of age up to 12 years were collected via a computerized patient record system (CPRS) from January 2012 to December 2018. Descriptive Chi-square test and Wilcoxon signed rank test were used to characterize baseline parameters. General linear regression models were run to find an unadjusted and adjusted odds ratio (OR).

Results

HAIs were found in 144 (34%) out of 423 patients. The most commonly seen infections were of the respiratory tract in 73 (17.26%) subjects. The most predominant microorganism isolated was Acinetobacter baumannii in 188 (41%) samples. A. baumannii was sensitive to colistin in 91 (48.4%) patients. Male gender (OR 0.630; p-value 0.035), fall from height (OR 0.374; p-value 0.008), and higher injury severity scale (ISS) (OR 1.040; p-value 0.002) were independent risk factors for development of HAIs. Severe TBI, higher ISS and Marshall grade, and HAIs were significantly associated with poor patient outcome.

Conclusion

Severe TBI poses a significant risk of HAIs. The most common site was the respiratory tract, predominately infected with A. baumannii. HAIs in pediatric TBI patients resulted in poor patient outcome.

How to cite this article

Prasad C, Bindra A, Singh P, Singh GP, Singh PK, Mathur P. Healthcare-associated Infections in Pediatric Patients in Neurotrauma Intensive Care Unit: A Retrospective Analysis. Indian J Crit Care Med 2021;25(11):1308-1313.

Physiologic Scoring Systems versus Glasgow Coma Scale in Predicting In-Hospital Mortality of Trauma Patients; a Diagnostic Accuracy Study

Introduction:

In recent years, several scoring systems have been developed to assess the severity of trauma and predict the outcome of trauma patients. This study aimed to compare Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), Injury Severity Score (ISS), and Glasgow Coma Scale (GCS) in predicting the in-hospital mortality of trauma patients.

Methods:

This diagnostic accuracy study was done on adult patients admitted to the emergency department (ED) between June 21, 2019, and September 21, 2020, following multiple trauma. Patients were followed as long as they were hospitalized. The REMS, MEWS, GCS, and ISS were calculated after data gathering and comprehensive assessment of injuries. Receiver operating characteristics (ROC) analysis was performed to examine the prognostic performance of the four different tools.

Results:

Of the 754 patients, 32 patients (4.2%) died and 722 (95.8%) survived after 24 hours of admission. The mean age of the patients was 38.54 ± 18.58 years (78.9% male). The area under the ROC curves (AUC) of REMS, MEWS, ISS, and GCS score for predicting in-hospital mortality were 0.942 (95% CI [0.923-0.958]), 0.886 (95% CI [0.861-0.908]), 0.866 (95% CI [0.839-0.889]), and 0.851 (95% CI [0.823-0.876]), respectively. The AUC of REMS was significantly higher than GCS (p=0.035). The sensitivities of GCS ≤ 11, ISS ≥ 13, REMS ≥ 4, and MEWS ≥ 3 scores for in-hospital mortality were 0.56, 0.97, 0.81, and 0.94, respectively. Also, the specificities of GCS, ISS, REMS, and MEWS scores for in-hospital mortality were 0.93, 0.82, 0.81, and 0.85, respectively.

Conclusion:

It seems that REMS is more accurate than GCS, ISS, and MEWS in predicting in-hospital mortality ≥ 24 hours of multiple trauma patients.

Development of a new score for early mortality prediction in trauma ICU patients: RETRASCORE

Background

Severity scores are commonly used for outcome adjustment and benchmarking of trauma care provided. No specific models performed only with critically ill patients are available. Our objective was to develop a new score for early mortality prediction in trauma ICU patients.

Methods

This is a retrospective study using the Spanish Trauma ICU registry (RETRAUCI) 2015–2019. Patients were divided and analysed into the derivation (2015–2017) and validation sets (2018–2019). We used as candidate variables to be associated with mortality those available in RETRAUCI that could be collected in the first 24 h after ICU admission. Using logistic regression methodology, a simple score (RETRASCORE) was created with points assigned to each selected variable. The performance of the model was carried out according to global measures, discrimination and calibration.

Results

The analysis included 9465 patients: derivation set 5976 and validation set 3489. Thirty-day mortality was 12.2%. The predicted probability of 30-day mortality was determined by the following equation: 1/(1 + exp (− y)), where y = 0.598 (Age 50–65) + 1.239 (Age 66–75) + 2.198 (Age > 75) + 0.349 (PRECOAG) + 0.336 (Pre-hospital intubation) + 0.662 (High-risk mechanism) + 0.950 (unilateral mydriasis) + 3.217 (bilateral mydriasis) + 0.841 (Glasgow ≤ 8) + 0.495 (MAIS-Head) − 0.271 (MAIS-Thorax) + 1.148 (Haemodynamic failure) + 0.708 (Respiratory failure) + 0.567 (Coagulopathy) + 0.580 (Mechanical ventilation) + 0.452 (Massive haemorrhage) − 5.432. The AUROC was 0.913 (0.903–0.923) in the derivation set and 0.929 (0.918–0.940) in the validation set.

Conclusions

The newly developed RETRASCORE is an early, easy-to-calculate and specific score to predict in-hospital mortality in trauma ICU patients. Although it has achieved adequate internal validation, it must be externally validated.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03845-6.

The association of ketamine induction with blood pressure changes in paramedic rapid sequence intubation of out-of-hospital traumatic brain injury

INTRODUCTION

Rapid sequence intubation (RSI) is used to secure the airway of traumatic brain injury (TBI) patients, with ketamine frequently used for induction. Studies show that ketamine-induction RSI might cause lower blood pressures when compared to etomidate. It is not clear if the results from that research can be extrapolated to systems that use different dosing regimens for ketamine RSI. Ambulance Victoria authorized the use of 1.5 mg/kg ketamine in January 2015 for head injury RSI induction by road-based paramedics. This study aims to examine whether systolic blood pressure changed when ketamine was introduced for prehospital head injury RSI.

METHODS

This study was a retrospective analysis of out-of-hospital suspected TBI that received RSI by paramedics. Our analysis employs an interrupted time-series analysis (ITSA), which is a quasi-experimental method that tested whether hypotension and systolic blood pressures changed after the switch to ketamine induction in 2015. This ITSA utilized an ordinary least squares regression on complete observations using Newey-West standard errors.

