The Kampala Trauma Score: A 20-year track record

Development of a Perioperative Risk Mortality Calculator for Humanitarian Surgical Care

BACKGROUND

Risk models to predict perioperative mortality rates (POMR) are critical to surgical quality improvement yet are not widely adapted for use in humanitarian and low-resource settings (LRS). We developed a POMR and corresponding nomogram and calculator for use in humanitarian surgical care.

METHODS

Electronic health record data from a high-income academic medical center from 2015 to 2019 were retrospectively extracted, selecting variables and operations specific to LRS. This development dataset was used to create a logistic regression POMR model, which was then prospectively validated using data from 2022 to 2023 from the same institution.

RESULTS

EHR from a total of 49,277 patients were used. The model fitted eight variables feasibly obtainable in LRS: age > 65 years (OR = 4.05 and 95% CI: 3.71-4.43), male sex (OR = 1.32 and 95% CI: 1.25-1.40), GCS < 13 (OR = 5.20 and 95% CI: 4.73-5.73), glucose > 200 mg/dL (OR = 2.19 and 95% CI: 2.01-2.38), Hgb ≤ 11 g/dL (OR = 2.65 and 95% CI: 2.43-2.89), HR > 120 bpm (OR = 2.49 and 95% CI: 2.35-2.64), T > 38 degrees Celsius (OR = 1.32 and 95% CI: 1.19-1.45), and SBP > 180 mmHg (OR = 1.18 and 95% CI: 1.02-1.37). The model demonstrated a high area under the curve (0.847, 0.867, and 0.925), sensitivity (0.739, 0.886, and 0.844), specificity (0.807, 0.780, and 0.864), and negative predictive value (0.750, 0.997, and 0.999) on training, holdout, and prospective validation sets.

CONCLUSION

We validated a POMR model for use in LRS using eight variables that are readily available in the target environment. This model's predictors and accompanying clinical tools of an Excel calculator and nomogram make it simultaneously comprehensive and accessible in LRS.

Predicting Mortality in Trauma Research: Evaluating the Performance of Trauma Scoring Tools in a South African Population

Background Trauma is a leading cause of death and disability in low-resource settings, yet trauma severity scores are seldom validated in these contexts. There is a pressing need to better characterize and compare trauma scoring tools, especially within research frameworks. This study aimed to evaluate the performance of various trauma scoring tools in predicting in-hospital mortality among trauma patients in South Africa. Methods This study conducted a secondary analysis of existing data from the multicenter Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study, which included 13,548 adult trauma patients aged 18 years and older, collected between August 2021 and March 2024. The predictive ability of the scoring tools was assessed by calculating the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Results The mortality rate was 2.5% (n = 298). The Kampala Trauma Score (KTS) demonstrated the highest predictive ability for seven-day in-hospital mortality, with an AUROC of 0.95 and an AUPRC of 0.53. Similarly, the Trauma and Injury Severity Score (TRISS) and the New Injury Severity Score (NISS) also exhibited strong predictive capabilities, with AUROC values of 0.96 and AUPRC values of 0.62 for TRISS and an AUROC of 0.96 and AUPRC of 0.53 for NISS. In contrast, the Revised Trauma Score and Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) showed lower predictive performance, with AUROC values of 0.87 (AUPRC = 0.51) and 0.86 (AUPRC = 0.47), respectively. Conclusions The KTS exhibited optimal performance characteristics for retrospectively predicting mortality in our cohort, outperforming other scoring tools. Notably, it is also the simplest scoring tool, featuring the fewest variables compared to other trauma severity assessments. These findings highlight the necessity for external validation of trauma scoring tools in resource-limited populations to ensure their applicability and effectiveness in trauma research across diverse healthcare settings.

New Trauma Score versus Kampala Trauma Score II in predicting mortality following road traffic crash: a prospective multi-center cohort study

INTRODUCTION

Mortality due to injuries disproportionately impact low income countries. Knowledge of who is at risk of poor outcomes is critical to guide resource allocation and prioritization of severely injured. Kampala Trauma Score (KTS), developed in 1996 and last modified in 2002 as KTS II, is still widely being used to predict injury outcomes in resource-limited settings with no further revisions in the past two decades, despite ongoing criticism of some of its parameters. The New Trauma Score (NTS), a recent development in 2017, has shown potential in mortality prediction, but a dearth of evidence exist regarding its performance in the African population.

OBJECTIVES

To compare NTS to the modified Kampala Trauma Score (KTS II) in the prediction of 30-day mortality, and injury severity amongst patients sustaining road traffic crashes in Ugandan low-resource settings.

METHODS

Multi-center prospective cohort study of patients aged 15 years and above. Of the 194 participants, 85.1% were males with a mean age of 31.7 years. NTS and KTS II were determined for each participant within 30-minutes of admission and followed-up for 30 days to determine their injury outcomes. The sensitivity, specificity, and area under receiver operating characteristics curve (AUC) for predicting mortality were compared between the two trauma scores using SPSS version 22. Ethical clearance: Research and Ethics Committee of Kampala International University Western Campus (Ref No: KIU-2022-125).

