Does Lactate Dehydrogenase Act as an Early Warning System Predicting Mortality in Trauma Patients?

Dementia as a predictor of mortality in adult trauma patients

Background: Traumatic injury accounts for 7.8% of all deaths globally, and 30% to 40% of those deaths are due to hemorrhage. Shock Index (SI) has been found to be useful in the recognition of hemorrhage but no definite threshold for predicting mortality has been determined. Our aim was to determine whether a SI ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to a SI < 1.
 Methods: We conducted a systematic review and meta-analysis using Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. EMBASE, MEDLINE, and Cochrane Library were searched using controlled vocabulary, and retrospective observational studies were included. Studies were included if they reported in-hospital mortality in trauma patients aged ≥ 16 years, with a measurement of SI from the emergency department or trauma center, dividing patients in groups of SI ≥ 1 and SI < 1. Risk of bias was assessed by using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence was assessed according to GRADE. Data was pooled using a random effects model.Results: We screened 1239 citations with an inter-rater reliability (Cohen’s kappa) of 0.90 (95% CI 0.88-0.93). Thirteen comparative cohort studies including 639210 patients were included. All studies reported a significant higher in-hospital mortality in adult trauma patients with a SI ≥ 1 compared to those having a SI < 1 at first assessment in the emergency department or trauma center. Eleven studies were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was RR 4.29 (95% confidence interval 3.00 - 6.12). The overall quality of evidence was low.
 Conclusion: This systematic review found a fourfold risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

Risk factors of mortality in nosocomial infected traumatic patients in a trauma referral center in south of Iran

Advanced age is a well-recognized risk factor for adverse outcomes after trauma. A substantial body of literature, much of it cited within this article, demonstrates increased morbidity and mortality in geriatric trauma patients compared with their younger counterparts. Whether this outcome difference is because of the decreased physiologic reserve that accompanies aging, a higher incidence of preexisting medical conditions in the geriatric patient, or other factors yet to be identified remains unclear. It is clear, however, that good outcomes can be achieved in this patient population when appropriately aggressive trauma care is directed toward geriatric patients with survivable injuries. Implicit in the above statement is the need to identify, as soon as possible after injury, those patients who will benefit from aggressive resuscitation, timely injury management, and posttrauma rehabilitation. It is equally important, however, to limit these intensive and expensive treatment modalities to patients whose injuries are not only survivable but also compatible with an acceptable quality of life. Our purpose in developing this guideline was to provide the trauma practitioner with some evidence-based recommendations that could be used to guide decision-making in the care of the geriatric trauma patient. We began this process by first developing a series of questions, the answers to which we hoped could be supported by the existing scientific literature. The initial set of questions were as follows: 1. Is age itself a marker of increased morbidity/ mortality? If so, what age should be used? 2. Is age instead a surrogate for increased preexisting conditions (PECs)? If so, which premorbid conditions are particularly predictive of poor outcomes? 3. Should age itself be a criterion for triage from the field directly to a trauma center, regardless of Glasgow Coma Scale (GCS) score, Trauma Score (TS), and so forth? If so, what age should be used? 4. Do trauma centers have better outcomes with geriatric trauma than nontrauma centers? 5. Are there specific injuries, scores (e.g., Injury Severity Score [ISS], TS, GCS score), or PEC/age combinations in geriatric trauma patients that are so unlikely to be survivable that a nonaggressive approach from the outset could be justified? 6. What resuscitation end-points should be used for the geriatric trauma patient? 7. Should all geriatric trauma patients receive invasive hemodynamic monitoring? If so, what specific types of monitoring should be used? If not, which geriatric patients benefit from invasive monitoring? Unfortunately, after examining the available literature, it is clear that evidence-based responses to all of the questions raised above are not possible. As the evidentiary tables demonstrate, there are few, if any, prospective, randomized, controlled trials that definitively address any of the above issues. Second, there is a lack of uniformity as to a specific age criterion for geriatric trauma. As shown in the evidentiary tables, geriatric trauma is variously defined in the literature as age greater than or equal to 55, 60, 65, 70, 75, and even 80 years of age. There is even literature support for increased mortality from trauma beginning at age 45! Furthermore, because age is a continuous variable, and not a dichotomous one, adverse outcomes associated with geriatric trauma are likely to increase in a continuous fashion with age as opposed to a stepwise leap as a given patient reaches a specific age. Third, there is no concise definition of a geriatric trauma patient. In some studies, all patients over a given age are included, whereas in others, patients with penetrating injuries, burns, and minor injuries, such as slip-and-falls, are excluded. Some studies include all patients regardless of hemodynamic instability or injury severity, whereas others impose strict entrance criteria or exclude patients who do not survive for a predetermined period of time after admission. Such lack of uniformity regarding inclusion criteria makes it Submitted for publication October 3, 2001. Accepted for publication September 16, 2002. Copyright © 2003 by Lippincott Williams & Wilkins, Inc. From the Carolinas Medical Center (D.G.J.), Charlotte, North Carolina, Trauma Service, Bronson Hospital (B.R.P.), Kalamazoo, and Trauma Burn Center, University of Michigan Health System (W.W.), Ann Arbor, Michigan, New York Hospital–Cornell Medical Center (P.S.B.), New York, New York, Robert Wood Johnson Medical School (J.S.H.), New Brunswick, New Jersey, Mt. Sinai Hospital (M.R.H.), Chicago, Illinois, Morehouse School of Medicine (K.E.S.), Atlanta, Georgia, and R Adams Cowley Shock Trauma Center, University of Maryland Medical Center (T.M.S.), Baltimore, Maryland. Address for reprints: David G. Jacobs, MD, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232; email: djacobs@carolinas.org.