RESULTS

During the study period, paramedics performed RSI in 8,613 patients, and 1,759 (20.4%) had a TBI. Ketamine usage increased by 52.7% in January 2015 (p < 0.001) after road-based paramedics were authorized to use ketamine induction. This analysis found significant 5% increase in post-RSI hypotension (p = 0.046) after the introduction of ketamine, and thereafter the incidence of post-RSI hypotension increased steadily by 0.5% every 3 months (p = 0.004). Concurrently, changes in systolic blood pressure, as measured by the interval just before induction to the last measured on scene, show an average decrease of 7.8 mm Hg (p = 0.04) at the start of 2015 with the ketamine rollout.

CONCLUSIONS

This ITSA shows that postinduction hypotension and also decreases in systolic blood pressures became evident after the introduction of ketamine. Further research to investigate the association between ketamine induction and survival is needed.

The Association Between D-dimer Levels and Long-Term Neurological Outcomes of Patients with Traumatic Brain Injury: An Analysis of a Nationwide Observational Neurotrauma Database in Japan

BACKGROUND

We evaluated the association between D-dimer (DD) levels and long-term neurological prognoses among patients with isolated traumatic brain injury.

METHODS

Using data from multiple centers in the Japanese Neurotrauma Data Bank, we conducted an observational retrospective cohort study. Patients with isolated traumatic brain injury (head Abbreviated Injury Scale score > 2; any other Abbreviated Injury Scale score < 3) who were registered in the Japanese Neurotrauma Data Bank from 2015 to 2017 were recruited. We excluded patients younger than age 16 years and those who developed cardiac arrest at hospital admission. We also excluded patients with unknown Glasgow Outcome Scale (GOS) scores at 6 months after injury and those with unknown DD levels. The primary outcome was the association of DD levels with GOS scores at 6 months. We defined GOS scores 1 to 3 as poor and GOS scores 4 and 5 as good. The secondary outcome was the association of DD levels with mortality at 6 months after injury. We conducted multivariate logistic regression analyses to calculate the adjusted odds ratios of DD levels at hospital admission and GOS scores at 6 months as tertiles with 95% confidence intervals (CIs). A total of 293 patients were enrolled (median age 67 years; interquartile range 51-79 years). The median DD level was 27.1 mg/L (interquartile range 9.7-70.8 mg/L), and 58.0% (n = 170) had poor GOS scores at 6 months.

RESULTS

The multivariable logistic regression analysis indicated that the adjusted odds ratios were 2.52 (95% CI 1.10-5.77) for middle DD levels with poor GOS scores at 6 months and 5.81 (95% CI 2.37-14.2) for high DD levels with poor GOS scores at 6 months.

CONCLUSIONS

We revealed an association between DD levels and poor long-term neurological outcomes among patients with isolated traumatic brain injury.

Traumatic brain injury in the homeless: health, injury mechanisms, and hospital course

Primary ObjectiveEstablished literature demonstrates that homeless individuals experience both greater disease burden and risk of experiencing traumatic brain injury (TBI) than the general population. Similarly, shared risk factors for both homelessness and/or TBI may exacerbate the risk of repetitive neurotrauma within homeless populations.Research DesignWe leveraged a state-wide trauma registry, the Pennsylvania Trauma Outcome Study (PTOS), to characterize 609 patients discharged to homeless (58% TBI, 42% orthopedic injury (OI)) in comparison to 609 randomly sampled adult patients discharged to home.Methods and ProceduresWe implemented Chi-square tests to examine preexisting health conditions (PECs), hospital course, and injury mechanisms for both patient groups.Main Outcomes and ResultsHomelessness affects a greater proportion of nonwhite patients, and homeless patients present for care with increased frequencies of psychiatric and substance use PECs, and alcohol-positive TBI. Furthermore, assault impacts a larger proportion of homeless patients, and the window for overnight assault risk resulting in TBI is extended for these patients compared to patients discharged to home.ConclusionGiven the shifting conceptualization of TBI as a chronic condition, identifying homeless patients on admission to trauma centers, rather than retrospectively at discharge, can enhance understanding of the challenges facing the homeless as they age with both a complex neurotrauma history and multimorbidity.

Influence of Severe Thoracic Trauma on Choosing the Correct Surgical Strategy in Patients with Polytrauma from Kosovo

Background

Severe thoracic trauma (TT) has a significant impact on the selection of treatment strategy in patients with polytrauma. Our aim was to assess the impact of severe TT on choosing the optimal surgical procedure to decrease mortality.

Material/Methods

Overall, 66 patients with polytrauma and significant TT were analyzed. Demographic data, trauma history, admittance imaging, injury details, injury severity scores, conservative treatment, surgical treatment, days of hospital stay, and mortality data were gathered. Frequencies of thoracic surgical procedures and other treatments were collected and compared with those in the literature.

Results

All patients had Abbreviated Injury Scale (AIS) scores of thorax >3. Injuries to extremities and/or the osseous pelvis accounted for 50% of injuries; 47.0% included the head and/or neck; 45.5% were external injuries; and 27.3% were abdominal injuries or included pelvic organs and/or lumbar spine. Mean prehospital time was 40.3 min. Mean time from trauma occurrence to tertiary treatment was 125 min. Blunt TT (BTT) was recorded in 59 patients (89.4%), and penetrant TT (PTT) was recorded in 7 patients (10.6%). Thoracic drainage, urgent thoracotomy and laparotomy were recorded procedures. The mean Injury Severity Score (ISS) of all patients was 31.17. Nine patients died (13.6%) and had BTT with a mean ISS of 48.44. The Trauma Injury Severity Score for BTT injuries was 77.08% and for PTT, 85.6%.

Conclusions

Factors that decreased hospital stay and mortality and increased survival included arriving in time after injury, aggressive reanimation/intensive care, and mandatory thoracic surgical procedure combined with laparotomy.

Helicopter emergency medical service dispatch in older trauma: time to reconsider the trigger?

