Performance of injury severity measures in trauma research: a literature review and validation analysis of studies from low-income and middle-income countries

Ganga hospital open injury severity score as a predictor of early failure of limb salvage among gustilo type III A and B tibia fractures in Uganda: a prospective cohort study

BACKGROUND

Despite advances in antibiotic therapy and microsurgery, the management of Gustilo and Anderson type IIIA and B open tibia fractures continues to pose a considerable challenge in developing countries. This has evolved from historical immediate amputation to modern approaches that prioritize both aesthetics and functional outcomes. Nonetheless, a consensus on limb salvage versus amputation remains elusive, prompting the development of prognostic limb scoring systems. Our study assessed the predictive accuracy of the Ganga Hospital Open Injury Severity Score (GHOISS) for early failure of limb salvage in Gustilo type IIIA and B tibia injuries.

METHODS

This was a prospective study that examined open tibia fractures at two tertiary hospitals in the emergency and orthopaedic units between June and October 2023. Fifty-three (26 IIIB and 27 IIIA) satisfied the study inclusion and exclusion criteria. Four injuries (type IIIA) in paediatric patients that had met the inclusion criteria were excluded from analysis to ensure homogeneity and generalizability of the results due to their small numbers. The severity of injury for each Gustilo type III A and B tibia fracture was determined using the GHOISS, and limb salvage decisions were made irrespective of the GHOISS. Follow-up was extended for up to fourteen days to assess the necessity of secondary amputation in salvaged limbs.

RESULTS

Among 49 Gustilo type IIIA and B tibia fractures, 43 were successfully salvaged, while 6 necessitated amputation (4 primary, 2 secondary). A GHOISS of 13 demonstrated maximum specificity (90.7%) and sensitivity (83.3%) in predicting amputation, with an AUC of 0.923 (95% CI 0.804-0.977), indicating strong discriminatory accuracy.

CONCLUSION

The GHOISS reliably predicted outcomes in patients with Gustilo type IIIA and B tibia fractures, with a score of 13 demonstrating optimal sensitivity and specificity above which early failure of limb salvage is anticipated.

Performance of ICD-10-based injury severity scores in pediatric trauma patients using the ICD-AIS map and survival rate ratios

OBJECTIVES

The performance of injury severity scores (ISSs), used widely to quantify injury severity and predict outcomes, has not been investigated in German pediatric cases. This study aims to identify the most feasible and accurate injury score predictor of mortality in German children with trauma using International Classification of Diseases 10 (ICD-10).

STUDY DESIGN AND SETTING

Between 2014 and 2020, a retrospective observational cohort study of hospital admissions cases aged <18 years with injury-related ICD-10 codes, using the German hospital database (GHD), was conducted. The maximum abbreviated injury scale and ISS were calculated using the International Classification of Diseases-Abbreviated Injury Scale (ICD-AIS) map provided by the Association for the Advancement of Automotive Medicine, adjusted to the German modification of the ICD-10 classification. The survival risk ratio was used to calculate the single-worst ICD-derived injury (single International Classification of Disease Injury Severity Score [ICISS]) and a multiplicative ICISS. Logistic regressions were conducted for each of the four above-mentioned scores (predictors) to predict in-hospital mortality (outcome) in the selected trauma population and within four clinically relevant subgroups using discrimination and calibration.

RESULTS

1,720,802 were trauma patients, and ICD-AIS mapping was possible in 1,328,377 cases. Cases with mapping failure (n = 392,425; 22.8%) were younger and had a higher mortality rate were excluded from the performance analysis. ICISS-derived scores had a better discrimination and calibration than ICD-AIS based scores in the overall cohort and all four subgroups (area under the curve [AUC] ranges between 0.985 and 0.998 vs 0.886 and- 0.972, respectively).