Hypocalcemia is commonly observed in trauma patients and has been linked to adverse clinical outcomes. However, its role as a predictor of mortality remains unclear. This systematic review and meta-analysis aim to evaluate the association between hypocalcemia and in-hospital mortality in trauma patients. A comprehensive literature search was conducted across multiple databases, including Medline (PubMed), Ovid (Embase), Scopus, Cochrane Central Register of Controlled Trials, and the US Clinical Trial Registry, up to September 2024. Additional manual searches were performed using Google Scholar and ResearchGate. Observational studies reporting mortality and other clinical outcomes in trauma patients with and without hypocalcemia were included. The risk of bias was assessed using the Cochrane Collaboration Risk of Bias 2.0 tool. Data were pooled using a random-effects model, and results were expressed as risk ratio (RR) or mean difference with 95% confidence intervals (CIs). A total of 11 observational studies involving 35,029 patients were included. Hypocalcemia was associated with a significantly increased risk of in-hospital mortality (RR = 1.82, 95% CI: 1.52–2.17, P < 0.00001) with moderate heterogeneity (I2 = 40%). Severe hypocalcemia further elevated mortality risk (RR = 2.74, 95% CI: 1.92–3.90, P < 0.00001, I2 = 22%). In addition, hypocalcemia was linked to an increased incidence of massive transfusion (RR = 2.40, 95% CI: 1.79–3.23, P < 0.00001, I2 = 65%). However, no significant differences were found in duration of hospital stay, intensive care unit stay, or ventilator days between patients with hypocalcemia and normocalcemia. Hypocalcemia is a significant predictor of in-hospital mortality and an increased need for massive transfusion in trauma patients. These findings highlight the importance of monitoring and managing calcium levels in trauma care. Further prospective studies are needed to establish causal relationships and optimize clinical interventions.