BACKGROUND

Helicopter Emergency Medical Services (HEMS) respond to serious trauma and medical emergencies. Geographical disparity and the regionalisation of trauma systems can complicate accurate HEMS dispatch. We sought to evaluate HEMS dispatch sensitivity in older trauma patients by analysing critical care interventions and conveyance in a well-established trauma system.

METHODS

All trauma patients aged ≥65 years that were attended by the Air Ambulance Kent Surrey Sussex over a 6-year period from 1 July 2013 to 30 June 2019 were included. Patient characteristics, critical care interventions and hospital disposition were stratified by dispatch type (immediate, interrogate and crew request).

RESULTS

1321 trauma patients aged ≥65 were included. Median age was 75 years [IQR 69-89]. HEMS dispatch was by immediate (32.0%), interrogation (43.5%) and at the request of ambulance clinicians (24.5%). Older age was associated with a longer dispatch interval and was significantly longer in the crew request category (37 min [34-39]) compared to immediate dispatch (6 min [5-6] (p = .001). Dispatch by crew request was common in patients with falls < 2 m, whereas pedestrian road traffic collisions and falls > 2 m more often resulted in immediate dispatch (p = .001). Immediate dispatch to isolated head injured patients often resulted in pre-hospital emergency anaesthesia (PHEA) (39%). However, over a third of head injured patients attended after dispatch by crew request received PHEA (36%) and a large proportion were triaged to major trauma centres (69%).

CONCLUSIONS

Many patients who do not fulfil the criteria for immediate HEMS dispatch need advanced clinical interventions and subsequent tertiary level care at a major trauma centre. Further studies should evaluate if HEMS activation criteria, nuanced by age-dependant triggers for mechanism and physiological parameters, optimise dispatch sensitivity and HEMS utilisation.

An analysis of air-crash injury patterns presenting at a level 1 trauma unit in Johannesburg, a retrospective cohort study

Background

In the twenty-first century, transportation disasters and subsequent injuries are on the rise, in particular air travel, and, thus, contributing significantly to the morbidity and mortality. Aviation injuries are not common in South Africa, injuries and outcomes of patients involved in aircraft crashes are unknown. We aimed to describe the injury patterns, and mortality rate resulting from air crashes presenting at a level 1 trauma centre in Johannesburg, South Africa.

Methods

Data was collected between January 2011 and December 2019. The hospital trauma database was used to obtain data related to patients who were involved in aircraft crashes. Their demographics, type of related aircraft, injuries sustained, injury severity score (ISS), new injury severity score (NISS), revised trauma score (RTS) surgical intervention carried out, length of stay in ICU, length of hospital stay, morbidities, 28-day mortality and outcomes (discharge/death).

Results

Fifty-two (52) patients (mean age was 44,8 years) were identified. The mean ISS was 9, and NISS was 11. Patients were occupants of civilian, non-commercial, powered aircraft. Fixed wing constituted 63,46%, followed by helicopters 21,15% and 7,69%. Spinal injuries were the most common injury in our patients, followed by soft tissue injuries and rib fractures. The median hospital stay was 10 ± 22 days. The overall in-hospital mortality rate was 7.7 %

Conclusion

Majority of patients sustained musculoskeletal injuries. We suggest that these injured patients should be managed at a Level 1 facility in view of combined multiple injuries sustained during the crash.

•

Aviation injuries post crashes are increasing.

•

Aircraft crashes are uncommon in south Africa.

•

Most common injuries are spinal injuries after aircraft injuries.

•

Most patients present with normal physiology.

•

Burn injuries carry a high mortality rate after an air crash.

Association of skull fracture with in-hospital mortality in severe traumatic brain injury patients

INTRODUCTION

To identify the association between skull fracture (SF) and in-hospital mortality in patients with severe traumatic brain injury (TBI).

MATERIALS AND METHODS

This multicenter cohort study included a retrospective analysis of data from the Japan Trauma Data Bank (JTDB). JTDB is a nationwide, prospective, observational trauma registry with data from 235 hospitals. Adult patients with severe TBI (Glasgow Coma Scale <9, head Abbreviated Injury Scale (AIS) ≥ 3, and any other AIS < 3) who were registered in the JTDB between January 2004 and December 2017 were included in the study. Patients who (a) were < 16 years old, (b) developed cardiac arrest before or at hospital arrival, and (c) had burns and penetrating injuries were excluded from the study. In-hospital mortality was the primary outcome assessed. Multivariable logistic regression analyses were performed to calculate the adjusted odds ratios (ORs) of SF and their 95% confidence intervals (CIs) for in-hospital mortality.

RESULTS

A total of 9607 patients were enrolled [median age: 67 (interquartile range: 50-78) years] in the study. Among those patients, 3574 (37.2%) and 6033 (62.8%) were included in the SF and non-SF groups, respectively. The overall in-hospital mortality rate was 44.1% (4238/9607). A multivariate analysis of the association between SF and in-hospital mortality yielded a crude OR of 1.63 (95% CI: 1.47-1.80). A subgroup analysis of the association of skull vault fractures, skull base fractures, and both fractures together with in-hospital mortality yielded adjusted ORs of 1.60 (95% CI: 1.42-1.98), 1.40 (95% CI: 1.16-1.70), and 2.14 (95% CI: 1.74-2.64), respectively, relative to the non-SF group.

CONCLUSIONS

This observational study showed that SF is associated with in-hospital mortality among patients with severe TBI. Furthermore, patients with both skull base and skull vault fractures were associated with higher in-hospital mortality than those with only one of these injuries.

A profile of a major trauma centre of North West England between 2011 and 2018

This study examined the trends and patterns of major trauma (MT) activities, causes, mortality and survival at the Aintree Major Trauma Centre (MTC), Liverpool, between 2011 and 2018. The number of trauma team activations (TTAs) rose sharply over time (n = 699 in 2013; n = 1522 in 2018). The proportion of TTAs that involved MT patients decreased from 75.1% in 2013 to 67.4% in 2018. The leading cause of MT was a fall from less than 2 m (36%). There has been a fivefold increase in the overall number of trauma procedures between 2011 and 2018. Orthopaedic surgeons have performed 80% of operations (n = 7732), followed by neurosurgeons, oral and maxillofacial surgeons, and general trauma surgeons. Both types of fall (> 2 m and < 2 m) and road traffic accidents were the three leading causes of death during the study period. The observed mortality rates exceeded that of expected rates in years 2012, 2014, 2016 and 2017. The all-cause observed to expected mortality ratio was 1.08 between 2012 and 2018. A change in care for MT patients was not directly associated with improved survival, although the marginally ascending trend line in survival rates between 2012 and 2018 reflects a gradual positive change.