CONCLUSION

Empirically derived measures of injury severity were superior to ICD-AIS mapped scores in the GHD to predict mortality in pediatric trauma patients. Given the high percentage of mapping failure and high mortality among cases with single-coded injury, the single ICISS may be the most suitable measure of injury severity in this group of patients.

Geriatric Trauma Outcome Score for Predicting Mortality among Older Korean Adults with Trauma: Is It Applicable in All Cases?

BACKGROUND

This study aimed to validate the Geriatric Trauma Outcome Score (GTOS) for predicting mortality associated with trauma in older Korean adults and compare the GTOS with the Trauma and Injury Severity Score (TRISS).

METHODS

This study included patients aged ≥65 years who visited the Chungbuk National University Hospital Regional Trauma Center between January 2016 and December 2022. We used receiver operating characteristic curves and calibration plots to assess the discrimination and calibration of the scoring systems.

RESULTS

Among 3,053 patients, the median age was 77 years, and the mortality rate was 5.2%. The overall GTOS-predicted mortality and 1-TRISS were 5.4% (interquartile range [IQR], 3.7-9.5) and 4.7% (IQR, 4.7-4.7), respectively. The areas under the curves (AUCs) of 1-TRISS and GTOS for the total population were 0.763 (95% confidence interval [CI], 0.719-0.806) and 0.794 (95% CI, 0.755-0.833), respectively. In the Glasgow Coma Scale (GCS) ≤12 group, the in-hospital mortality rate was 27.5% (79 deaths). The GTOS-predicted mortality and 1-TRISS in this group were 18.6% (IQR, 7.5-34.7) and 26.9% (IQR, 11.9-73.1), respectively. The AUCs of 1-TRISS and GTOS for the total population were 0.800 (95% CI, 0.776-0.854) and 0.744 (95% CI, 0.685-0.804), respectively.

CONCLUSION

The GTOS and TRISS demonstrated comparable accuracy in predicting mortality, while the GTOS offered the advantage of simpler calculations. However, the GTOS tended to underestimate mortality in patients with GCS ≤12; thus, its application requires care in such cases.

Unveiling the performance of the prehospital Rapid Emergency Medicine Score (pREMS): How the predictive score impacts in-hospital outcomes in traumatic brain injury (TBI): A retrospective observational cohort study

INTRODUCTION

This study aimed to evaluate the predictive accuracy of the prehospital rapid emergency medicine score (pREMS) for predicting the outcomes of hospitalized patients with traumatic brain injury (TBI) who died, were discharged, were admitted to the intensive care unit (ICU), or were admitted to the operating room (OR) within 72 h.

METHODS

A retrospective cohort analysis was performed on a sample of 513 TBI patients admitted to the emergency department (ED) of Besat Hospital in 2023. Only patients of both sexes aged 18 years or older who were not pregnant and had adequate documentation of vital signs were included in the analysis. Patients who died during transport and patients who were transferred from other hospitals were excluded. The predictive power of the pREMS for each outcome was assessed by calculating the sensitivity and specificity curves and by analyzing the area under the receiver operating characteristic curve (AUROC).

RESULTS

The mean pREMS scores for hospital discharge, death, ICU admission and OR admission were 11.97 ± 3.84, 6.32 ± 3.15, 8.24 ± 5.17 and 9.88 ± 2.02, respectively. pREMS accurately predicted hospital discharge and death (AOR = 1.62, P < 0.001) but was not a good predictor of ICU or OR admission (AOR = 1.085, P = 0.603). The AUROCs for the ability of the pREMS to predict outcomes in hospitalized TBI patients were 0.618 (optimal cutoff point = 7) for ICU admission and OR and 0.877 (optimal cutoff point = 9.5) for hospital discharge and death at 72 h.

CONCLUSION

The results indicate that the pREMS, a new preclinical trauma score for traumatic brain injury, is a useful tool for prehospital risk stratification (RST) in TBI patients. The pREMS showed good discriminatory power for predicting in-hospital mortality within 72 h in patients with traumatic brain injury.