Objective:To compare the injury severity scales as predictors of mortality in trauma patients to search for the best scale.Methods:In a prospective cohort study and systematical random sampling conducted from March to September 2017, trauma patients over the age of 13 years were enrolled. The investigated variables were age, gender, systolic blood pressure, heart rate, respiratory rate, injured body region, Glasgow Coma Scale (GCS), injury severity score (ISS), revised trauma score (RTS), trauma injury severity score (TRISS) and the outcome. Results:Totally, 1410 trauma patients were followed up, out of which 68.5% were male. The participants’ mean age was 43.5±20.88 years. After adjusting the confounding effects, age over 60 years (OR=7.38, CI [3.91-13.93]), GCS<8 (OR=6.5, CI [2.38-18.16]), RTS<7.6 (OR=6.04, CI [2-13.7]), and TRISS<0.9 (OR=3.09, CI [1.39-6.88]) were determined as the most significant predictor variables for in-hospital mortality. The results of Receiver Operating Characteristic (ROC) curve revealed that TRISS had the highest area under the curve in comparison to other tests that were evaluated. Furthermore, TRISS had the highest sensitivity and specificity for scores higher than 96.15. By contrast, the sensitivity and specificity of GCS decreased for scores higher than 5.5.Conclusion:Our results showed that TRISS, RTS, GCS, and ISS were all very effective approaches for evaluating prognosis, mortality and probable complications in trauma patients; thus, these systems of injury evaluation and scoring are recommended to facilitate treatment. TRISS, RTS, and ISS had almost the same sensitivity that was higher than GCS, but GCS had the most specificity. Finally, TRISS was selected as the most efficient scale for predicting mortality.

BackgroundHaemorrhage is a significant cause of death in trauma patients. There is evidence that individuals with blood group O have higher rates of non-traumatic haemorrhage. It has been suggested that blood group O may be associated with higher mortality in trauma, however existing evidence is limited and conflicting. ObjectiveA systematic review was conducted to evaluate the impact of ABO blood group on mortality in trauma patients. MethodsMEDLINE via OVID, the Cochrane library and grey literature were searched to identify studies investigating the effect of ABO blood group on mortality of trauma patients admitted to hospital. PRISMA guidelines were followed throughout, study quality was assessed using CASP checklists and certainty of evidence was evaluated using GRADE. Meta-analysis was precluded by significant study heterogeneity. Results180 relevant records were screened and seven studies met inclusion criteria, representing 12,240 patients. Two studies found that there was a higher mortality in blood group O compared to other ABO groups. Included studies had substantial variability in methods and population. Study quality was variable with certainty of evidence rated as very low. ConclusionsThere is insufficient evidence to definitively establish an association between mortality and ABO group in trauma patients. In an age of increasingly individualised care, there is a need to determine the existence and cause for any association through further studies across multiple settings, trauma mechanisms and populations.

Extensive hemorrhage is a significant cause of mortality in trauma patients. Tranexamic acid has been used for controlling bleeding in cardiovascular surgeries and dental manipulations in patients with hemophilia. However, in traumatic patients with bleeding, its use dates back to more recent years. This study aims to examine the effects of this drug on reducing mortality and blood transfusion rate in trauma patients with significant hemorrhage. A total of 60 patients with significant trauma-related hemorrhage (systolic blood pressure &lt; 90 mmHg/heart rate &gt; 110/min) from the emergency department of Imam Reza Hospital (Tabriz, Iran), were randomized in two groups. The case group received intravenous Tranexamic acid (1 g in 10 min and then 1 g over 8 h). The control group received placebo. Rate of transfusion and rate of one-month mortality were compared between the study groups. The mean ICU stay and overall hospitalization times did not have significant difference between two groups (p&lt;0.05). Transfusion of packed cells was 6.03±1.50 and 6.03±1.22 units in case and control groups respectively. Transfusion of fresh frozen plasma (FFP) was 2.50±1.36 and 3.03±0.96 units in case and control groups respectively (p=0.09). Transfusion of platelets was 0.40±0.20 1.33±0.31 units in case and control groups respectively (p=0.01). Three patients (10%) in the case group and 4 patients (13.3%) in the control group were expired (p=0.50). Tranexamic acid is safe and effective in reducing platelet transfusion rate in patients with trauma-related significant hemorrhage. However, transfusion need and mortality would not reduce by its use in trauma patients.