Machine learning-based prediction models for accidental hypothermia patients

Background

Accidental hypothermia is a critical condition with high risks of fatal arrhythmia, multiple organ failure, and mortality; however, there is no established model to predict the mortality. The present study aimed to develop and validate machine learning-based models for predicting in-hospital mortality using easily available data at hospital admission among the patients with accidental hypothermia.

Method

This study was secondary analysis of multi-center retrospective cohort study (J-point registry) including patients with accidental hypothermia. Adult patients with body temperature 35.0 °C or less at emergency department were included. Prediction models for in-hospital mortality using machine learning (lasso, random forest, and gradient boosting tree) were made in development cohort from six hospitals, and the predictive performance were assessed in validation cohort from other six hospitals. As a reference, we compared the SOFA score and 5A score.

Results

We included total 532 patients in the development cohort [N = 288, six hospitals, in-hospital mortality: 22.0% (64/288)], and the validation cohort [N = 244, six hospitals, in-hospital mortality 27.0% (66/244)]. The C-statistics [95% CI] of the models in validation cohorts were as follows: lasso 0.784 [0.717–0.851] , random forest 0.794[0.735–0.853], gradient boosting tree 0.780 [0.714–0.847], SOFA 0.787 [0.722–0.851], and 5A score 0.750[0.681–0.820]. The calibration plot showed that these models were well calibrated to observed in-hospital mortality. Decision curve analysis indicated that these models obtained clinical net-benefit.

Conclusion

This multi-center retrospective cohort study indicated that machine learning-based prediction models could accurately predict in-hospital mortality in validation cohort among the accidental hypothermia patients. These models might be able to support physicians and patient’s decision-making. However, the applicability to clinical settings, and the actual clinical utility is still unclear; thus, further prospective study is warranted to evaluate the clinical usefulness.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40560-021-00525-z.

The usefulness of a trauma probability of survival model for forensic life-threatening danger assessments

Clinical forensic medical examinations constitute an increasing proportion of our institution’s tasks, and, concomitantly, the authorities are now requesting forensic life-threatening danger assessments based on our examinations. The aim of this retrospective study was to assess if a probability of survival (PS) trauma score could be useful for these forensic life-threatening danger assessments and to identify a cut-off PS score as a supporting tool for the forensic practice of assessing life-threatening danger. We compared a forensic database and a trauma database and identified 161 individuals (aged 15 years or older) who had both a forensic life-threatening danger assessment and a PS score. The life-threatening danger assessments comprised the following statements: was not in life-threatening danger (NLD); could have been in life-threatening danger (CLD); or was in life-threatening danger (LD). The inclusion period was 2012–2016. A statistically significant difference was found in the PS scores between NLD, CLD and LD (chi-square test: p < 0.0001). The usefulness of the PS score for categorizing life-threatening danger assessments was determined by a receiver-operator characteristic (ROC) curve. The area under the curve was 0.76 (95% CI, 0.69 to 0.84) and the ROC curve revealed that a cut-off PS score of 95.8 would appropriately identify LD. Therefore, a PS score below 95.8 would indicate life-threatening danger. We propose a further exploration of how the evidence-based PS score, including a cut-off value, might be implemented in clinical forensic medical statements to add to the scientific strength of these statements.

Validation of age-specific survival prediction in pediatric patients with blunt trauma using trauma and injury severity score methodology: a ten-year Nationwide observational study

BACKGROUND

In-hospital mortality in trauma patients has decreased recently owing to improved trauma injury prevention systems. However, no study has evaluated the validity of the Trauma and Injury Severity Score (TRISS) in pediatric patients by a detailed classification of patients' age and injury severity in Japan. This retrospective nationwide study evaluated the validity of TRISS in predicting survival in Japanese pediatric patients with blunt trauma by age and injury severity.

METHODS

Data were obtained from the Japan Trauma Data Bank during 2009-2018. The outcomes were as follows: (1) patients' characteristics and mortality by age groups (neonates/infants aged 0 years, preschool children aged 1-5 years, schoolchildren aged 6-11 years, and adolescents aged 12-18 years), (2) validity of survival probability (Ps) assessed using the TRISS methodology by the four age groups and six Ps-interval groups (0.00-0.25, 0.26-0.50, 0.51-0.75, 0.76-0.90, 0.91-0.95, and 0.96-1.00), and (3) the observed/expected survivor ratio by age- and Ps-interval groups. The validity of TRISS was evaluated by the predictive ability of the TRISS method using the receiver operating characteristic (ROC) curves that present the sensitivity, specificity, positive predictive value, negative predictive value, accuracy, area under the receiver operator characteristic curve (AUC) of TRISS.

RESULTS

In all the age categories considered, the AUC for TRISS demonstrated high performance (0.935, 0.981, 0.979, and 0.977). The AUC for TRISS was 0.865, 0.585, 0.614, 0.585, 0.591, and 0.600 in Ps-interval groups (0.96-1.00), (0.91-0.95), (0.76. - 0.90), (0.51-0.75), (0.26-0.50), and (0.00-0.25), respectively. In all the age categories considered, the observed survivors among patients with Ps interval (0.00-0.25) were 1.5 times or more than the expected survivors calculated using the TRISS method.

CONCLUSIONS

The TRISS methodology appears to predict survival accurately in Japanese pediatric patients with blunt trauma; however, there were several problems in adopting the TRISS methodology for younger blunt trauma patients with higher injury severity. In the next step, it may be necessary to develop a simple, high-quality prediction model that is more suitable for pediatric trauma patients than the current TRISS model.

Association of body temperature with in-hospital mortality among paediatric trauma patients: an analysis of a nationwide observational trauma database in Japan

OBJECTIVES

To examine the association between body temperature (BT) on hospital arrival and in-hospital mortality among paediatric trauma patients.