The new injury severity score underestimates true injury severity in a resource-constrained setting

Background

The new injury severity score (NISS) is widely used within trauma outcomes research. NISS is a composite anatomic severity score derived from the Abbreviated Injury Scale (AIS) protocol. It has been postulated that NISS underestimates trauma severity in resource-constrained settings, which may contribute to erroneous research conclusions. We formally compare NISS to an expert panel's assessment of injury severity in South Africa.

Methods

This was a retrospective chart review of adult trauma patients seen in a tertiary trauma center. Randomly selected medical records were reviewed by an AIS-certified rater who assigned an AIS severity score for each anatomic injury. A panel of five South African trauma experts independently reviewed the same charts and assigned consensus severity scores using a similar scale for comparability. NISS was calculated as the sum of the squares of the three highest assigned severity scores per patient. The difference in average NISS between rater and expert panel was assessed using a multivariable linear mixed effects regression adjusted for patient demographics, injury mechanism and type.

Results

Of 49 patients with 190 anatomic injuries, the majority were male (n = 38), the average age was 36 (range 18-80), with either a penetrating (n = 23) or blunt (n = 26) injury, resulting in 4 deaths. Mean NISS was 16 (SD 15) for the AIS rater compared to 28 (SD 20) for the expert panel. Adjusted for potential confounders, AIS rater NISS was on average 11 points (95 % CI: 7, 15) lower than the expert panel NISS (p < 0.001). Injury type was an effect modifier, with the difference between the AIS rater and expert panel being greater in penetrating versus blunt injury (16 vs. 7; p = 0.04). Crush injury was not well-captured by AIS protocol.

Conclusion

NISS may under-estimate the 'true' injury severity in a middle-income country trauma hospital, particularly for patients with penetrating injury.

Validation of the Pediatric Resuscitation and Trauma Outcome (PRESTO) model in injury patients in Tanzania

INTRODUCTION

Sub-Saharan Africa has the highest rate of unintentional paediatric injury deaths. The Pediatric Resuscitation and Trauma Outcome (PRESTO) model predicts mortality using patient variables available in low-resource settings: age, systolic blood pressure (SBP), heart rate (HR), oxygen saturation, need for supplemental oxygen (SO) and neurologic status (Alert Verbal Painful Unresponsive (AVPU)). We sought to validate and assess the prognostic performance of PRESTO for paediatric injury patients at a tertiary referral hospital in Northern Tanzania.

METHODS

This is a cross-sectional study from a prospective trauma registry from November 2020 to April 2022. We performed exploratory analysis of sociodemographic variables and developed a logistic regression model to predict mortality using R (V.4.1). The logistic regression model was evaluated using area under the receiver operating curve (AUC).

RESULTS

499 patients were enrolled with a median age of 7 years (IQR 3.41-11.18). 65% were boys, and in-hospital mortality was 7.1%. Most were classified as alert on AVPU Scale (n=326, 86%) and had normal SBP (n=351, 98%). Median HR was 107 (IQR 88.5-124). The logistic regression model based on the original PRESTO model revealed that AVPU, HR and SO were statistically significant to predict in-hospital mortality. The model fit to our population revealed AUC=0.81, sensitivity=0.71 and specificity=0.79.

CONCLUSION

This is the first validation of a model to predict mortality for paediatric injury patients in Tanzania. Despite the low number of participants, our results show good predictive potential. Further research with a larger injury population should be done to improve the model for our population, such as through calibration.

Biopsychosocial sequelae of chronically painful injuries sustained in motor vehicle accidents contributing to non-recovery: A retrospective cohort study

BACKGROUND

Claimants with chronically painful injuries sustained in motor vehicle accidents (MVAs) undergo assessment and management influenced by insurance and medico-legal processes defined by a biomedical paradigm which is discordant with best evidence. We aim to demonstrate the impact of biopsychosocial factors on post-MVA sequelae which contribute to non-recovery.