Previous studies have documented that blood transfusion incites a substantial inflammatory response with the systemic release of cytokines. Furthermore, blood transfusion is a significant independent predictor of multiple organ failure in trauma. The objective of this study was to assess the risk of systemic inflammatory response syndrome (SIRS) and intensive care unit (ICU) admission, length of stay (LOS), and mortality in trauma patients who require blood transfusion. Prospective data were collected on 9,539 trauma patients admitted to the R. Adams Cowley Shock Trauma Center over a 30-month period from January, 1997 to July, 1999. Complete SIRS data were available on 7,602 patients. Patients were stratified by age, gender, race, Glasgow coma scale (GCS), and injury severity score (ISS). A systemic inflammatory response to a wide variety of severe clinical insults (SIRS) was defined as a SIRS score of > or =2, as calculated on admission. Blood transfusion was assessed as an independent predictor of SIRS, ICU admission and length of stay, and mortality. The mean age of the study cohort was 37 +/- 17 years; the mean ISS was 9 +/- 9 points. Seventy-one percent of the patients were male, and 85% sustained blunt trauma. Blood transfusion within the first 24 h was administered to 954 patients, comprising 10% of the study cohort. Transfused patients were significantly older (43 +/- 20 vs. 36 +/- 16 years, p < 0.00001), had higher ISS (22 +/- 12 vs. 8 +/- 7 points, p < 0.00001), and lower GCS (12 +/- 4 vs. 14 +/- 2 points, p < 0.00001) than non-transfused patients. Blood transfusion and increased total volume of blood transfusion was associated with SIRS. Blood transfusion was also a significant independent predictor of SIRS, ICU admission, and mortality in trauma patients by multinomial logistic regression analysis. Trauma patients who received blood transfusion had a two- to nearly sixfold increase in SIRS (p < 0.0001) and more than a fourfold increase in ICU admission (OR 4.62, 95% CI 3.84-5.55, p < 0.0001) and mortality (OR 4.23, 95% CI 3.07-5.84, p < 0.0001) compared to those that were not transfused. Linear regression analysis revealed that transfusion was an independent predictor of ICU LOS (Coef. 5.20, SE 0.43, p < 0.0001). Transfused patients had significantly longer ICU LOS (16.8 +/- 14.9 vs. 9.9 +/- 10.6 days, p < 0.00001) and hospital LOS (14.5 +/- 15.5 vs. 2.5 +/- 5.3 days, p < 0.00001) compared to non-transfused patients. Blood transfusion within the first 24 h was an independent predictor of mortality, SIRS, ICU admission, and ICU LOS in trauma patients. The use of blood substitutes and alternative agents to increase serum hemoglobin concentration in the post-injury period warrants further investigation.

The primary aim was to determine whether a shock index (SI) ≥ 1 in adult trauma patients was associated with increased in-hospital mortality compared to an SI < 1. This systematic review including a meta-analysis was performed in accordance with the PRISMA guidelines. EMBASE, MEDLINE, and Cochrane Library were searched, and two authors independently screened articles, performed the data extraction, and assessed risk of bias. Studies were included if they reported in-hospital, 30-day, or 48-h mortality, length of stay, massive blood transfusion or ICU admission in trauma patients with SI recorded at arrival in the emergency department or trauma center. Risk of bias was assessed using the Newcastle-Ottawa Scale, and the strength and quality of the body of evidence according to GRADE. Data were pooled using a random effects model. Inter-rater reliability was assessed with Cohen's kappa. We screened 1350 citations with an inter-rater reliability of 0.90. Thirty-eight cohort studies were included of which 14 reported the primary outcome. All studies reported a significant higher in-hospital mortality in adult trauma patients with an SI ≥ 1 compared to those having an SI < 1. Twelve studies involving a total of 348,687 participants were included in the meta-analysis. The pooled risk ratio (RR) of in-hospital mortality was 4.15 (95% CI 2.96-5.83). The overall quality of evidence was low. This systematic review found a fourfoldincreased risk of in-hospital mortality in adult trauma patients with an initial SI ≥ 1 in the emergency department or trauma center.