DESIGN

A retrospective cohort study.

SETTING

Japan Trauma Data Bank (JTDB, which is a nationwide, prospective, observational trauma registry with data from 235 hospitals).

PARTICIPANTS

Paediatric trauma patients <16 years old who were transferred directly from the scene of injury to the hospital and registered in the JTDB from January 2004 to December 2017 were included. We excluded patients >16 years old and those who developed cardiac arrest before or on hospital arrival.

PRIMARY OUTCOME

The association between BT on hospital arrival and in-hospital mortality. We conducted multivariate logistic regression analyses to calculate the adjusted ORs, with their 95% CIs, of the association between BT and in-hospital mortality.

RESULTS

A total of 9012 patients were included (median age: 9 years (IQR, 6.0-13.0 years), mortality: 2.5% (mortality number was 226 in total 9012 patients)). In the multivariate logistic regression analysis, the corresponding adjusted ORs of BT <36.0°C and BT ≥37.0°C, relative to a BT of 36°C-36.9°C, for in-hospital mortality were 2.83 (95% CI: 1.85 to 4.33) and 0.93 (95% CI: 0.53 to 1.63), respectively.

CONCLUSIONS

In paediatric patients with hypothermia (BT <36.0°C) on hospital arrival, a clear association with in-hospital mortality was observed; no such association was observed between higher BT values (≥37.0°C) and outcomes.

Assessment of trauma scoring systems in patients subjected to exploratory laparotomy

OBJECTIVE

to assess the epidemiological profile of patients undergoing exploratory trauma laparotomy based on severity and prognosis criteria, and to determine the predictive accuracy of trauma scoring systems in terms of morbidity and mortality.

METHODS

retrospective cohort study and review of medical records of patients undergoing exploratory laparotomy for blunt or penetrating trauma at the Hospital de Pronto Socorro de Porto Alegre, from November 2015 to November 2019. Demographic data, mechanism of injury, associated injuries, physiological (RTS and Shock Index), anatomical (ISS, NISS and ATI) and combined (TRISS and NTRISS) trauma scores, intraoperative findings, postoperative complications, length of stay and outcomes.

RESULTS

506 patients were included in the analysis. The mean age was 31 ± 13 years, with the majority being males (91.3%). Penetrating trauma was the most common mechanism of injury (86.2%), predominantly by firearms. The average RTS at hospital admission was 7.5 ± 0.7. The mean ISS and NISS was 16.5 ± 10.1 and 22.3 ± 13.6, respectively. The probability of survival estimated by TRISS was 95.5%, and by NTRISS 93%. The incidence of postoperative complications was 39.7% and the overall mortality was 12.8%. The most accurate score for predicting mortality was the NTRISS (88.5%), followed by TRISS, NISS and ISS.

CONCLUSION

the study confirms the applicability of trauma scores in the studied population. The NTRISS seems to be the best predictor of morbidity and mortality.

Time to definitive care within major trauma networks in England

BACKGROUND

Significant mortality improvements have been reported following the implementation of English trauma networks. Timely transfer of seriously injured patients to definitive care is a key indicator of trauma network performance. This study evaluated timelines from emergency service (EMS) activation to definitive care between 2013 and 2016.

METHODS

An observational study was conducted on data collected from the UK national clinical audit of major trauma care of patients with an Injury Severity Score above 15. Outcomes included time from EMS activation to: arrival at a trauma unit (TU) or major trauma centre (MTC); to CT; to urgent surgery; and to death.

RESULTS

Secondary transfer was associated with increased time to urgent surgery (median 7·23 (i.q.r. 5·48-9·28) h versus 4·37 (3·00-6·57) h for direct transfer to MTC; P < 0·001) and an increased crude mortality rate (19·6 (95 per cent c.i. 16·9 to 22·3) versus 15·7 (14·7 to 16·7) per cent respectively). CT and urgent surgery were performed more quickly in MTCs than in TUs (2·00 (i.q.r. 1·55-2·73) versus 3·15 (2·17-4·63) h and 4·37 (3·00-6·57) versus 5·37 (3·50-7·65) h respectively; P < 0·001). Transfer time and time to CT increased between 2013 and 2016 (P < 0·001). Transfer time, time to CT, and time to urgent surgery varied significantly between regional networks (P < 0·001).

CONCLUSION

Secondary transfer was associated with significantly delayed imaging, delayed surgery, and increased mortality. Key interventions were performed more quickly in MTCs than in TUs.

STING-Mediated Autophagy Is Protective against H2O2-Induced Cell Death

Stimulator of interferon genes (STING)-mediated type-I interferon signaling is a well characterized instigator of the innate immune response following bacterial or viral infections in the periphery. Emerging evidence has recently linked STING to various neuropathological conditions, however, both protective and deleterious effects of the pathway have been reported. Elevated oxidative stress, such as neuroinflammation, is a feature of a number of neuropathologies, therefore, this study investigated the role of the STING pathway in cell death induced by elevated oxidative stress. Here, we report that the H₂O₂-induced activation of the STING pathway is protective against cell death in wildtype (WT) MEFSV40 cells as compared to STING^−/− MEF SV40 cells. This protective effect of STING can be attributed, in part, to an increase in autophagy flux with an increased LC3II/I ratio identified in H₂O₂-treated WT cells as compared to STING^−/− cells. STING^−/− cells also exhibited impaired autophagic flux as indicated by p62, LC3-II and LAMP2 accumulation following H₂O₂ treatment, suggestive of an impairment at the autophagosome-lysosomal fusion step. This indicates a previously unrecognized role for STING in maintaining efficient autophagy flux and protecting against H₂O₂-induced cell death. This finding supports a multifaceted role for the STING pathway in the underlying cellular mechanisms contributing to the pathogenesis of neurological disorders.

Body temperature and in-hospital mortality in trauma patients: analysis of a nationwide trauma database in Japan

PURPOSE

Avoiding body temperature (BT) abnormalities has been emphasized in trauma care, and BT correction in the initial treatment period may improve patient outcome. However, the effect of hyperthermia at hospital arrival on mortality in trauma patients is unclear. This study aimed to identify the association between BT and in-hospital mortality among adult trauma patients.