METHODS

This was a retrospective cohort study of medico-legal documents and reports on 300 consecutive claimants referred to a pain medicine physician over 7 years (2012-2018) for assessment of painful musculoskeletal injuries post-MVA. One hundred data items were extracted from the medico-legal documents and reports for each claimant and entered into an electronic database. Post-MVA sequelae were analysed using chi-square analysis (OR >2) for significant associations with demographic, pre-MVA and post-MVA variables. Factors with significant associations were entered into a logistic regression model to determine significant statistical predictors of post-MVA sequelae contributing to non-recovery.

RESULTS

The claimants were aged 17 to 80 years (mean age 42 years), and approximately half (53%, n=159) were female. The time from MVA to interview averaged 2.5 years. Widespread pain was present in 18% (n=54), and widespread somatosensory signs implying central sensitisation (OR=9.85, p<.001) was the most significant multivariate association. Long-term opiate use post-MVA (32%) was predicted by pre-MVA sleep disturbance (OR=5.08, p=.001), post-MVA major depressive disorder (MDD) (OR=3.02, p=.003) and long-term unemployment (OR=2.22. p=.007). Approximately half (47%, n=142) required post-MVA support from a psychologist or psychiatrist. Post-traumatic stress disorder (PTSD) was diagnosed by a psychiatrist or psychologist in 20% (n=59), yet early identification of risk of PTSD was rare. Pre-MVA, 89.4% (n=268) were studying or employed. Permanent unemployability post-MVA occurred in 35% (n=104) and was predicted by MDD (OR=3.59, p=.001) and antidepressant use (OR=2.17, p=.005). Major social change post-MVA (70%) was predicted by older age (OR=.966, p=.003), depressive symptoms (OR=3.71, p<.001) and opiate use (OR=2.00, p=.039).

CONCLUSIONS

Biomedical factors, including older age, impaired sleep and indicators of widespread central sensitisation, and psychological factors, including stress, anxiety and depression, were the most prominent multivariate associations as statistical predictors of major adverse sequelae contributing to non-recovery for claimants with chronic pain post-MVA.

A computational study on the basis for a safe speed limit for bicycles on shared paths considering the severity of pedestrian head injuries in bicyclist-pedestrian collisions

Bicyclists and pedestrians are two large vulnerable groups of road users. Many cities have allowed cyclists to share space with pedestrians on footpaths and off-road paths to reduce conflict with motor vehicles. The risk of bicyclist-pedestrian accidents is also increasing accordingly. Therefore, there is a need to understand the factors that affect the risk of injury in such accidents, especially to pedestrians who are considered more vulnerable. This paper presents a detailed investigation of bicyclist-pedestrian collisions and possible injury outcomes. The study has considered five levels of collision speed ranging from 10 km/h to 30 km/h, three pedestrian profiles (adult, child, and elderly) differentiated by their weight and height, three bicycles with different masses, and five impact directions. The bicyclist-pedestrian collision simulations have been analyzed based on four metrics: throw distance, peak head velocity on impact with the ground, head injury criterion (HIC) value, and the probability of severe head injury. For each simulation, the throw distance and peak head velocity on impact with the ground are extracted. Following that, the HIC and the probability of severe head injury to pedestrians are computed. The results show a significant effect of collision speed (p < 0.05) on all four metrics. The analysis has been further extended to study the effect of height and weight profile, bicycle mass, and impact directions on bicyclist-pedestrian collisions. According to the results, the impact directions largely influence the outcome of bicycle-pedestrian collisions. In general, direct impacts on pedestrian body center have been found to yield higher HIC values and probability of severe head injury to pedestrians than off-center impacts. Also, video analysis of simulated collisions has suggested that the accident mechanism depends on weight and height profiles (correlated with different age groups) and impact directions. Finally, recommendations have been proposed based on the study, including a speed limit of not more than 12 km/h for bicyclists on narrow shared paths and footpaths where risks of collisions with pedestrians are high. The results and analysis presented could be helpful for developing legislation to minimize conflicts between bicyclists and pedestrians on shared paths and to reduce potential injury to pedestrians.