RESULTS

The injury severity classifications based on NTS vs. KTS II were mild (55.7% vs. 25.8%), moderate (29.9% vs. 30.4%), and severe (14.4% vs. 43.8%). The mortality rates for each injury severity category based on NTS vs. KTS II were mild (0.9% v 0%), moderate (20.7% vs. 5.1%), and severe (50% vs. 28.2%). The AUC was 0.87 for NTS (95% CI 0.808-0.931) vs. 0.86 (95% CI 0.794-0.919) for KTS II respectively. The sensitivity of NTS vs. KTS II in predicting mortality was 92.6% (95% CI: 88.9-96.3) vs. 70.4% (95% CI: 63.0-77.8) while the specificity was 70.7% (95% CI: 64.2-77.2) vs. 78.4% (95% CI: 72.1-84.7) at cut off points of 17 for NTS and 6 for KTS II respectively.

CONCLUSIONS

NTS was more sensitive but its specificity for purposes of 30-day mortality prediction was lower compared to KTS II. Thus, in low-resourced trauma environment where time constraints and pulse oximeters are of concern, KTS II remains superior to NTS.

The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS)

PURPOSE

The classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting.

METHODS

We conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed.

RESULTS

381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888-0.958) and for eISS was 0.910 (95% CI: 0.877-0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively.

CONCLUSION

In our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.

Effect of Rural Trauma Team Development on the Outcomes of Motorcycle Accident-Related Injuries (Motor Registry Project): Protocol for a Multicenter Cluster Randomized Controlled Trial

BACKGROUND

Injury is a global health concern, and injury-related mortality disproportionately impacts low- and middle-income countries (LMICs). Compelling evidence from observational studies in high-income countries shows that trauma education programs, such as the Rural Trauma Team Development Course (RTTDC), increase clinician knowledge of injury care. There is a dearth of such evidence from controlled clinical trials to demonstrate the effect of the RTTDC on process and patient outcomes in LMICs.

OBJECTIVE

This multicenter cluster randomized controlled clinical trial aims to examine the impact of the RTTDC on process and patient outcomes associated with motorcycle accident-related injuries in an African low-resource setting.

METHODS

This is a 2-arm, parallel, multi-period, cluster randomized, controlled, clinical trial in Uganda, where rural trauma team development training is not routinely conducted. We will recruit regional referral hospitals and include patients with motorcycle accident-related injuries, interns, medical trainees, and road traffic law enforcement professionals. The intervention group (RTTDC) and control group (standard care) will include 3 hospitals each. The primary outcomes will be the interval from the accident to hospital admission and the interval from the referral decision to hospital discharge. The secondary outcomes will be all-cause mortality and morbidity associated with neurological and orthopedic injuries at 90 days after injury. All outcomes will be measured as final values. We will compare baseline characteristics and outcomes at both individual and cluster levels between the intervention and control groups. We will use mixed effects regression models to report any absolute or relative differences along with 95% CIs. We will perform subgroup analyses to evaluate and control confounding due to injury mechanisms and injury severity. We will establish a motorcycle trauma outcome (MOTOR) registry in consultation with community traffic police.

RESULTS

The trial was approved on August 27, 2019. The actual recruitment of the first patient participant began on September 01, 2019. The last follow-up was on August 27, 2023. Posttrial care, including linkage to clinical, social support, and referral services, is to be completed by November 27, 2023. Data analyses will be performed in Spring 2024, and the results are expected to be published in Autumn 2024.

CONCLUSIONS

This trial will unveil how a locally contextualized rural trauma team development program impacts organizational efficiency in a continent challenged with limited infrastructure and human resources. Moreover, this trial will uncover how rural trauma team coordination impacts clinical outcomes, such as mortality and morbidity associated with neurological and orthopedic injuries, which are the key targets for strengthening trauma systems in LMICs where prehospital care is in the early stage. Our results could inform the design, implementation, and scalability of future rural trauma teams and trauma education programs in LMICs.

TRIAL REGISTRATION

Pan African Clinical Trials Registry (PACTR202308851460352); https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=25763.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/55297.

Pediatric Traumatic Brain Injury in Malawi: A Propensity-Weighted Analysis of Outcomes and Trends Over Time

BACKGROUND

Pediatric injuries contribute to substantial mortality and morbidity worldwide, particularly in sub-Saharan Africa. We aim to identify predictors of mortality and time trends for pediatric traumatic brain injuries (TBIs) in Malawi.

METHODS

We performed a propensity-matched analysis of data from the trauma registry at Kamuzu Central Hospital in Malawi from 2008 to 2021. All children ≤16 years of age were included. Demographic and clinical data were collected. Outcomes were compared between patients with and without head injuries.

RESULTS

A cohort of 54,878 patients was included, with 1755 having TBI. The mean ages of patients with and without TBI were 7.8 ± 7.8 years and 7.1 ± 4.5 years, respectively. The most common mechanism for patients with and without TBI was road traffic injury and falls, respectively (48.2% vs. 47.8%, P < 0.01). The crude mortality rate for the TBI cohort was 20.9% compared to 2.0% in the non-TBI cohort (P < 0.01). After propensity matching, patients with TBI had 4.7 higher odds of mortality (95% confidence interval 1.9-11.8). Over time, patients with TBI had an increasing predicted probability of mortality for all age categories, with the most significant increase among children younger than 1 year.