METHODS

This was a retrospective analysis of a multi-centre prospective cohort study. Data were obtained from the Japan Trauma Data Bank (JTDB). Adult trauma patients who were transferred directly from the scene of injury to the hospital and registered in the JTDB between January 2004 and December 2017 were included. The primary outcome was the association between BT at hospital arrival and in-hospital mortality. BT at hospital arrival was classified by 1 °C strata. We conducted multivariable logistic regression analyses to calculate the adjusted odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality for each BT group using 36.0-36.9 °C as a reference.

RESULTS

Overall, 153,117 patients were included. The total mortality rate was 7% (n = 10,118). The adjusted OR for in-hospital mortality for < 35.0 °C was 1.65 (95% CI 1.51-1.79, p < 0.001), 35.0-35.9 °C was 1.33 (95% CI 1.25-1.41, p < 0.001), 37.0-37.9 °C was 0.99 (95% CI 0.91-1.07, p = 0.639), 38.0-38.9 °C was 1.30 (95% CI 1.08-1.56, p = 0.007) and > 39.0 °C was 1.62 (95% CI 1.18-2.22, p = 0.003) compared to that for normothermia.

CONCLUSIONS

Our results reveal that hypothermia and hyperthermia at hospital arrival are associated with increased in-hospital mortality in adult trauma patients.

Comparing the Clinical Features and Trauma Scores of Trauma Patients Aged Under 65 Years with Those of Patients Aged over 65 Years in the Intensive Care Unit: A Retrospective Study for Last Ten Years

Objective

This retrospective study aimed to compare the clinical characteristics and trauma scores of Intensive Care Unit (ICU) trauma patients 65 years and older with the patients under 65 years old.

Materials and Methods

Trauma patients (n=161) who stayed at least 24 hours in ICU were included. Patients younger than 65 years were included into Group 1 (n=109) and patients aged ≥65 years (n=52) were included into Group 2. Patient characteristics and trauma index scores (GCS; APACHE II score, ISS; TRISS and RTS) at ICU admission were calculated.

Results

The patients in Group 2 had more comorbid disease compared with Group 1 (61.5%, 6.4%) (p=0.001). The Trauma-related Injury Severity Score score were higher in Group 1 (49.76±33.75) compared with Group 2 (35.38±34.93) (p=0.006). The APACHE II score were higher in Group 2 (20.08±7.60) compared with Group 1 (17.00±6.90) (p=0.007). The need for invasive mechanical ventilation and tracheostomy were more frequent in Group 2 trauma patients compared with those of patients in Group 1 (92.3%, 73.4%; p=0.003; 26.9%, 8.3%; p=0.002; respectively). The need for transfusion of packed red blood cell suspension (PRBC) was more frequent in Group 2 compared with Group 1 (92.3%, 55.0%; respectively) (p=0.001). The mortality rate was found to be higher in Group 2 compared with Group 1 (48.1%, 19.3%; respectively) (p=0.001).

Conclusion

The elderly trauma patients have more comorbid disease, higher scores for APACHE II and lower scores for TRISS, more mechanical ventilation and tracheostomy requirements and higher mortality rate compared with young trauma patients.

The utility of the brain trauma evidence to inform paramedic rapid sequence intubation in out-of-hospital stroke

Background

Rapid sequence intubation (RSI) is used to secure the airway of stroke patients. Randomized controlled trial evidence exists to support the use of paramedic RSI for traumatic brain injury (TBI), but cannot necessarily be applied to stroke RSI because of differences between the stroke and TBI patient. To understand if the TBI evidence can be used for stroke RSI, we analysed a retrospective cohort of TBI and strokes to compare how survival is impacted differently by RSI when comparing strokes and TBI.

Methods

This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all stroke and TBI patients attended by Ambulance Victoria, Australia. Logistic regression predicted the survival for ischemic and haemorrhagic strokes as well as TBI. The constituents of RSI, such a medications, intubation success and time intervals were analysed against survival using interactions to asses if RSI impacts survival differently for strokes compared to TBI.

Results

This analysis found significant interactions in the RSI-only group for age, number of intubation attempts, atropine, fentanyl, pulse rate and perhaps scene time and time- to-RSI. Such interactions imply that RSI impact survival differently for TBI versus strokes. Additionally, no significant difference in survival for TBI was found, with a − 0.7% lesser survival for RSI compared to no-RSI; OR 0.86 (95% CI 0.67 to 1.11; p = 0.25). Survival for haemorrhagic stroke was − 14.1% less for RSI versus no-RSI; OR 0.44 (95% CI 0.33 to 0.58; p = 0.01) and was − 4.3%; OR 0.67 (95% CI 0.49 to 0.91; p = 0.01) lesser for ischemic strokes.

Conclusions

Rapid sequence intubation and related factors interact with stroke and TBI, which suggests that RSI effects stroke survival in a different way from TBI. If RSI impact survival differently for strokes compared to TBI, then perhaps the TBI evidence cannot be used for stroke RSI.

Development and validation of a model to predict the need for emergency front-of-neck airway procedures in trauma patients

The present study aimed to develop and validate a model for predicting the need for emergency front-of neck airway (eFONA) procedures among trauma patients. This was a multicentre retrospective cohort study using data from the Japan Trauma Data Bank between January 2004 and December 2017. Only adult trauma patients were included. The cohort was divided into development and validation cohorts. A simple scoring system was developed to predict the necessity for emergency front-of neck airway procedures in the development cohort using a logistic regression model. The external validity and diagnostic ability of the scoring system was assessed in the validation cohort. In total, 198,182 out of 294,274 patients were included; emergency front-of-neck airway occurred in 467 patients (0.24%) they were divided into development (n = 100,120 with 0.22% undergoing emergency front-of neck airway) and validation (n = 98,062 with 0.25% undergoing emergency front-of neck airway) cohorts. The 'eFONA' prediction scoring system was developed in the development cohort, with a score of +1 for each of the following: Eye opening (no eye opening in response to any stimuli); Fall from height or motor bike; Oral-maxillofacial injury; Neck tracheal injury; and Airway management by paramedics. In the validation cohort, the C-statistic of the scoring system was 0.820. Setting the cut-off value at one for rule-out, the sensitivity and negative likelihood ratios were 0.86 and 0.22, respectively. Setting the cut-off value at two for rule-in, the specificity and positive likelihood ratios were 0.91 and 6.6, respectively. The present scoring system may assist in predicting the need for emergency front-of neck airway procedures among the general trauma population.