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.

The Kampala Trauma Score: A 20-year track record

ABSTRACT

Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.

The Curtis Hand Injury Matrix Score: Determining the Need for Specialized Upper Extremity Care

PURPOSE

Given the limited impact of transfer guidelines and the lack of comparative metrics for upper extremity trauma, we introduced the Curtis Hand Injury Matrix (CHIM) score to evaluate upper extremity injury acuity from the specialist perspective. Our goal was to evaluate the CHIM score as an indicator of complexity and specialist need by correlating the score with arrival mode, length of stay (LOS), discharge disposition, and procedure location.

METHODS

We identified all hand and upper extremity emergency room visits at our institution in 2018 and 2019. On initial evaluation, our institution's hand surgery team assigned each patient an alphanumeric score with a number (1-5) and letter (A-H) corresponding to injury severity and pathology, respectively. Patients were divided into 5 groups (1-5) with lower scores indicating greater severity. We compared age, LOS, discharge disposition, procedure location, transfer status, and arrival mode between groups and assessed the relationships between matrix scores and discharge disposition, procedure performed, and LOS.

RESULTS

There were 3,822 patients that accounted for 4,026 upper extremity evaluations. There were significant differences in LOS, discharge dispositions, procedure locations, transfer status, and arrival modes between groups. Patients with more severe scores had higher rates of admission and more operating room procedures. Higher percentages of patients who arrived via helicopter, ambulance, or transfer had more severe scores. Patients with more severe scores were significantly more likely to have a procedure, hospital admission, and longer hospital stay.

CONCLUSIONS

The CHIM score provides a framework to catalog the care and resources required when covering specialized hand and upper extremity calls and accepting transfers. This clinical validation supports considering broader use.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

INTRODUCTION

Amongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.

METHODS

The Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.

RESULTS

Overall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.

CONCLUSION

In ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.

Calibration and validation of the pediatric resuscitation and trauma outcome model among injured children in Rwanda

BACKGROUND

Trauma is a leading cause of mortality in low- and middle-income countries. The Pediatric Resuscitation and Trauma Outcomes (PRESTO) model uses six low-tech variables available at point of care in resource-limited environments to predict in-hospital mortality of injured children. This model was never calibrated and validated in a low-income country. We aimed to calibrate the model's coefficients and compare its performance against the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) using data from a low-income country.

STUDY DESIGN

Data from 2011 to 2015 in the prospectively-maintained Rwanda Injury Registry were reviewed after ethical approval was obtained. Patients were included for analysis if they were referred or admitted for traumatic injury, were younger than 15 years and if hospital outcomes were recorded. The variables in the PRESTO model include age, hypotension, heart rate, neurological status, oxygen saturation and airway intervention. The outcome of interest was in-hospital death. After calibration, Receiver-Operating-Characteristic curves were constructed to compare the area-under-curve (AUC) of PRESTO, RTS, and KTS with imputation of missing data. Comparisons of the relative AUC's were performed using Delong's test after bootstrapping in the full cohort and in a subset of patients <5 years-old.

RESULTS

There were 113 in-hospital deaths out of 1695 included patients (6.7%). The AUC for the PRESTO model was 0.90 (95% CI [0.82-0.91]), higher than for RTS (0.77, 95% CI [0.80-0.97], p < 0.01) but not statistically different from KTS (0.89, 95% CI [0.72-0.82], p = 0.856). In the under-five cohort, the PRESTO model AUC was 0.84 (95% CI [0.75-0.92]), significantly higher than RTS (0.73 95% CI [0.64-0.81], p < 0.01) and KTS (0.58, 95% CI [0.50-0.66], p < 0.01).