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

The elevated neutrophil-to-lymphocyte ratio (NLR) is associated with poor clinical outcomes, especially in pro-inflammatory states such as surgical injuries and severe hemorrhages. Therefore, it was hypothesized whether NLR value at the time of admission could be a prognostic indicator of hospital mortality in trauma patients. This retrospective cohort study was conducted on 865 trauma patients referred to Rajaee Hospital between April 2016 and July 2019. The NLR value was calculated at the time of admission, and receiver operating characteristics (ROC) curve analysis was used to determine the cut-off point value of admission NLR related to hospital mortality of trauma patients. Furthermore, Kaplan-Meier survival analysis and Cox regression models have been applied to determine the effectiveness and prognostic potential of the admission NLR in the hospital mortality of trauma patients. The median age of the trauma patients was 32 years with an interquartile range (IQR) of 23 to 48 years, and most of them were male (83.9%). Also, trauma patients had a median injury severity score (ISS) of 9 (IQR=4-16) and a median Glasgow coma scale (GCS) of 14 (IQR=9-15). The cut-off value for admission NLR was 5.27 (area under the curve: 0.642, 95%CI: 0.559-0.726, p=0.001). In Kaplan-Meier survival analysis, the admission NLR>5.27 was an indicator of hospital mortality in trauma patients (p=0.001). Multivariate Cox regression models demonstrated that trauma patients with an admission NLR>5.27 had a 2.33-fold risk of hospital mortality (hazard ratio=2.33, 95%CI: 1.02-5.38, p=0.041). Furthermore, the admission NLR>5.27 was associated with a higher risk of hospital mortality in trauma patients with age≥65 years, systolic blood pressure≤90 mmHg, blood potassium>4.5 mmol/L, blood sodium>144 mEq/L, blood potential hydrogen (pH)≤7.28, GCS≤8, ISS>24 and blood base excess≤-6.1 mEq/L. The NLR value greater than 5.27 at the time of admission was associated with poorer outcomes, and it can be considered an independent prognostic indicator of hospital mortality in trauma patients.

Perioperative cardiac arrest and mortality in trauma patients: A systematic review of observational studies

ObjectiveTo test the following hypothesis: the ratio of shock index to pulse oxygen saturation can better predict the mortality of emergency trauma patients than shock index.Methods1723 Patients of trauma admitted to the Emergency Department of the First Affiliated Hospital of Soochow University from 1 November 2016 to 30 November 2019 were retrospectively evaluated. We defined SS as the ratio of SI to SPO2, and the mortality of trauma patients in the emergency department as end-point of outcome. We calculated the crude HR of SS and adjusted HR with the adjustment for risk factors including sex, age, revised trauma score (RTS) by Cox regression model. ROC curve analyses were performed to compare the area under the curve (AUC) of SS and SI.ResultsThe crude HR of SS was: 4.31, 95%CI (2.89–6.42) and adjusted HR: 3.01, 95%CI(1.86–4.88); ROC curve analyses showed that AUC of SS was higher than that of shock index (SI), and the difference was statistically significant: 0.69, 95%CI(0.55–0.83) vs 0.65, 95%CI (0.51–0.79), P = 0.001.ConclusionThe ratio of shock index to pulse oxygen saturation is good predictor for emergency trauma patients, which has a better prognostic value than shock index.

Background:The shock index (SI) predicts short-term mortality in trauma patients. Other shock indices have been developed to improve discriminant accuracy. The authors examined the discriminant ability of the SI, modified SI (MSI), and reverse SI multiplied by the Glasgow Coma Scale (rSIG) on short-term mortality and functional outcomes.Methods:The authors evaluated a cohort of adult trauma patients transported to emergency departments. The first vital signs were used to calculate the SI, MSI, and rSIG. The areas under the receiver operating characteristic curves and test results were used to compare the discriminant performance of the indices on short-term mortality and poor functional outcomes. A subgroup analysis of geriatric patients with traumatic brain injury, penetrating injury, and nonpenetrating injury was performed.Results:A total of 105 641 patients (49±20 years, 62% male) met the inclusion criteria. The rSIG had the highest areas under the receiver operating characteristic curve for short-term mortality (0.800, CI: 0.791–0.809) and poor functional outcome (0.596, CI: 0.590–0.602). The cutoff for rSIG was 18 for short-term mortality and poor functional outcomes with sensitivities of 0.668 and 0.371 and specificities of 0.805 and 0.813, respectively. The positive predictive values were 9.57% and 22.31%, and the negative predictive values were 98.74% and 89.97%. rSIG also had better discriminant ability in geriatrics, traumatic brain injury, and nonpenetrating injury.Conclusion:The rSIG with a cutoff of 18 was accurate for short-term mortality in Asian adult trauma patients. Moreover, rSIG discriminates poor functional outcomes better than the commonly used SI and MSI.