Mode of Transport and Trauma Activation Status in Admitted Pediatric Trauma Patients

BACKGROUND

Injured children who arrive by self-transport to the emergency department (ED) may receive delayed or inadequate care. We studied differences in demographics, clinical characteristics, and trauma activation status for admitted pediatric trauma patients based on arrival by self-transport or Emergency Medical Services (EMS).

MATERIALS AND METHODS

We performed a retrospective cohort study at two level I pediatric trauma centers.

INCLUSION CRITERIA

<15 y old with blunt or penetrating injury. We used univariate and multivariate logistic regression analyses to determine associations between trauma activation, ED length of stay (LOS), and hospital LOS with demographic and clinical characteristics.

RESULTS

We identified 1161 patients: 40.1% arrived by self-transport and 59.9% by EMS. Self-transport patients were less likely to have an abnormal Glasgow Coma Scale score < 15 (2.1% versus 22.0%, P < 0.001) and Injury Severity Score > 15 (2.4% versus 11.7%, P < 0.001). Trauma activation was initiated in 52.5% of patients, occurring less often in self-transport than EMS patients (2.4% versus 86.2%, P < 0.001). Trauma activation rate was negatively associated with arrival by self-transport (odds ratio [OR] 0.001, 95% CI 0.00-0.003), positively associated with Glasgow Coma Scale <15 (OR 25.9, 95% CI 6.6-101.2) and site (OR 15.4, 95% CI 6.3-37.5) but not with Injury Severity Score >15 (OR 2.8, 95% CI 0.8-9.2). Self-transport arrival was associated with longer ED LOS (estimated regression slope 0.47, 95% CI 0.13-0.82).

CONCLUSIONS

Almost half of admitted pediatric trauma patients arrived by self-transport; however, trauma team activation rarely occurs for these patients. Trauma team activation may be underutilized in self-transport patients with injuries resulting in hospital admission.

The role of the American Society of anesthesiologists physical status classification in predicting trauma mortality and outcomes

BACKGROUND

Trauma prediction scores such as Revised Trauma Score (RTS) and Trauma and Injury Severity Score (TRISS)) are used to predict mortality, but do not include comorbidities. We analyzed the American Society of Anesthesiologists physical status (ASA PS) for predicting mortality in trauma patients undergoing surgery.

METHODS

This multicenter, retrospective study compared the mortality predictive ability of ASA PS, RTS, Injury Severity Score (ISS), and TRISS using a complete case analysis with mixed effects logistic regression. Associations with mortality and AROC were calculated for each measure alone and tested for differences using chi-square.

RESULTS

Of 3,042 patients, 230 (8%) died. The AROC for mortality for TRISS was 0.938 (95%CI 0.921, 0.954), RTS 0.845 (95%CI 0.815, 0.875), and ASA PS 0.886 (95%CI 0.864, 0.908). ASA PS + TRISS did not improve mortality predictive ability (p = 0.18).

CONCLUSIONS

ASA PS was a good predictor of mortality in trauma patients, although combined with TRISS it did not improve predictive ability.

Performance evaluation and validation of the Animal Trauma Triage score and modified Glasgow Coma Scale in injured cats: A Veterinary Committee on Trauma registry study

OBJECTIVES

To examine the Animal Trauma Triage (ATT) and modified Glasgow Coma Scale (mGCS) scores as predictors of mortality in injured cats.

DESIGN

Observational cohort study conducted September 2013 to March 2015.

SETTING

Nine Level I and II veterinary trauma centers.

ANIMALS

Consecutive sample of 711 cats reported on the Veterinary Committee on Trauma (VetCOT) case registry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared the predictive power (area under receiver operating characteristic curve; AUROC) and calibration of the ATT and mGCS scores to their components. Overall mortality risk was 16.5% (95% confidence interval [CI], 13.9-19.4). Head trauma prevalence was 11.8% (n = 84). The ATT score showed a linear relationship with mortality risk. Discriminatory performance of the ATT score was excellent (AUROC = 0.87 [95% CI, 0.84-0.90]). Each ATT score increase of 1 point was associated with an increase in mortality odds of 1.78 (95% CI, 1.61-1.97, P < 0.001). The eye/muscle/integument category of the ATT showed the lowest discrimination (AUROC = 0.60). When this component, skeletal, and cardiac components were omitted from score calculation, there was no loss in discriminatory capacity compared with the full score (AUROC = 0.86 vs 0.87, respectively, P = 0.66). The mGCS showed fair performance overall for prediction of mortality, but the point estimate of performance improved when restricted to head trauma patients (AUROC = 0.75, 95% CI, 0.70-0.80 vs AUROC = 0.80, 95% CI, 0.70-0.90). The motor component of the mGCS showed the best predictive performance (AUROC = 0.71); however, the full score performed better than the motor component alone (P = 0.004). When assessment was restricted to patients with head injury (n = 84), there was no difference in performance between the ATT and mGCS scores (AUROC = 0.82 vs 0.80, P = 0.67).

CONCLUSION

On a large, multicenter dataset of feline trauma patients, the ATT score showed excellent discrimination and calibration for predicting mortality; however, an abbreviated score calculated from the perfusion, respiratory, and neurologic categories showed equivalent performance.

Association between the Japan Coma Scale scores at the scene of injury and in-hospital outcomes in trauma patients: an analysis from the nationwide trauma database in Japan

OBJECTIVE

Japan Coma Scale (JCS) is a grading system used to evaluate disturbed consciousness in prehospital care settings. We aimed to identify the association between the JCS levels at the scene with in-hospital mortality, as well as the discrimination ability for the outcomes.

DESIGN

A retrospective cohort study based on the nationwide trauma database in Japan.

SETTING

Multicentre cohort study using data from the Japan Trauma Data Bank, which is a nationwide, prospective, observational trauma registry derived from 235 hospitals.