CONCLUSION

PRESTO appears to be the superior benchmarking tool for pediatric patients in a low- and middle-income country context. The PRESTO score outperforms the KTS in children <5 years of age. Further validation of the PRESTO model is needed from other low- and middle-income settings.

LEVEL OF EVIDENCE

Level III: case-control (prognostic) study.

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

Purpose

The study aimed to examine the changing incidence of geriatric trauma and evaluate the predictive ability of different scoring tools for in-hospital mortality in geriatric trauma patients.

Methods

Annual reports released by the National Trauma Database (NTDB) in the USA from 2005 to 2015 and the Trauma Register DGU® in Germany from 1994 to 2012 were analyzed to examine the changing incidence of geriatric trauma. Secondary analysis of a single-center cohort study conducted among 311 severely injured geriatric trauma patients in a level I trauma center in Switzerland was completed. According to the in-hospital survival status, patients were divided into the survival and non-survival group. The differences of the ISS (injury severity score), NISS (new injury severity score), TRISS (Trauma and Injury Severity Score), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SPAS II (simplified acute physiology score II) between two groups were evaluated. Then, the areas under the receiver-operating characteristic curve (AUC-ROC) of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients were calculated.

Results

The analysis of the NTDB showed that the increase in the number of geriatric trauma ranged from 18 to 30% between 2005 and 2015. The analysis of the DGU® showed that the mean age of trauma patients rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥ 60 years rose from 16.5 to 37.5%. The findings from the secondary analysis showed that 164 (52.73%) patients died in the hospital. The ISS, NISS, APACHE II, and SAPS II in the death group were significantly higher than those in the survival group, and the TRISS in the death group was significantly lower than those in the survival group. The AUCs of the ISS, NISS, TRISS, APACHE II, and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients were 0.807, 0.850, 0.828, 0.715, and 0.725, respectively.

Conclusion

The total number of geriatric trauma is increasing as the population ages. The accuracy of ISS, NISS and TRISS was higher than the APACHE II and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients.

Factors affecting mortality in major trauma patients in Trinidad and Tobago – A view from the developing world

Introduction

There are few data on major trauma in the developing world. This study investigated the characteristics and outcomes of seriously injured patients in Trinidad and Tobago, using Trauma and Injury Severity Score (TRISS) methodology. We also aimed to assess the predictive accuracy of the TRISS model in patients in Trinidad and Tobago.

Methods

Retrospective data from major trauma patients attending the Emergency Department of a tertiary hospital in Trinidad between 2010 and 2014 were analysed. Patients ≥18 years having an Injury Severity Score >15 were included. The impact of age, gender, comorbidities, mechanisms and patterns of injury on mortality was investigated. Using TRISS methodology, predicted mortality was calculated and compared to actual mortality.

Results

Of 323 patients analysed, 284 were male and 24 were aged ≥65 years. The commonest injury mechanisms in younger people were motor vehicle accidents (34.1%) and stabbings (30.8%) compared to falls (66.7%) and motor vehicle accidents (20.8%) in people aged ≥65 years. The commonest areas injured were the chest in younger patients (81.9%) and the head and neck in patients aged ≥65 years (58.3%). Women’s mortality rates were similar to men (RR 1.8; 95% CI 0.7–4.9). Mortality was higher with age ≥65 years (RR 7.0; 95% CI 3.1–15.9), blunt trauma (RR 7.6; 95% CI 1.8–32.4) and Charlson Comorbidity Index of 1 or more (RR 3.2; 95% CI 1.3–8.0). The TRISS model performed well at lower ISS scores and was excellent at predicting survival (discrimination statistic 0.94).

Conclusion

Multiple factors influence mortality in major trauma patients in Trinidad and Tobago, including age, co-morbidities and injury mechanism. TRISS methodology accurately predicted survival in this population but was better at predicting mortality in patients with lower Injury Severity Score.