CONCLUSIONS

TBI confers a greater than 4-fold higher likelihood of mortality in this pediatric trauma population in a low-resource setting. These trends have worsened over time.

The CBS test: Development, evaluation & cross-validation of a community-based injury severity scoring system in Cameroon

Injury-related deaths overwhelmingly occur in low and middle-income countries (LMICs). Community-based injury surveillance is essential to accurately capture trauma epidemiology in LMICs, where one-third of injured individuals never present to formal care. However, community-based studies are constrained by the lack of a validated surrogate injury severity metric. The primary objective of this bipartite study was to cross-validate a novel community-based injury severity (CBS) scoring system with previously-validated injury severity metrics using multi-center trauma registry data. A set of targeted questions to ascertain injury severity in non-medical settings-the CBS test-was iteratively developed with Cameroonian physicians and laypeople. The CBS test was first evaluated in the community-setting in a large household-based injury surveillance survey in southwest Cameroon. The CBS test was subsequently incorporated into the Cameroon Trauma Registry, a prospective multi-site national hospital-based trauma registry, and cross-validated in the hospital setting using objective injury metrics in patients presenting to four trauma hospitals. Among 8065 surveyed household members with 503 injury events, individuals with CBS indicators (CBS+) were more likely to report ongoing disability after injury compared to CBS- individuals (OR 1.9, p = 0.004), suggesting the CBS test is a promising injury severity proxy. In 9575 injured patients presenting for formal evaluation, the CBS test strongly predicted death in patients after controlling for age, sex, socioeconomic status, and injury type (OR 30.26, p<0.0001). Compared to established injury severity scoring systems, the CBS test comparably predicts mortality (AUC: 0.8029), but is more feasible to calculate in both the community and clinical contexts. The CBS test is a simple, valid surrogate metric of injury severity that can be deployed widely in community-based surveys to improve estimates of injury severity in under-resourced settings.

Back to the basics: Clinical assessment yields robust mortality prediction and increased feasibility in low resource settings

INTRODUCTION

Mortality prediction aids clinical decision-making and is necessary for trauma quality improvement initiatives. Conventional injury severity scores are often not feasible in low-resource settings. We hypothesize that clinician assessment will be more feasible and have comparable discrimination of mortality compared to conventional scores in low and middle-income countries (LMICs).

METHODS

Between 2017 and 2019, injury data were collected from all injured patients as part of a prospective, four-hospital trauma registry in Cameroon. Clinicians used physical exam at presentation to assign a highest estimated abbreviated injury scale (HEAIS) for each patient. Discrimination of hospital mortality was evaluated using receiver operating characteristic curves. Discrimination of HEAIS was compared with conventional scores. Data missingness for each score was reported.

RESULTS

Of 9,635 presenting with injuries, there were 206 in-hospital deaths (2.2%). Compared to 97.5% of patients with HEAIS scores, only 33.2% had sufficient data to calculate a Revised Trauma Score (RTS) and 24.8% had data to calculate a Kampala Trauma Score (KTS). Data from 2,328 patients with all scores was used to compare models. Although statistically inferior to the prediction generated by RTS (AUC 0.92-0.98) and KTS (AUC 0.93-0.99), HEAIS provided excellent overall discrimination of mortality (AUC 0.84-0.92). Among 9,269 patients with HEAIS scores was strongly predictive of mortality (AUC 0.93-0.96).

CONCLUSION

Clinical assessment of injury severity using HEAIS strongly predicts hospital mortality and far exceeds conventional scores in feasibility. In contexts where traditional scoring systems are not feasible, utilization of HEAIS could facilitate improved data quality and expand access to quality improvement programming.

HIV Prevalence among Injury Patients Compared to Other High-Risk Groups in Tanzania

Sixty-eight percent of persons infected with HIV live in Africa, but as few as 67% of those know their infection status. The emergency department (ED) might be a critical access point to HIV testing. This study sought to measure and compare HIV prevalence in an ED injury population with other clinical and nonclinical populations across Tanzania. Adults (≥18 years) presenting to Kilimanjaro Christian Medical Center ED with acute injury of any severity were enrolled in a trauma registry. A systematic review and meta-analysis was conducted to compare HIV prevalence in the trauma registry with other population groups. Further, 759 injury patients were enrolled in the registry; 78.6% were men and 68.2% consented to HIV counseling and testing. The HIV prevalence was 5.02% (tested), 6.25% (self-report), and 5.31% (both). The systematic review identified 79 eligible studies reporting HIV prevalence (tested) in 33 clinical and 12 nonclinical population groups. Notable groups included ED injury patients (3.53%, 95% CI), multiple injury patients (10.67%, 95% CI), and people who inject drugs (17.43%, 95% CI). These findings suggest that ED injury patients might be at higher HIV risk compared to the general population, and the ED is a potential avenue to increasing HIV testing among young adults, particularly men.