PARTICIPANTS

Adult trauma victims transferred directly from the scene of injury to the hospital from January 2004 to December 2017 were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOMES

Primary outcome was the association between the JCS levels at the scene with in-hospital mortality. We conducted a multivariate logistic regression analysis to calculate the adjusted ORs of JCS levels with 95% CIs for in-hospital mortality. We also calculated the c-statistics for in-hospital mortality.

RESULTS

164 723 patients were included in the analysis. In a multivariate logistic regression analysis, the corresponding adjusted ORs of JCS levels 2 and 3 referred to level 1 for in-hospital mortality were 4.1 (95% CI 3.8 to 4.4) and 26.0 (95% CI 24.8 to 27.2). The c-statistics of the JCS level for in-hospital mortality was 0.845 (95% CI 0.842 to 0.849).

CONCLUSIONS

Data from large multicentre prospective registry revealed strong associations of the JCS level at the scene of injury with in-hospital mortality as well as the good discriminatory performance for this outcome.

Comorbidities in Trauma Injury Severity Scoring System: Refining Current Trauma Scoring System

The revised trauma score combined with the Injury Severity Score (ISS) remains the mostly commonly used system for predicting trauma mortality, but these scoring systems do not account for the patient's comorbidities. This study aims to evaluate the effect of comorbidities on ISS-related mortality and length of stay. A review of our trauma center's data registry from 2014 to 2016 was carried out. Patients were divided according to ISS into two groups: ISS ≤ 15 and ISS > 15. Each ISS group was then subdivided by number of comorbidities into two groups: 1 to 2 or ≥3 comorbidities. Demographic characteristics and outcome measures were compared. ANOVA, chi-squared, and t tests were used with significance defined as P < 0.05. A total 9845 adult trauma patients were admitted to our trauma center during the three-year study period. In the ISS ≤ 15 group, patients with <3 comorbidities had significantly higher mortality rate compared with patients with 1 to 2 comorbidities (1.50% vs 0.12%, P << 0.000007). Comparing the ISS ≤ 15 group with ≥3 comorbidities with the ISS > 15 group with 1 to 2 comorbidities, the mortality rate was significantly higher (23.40% vs 4.50%, P << 0.000002). The ICU length of stay was significantly higher in the ISS ≤ 15 groups (17 vs 10 days, P < 0.05) but similar in the ISS > 15 groups (31 vs 29 days) (P > 0.05). It was concluded that when controlling for injury severity, increased comorbidities are associated with a significantly higher mortality, indicating that they may serve as a marker of lower physiologic reserve and be an independent variable. Adding comorbidity parameters to the current trauma scoring systems can assist in predicting more accurate/reliable outcomes.

Performance evaluation and validation of the animal trauma triage score and modified Glasgow Coma Scale with suggested category adjustment in dogs: A VetCOT registry study

OBJECTIVE

To examine the animal trauma triage (ATT) and modified Glasgow Coma Scale (mGCS) scores as predictors of mortality outcome (death or euthanasia) in injured dogs.

DESIGN

Observational cohort study conducted from September 2013 to March 2015 with follow-up until death or hospital discharge.

SETTING

Nine veterinary hospitals including private referral and veterinary teaching hospitals.

ANIMALS

Consecutive sample of 3,599 dogs with complete data entries recruited into the Veterinary Committee on Trauma patient registry.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We compared the predictive power (area under receiver operating characteristic [AUROC]) and calibration of the ATT and mGCS scores to their components. Overall mortality risk was 7.3% (n = 264). Incidence of head trauma was 9.5% (n = 341). The ATT score showed a linear relationship with mortality risk. Discriminatory performance of the ATT score was excellent with AUROC = 0.92 (95% confidence interval [CI] 0.91 to 0.94) and pseudo R² = 0.42. Each ATT score increase of 1 point was associated with an increase in mortality odds of 2.07 (95% CI = 1.94-2.21, P < 0.001). The "eye/muscle/integument" category of the ATT showed poor discrimination (AUROC = 0.55). When this component together with the skeletal and cardiac components were omitted from calculation of the overall score, there was no loss in discriminatory capacity (AUROC = 0.92 vs 0.91, P = 0.09) compared with the full score. The mGCS showed good performance overall, but performance improved when restricted to head trauma patients (AUROC = 0.84, 95% CI = 0.79-0.90, n = 341 vs 0.82, 95% CI = 0.79-0.85, n = 3599). The motor component of the mGCS showed the best predictive performance (AUROC = 0.79 vs 0.66/0.69); however, the full score performed better than the motor component alone (P = 0.002). When assessment was restricted to patients with head injury (n = 341), the ATT score still performed better than the mGCS (AUROC = 0.90 vs 0.84, P = 0.04).

CONCLUSIONS

In external validation on a large, multicenter dataset, the ATT score showed excellent discrimination and calibration; however, a more parsimonious score calculated on only the perfusion, respiratory, and neurological categories showed equivalent performance.

Guiding Management in Severe Trauma: Reviewing Factors Predicting Outcome in Vastly Injured Patients

Trauma is one of the leading causes of death worldwide, with road traffic collisions, suicides, and homicides accounting for the majority of injury-related deaths. Since trauma mainly affects young age groups, it is recognized as a serious social and economic threat, as annually, almost 16,000 posttrauma individuals are expected to lose their lives and many more to end up disabled. The purpose of this research is to summarize current knowledge on factors predicting outcome - specifically mortality risk - in severely injured patients. Development of this review was mainly based on the systematic search of PubMed medical library, Cochrane database, and advanced trauma life support Guiding Manuals. The research was based on publications between 1994 and 2016. Although hypovolemic, obstructive, cardiogenic, and septic shock can all be seen in multi-trauma patients, hemorrhage-induced shock is by far the most common cause of shock. In this review, we summarize current knowledge on factors predicting outcome - more specifically mortality risk - in severely injured patients. The main mortality-predicting factors in trauma patients are those associated with basic human physiology and tissue perfusion status, coagulation adequacy, and resuscitation requirements. On the contrary, advanced age and the presence of comorbidities predispose patients to a poor outcome because of the loss of physiological reserves. Trauma resuscitation teams considering mortality prediction factors can not only guide resuscitation but also identify patients with high mortality risk who were previously considered less severely injured.