Revised Injury Severity Classification Score Research Articles

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure.

Using tetrastarch for fluid resuscitation after asevere trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown. Aretrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF). We studied 271 patients who had sustained asevere blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with acrystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found aU-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023). There was acomplex U‑shaped association between the tetrastarch dose and morbidity/mortality of patients after asevere trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

The influence of alcohol on the outcome of trauma patients: a matched-pair analysis of the TraumaRegister DGU®.

In the diagnosis and treatment of trauma patients, numerous individual and trauma-related factors must be considered, all of which may influence the outcome. Although alcohol exposure is a major risk factor for an accident, its influence on the outcome is unclear. This matched-pair analysis investigates the hypothesis that alcohol has no negative impact on the outcome of trauma patients. In a retrospective matched-pair analysis of the multi-centre database of the TraumaRegister DGU® patients with a maximum Abbreviated Injury Scale (MAIS) of 3 or greater from the years 2015 and 2016 with an alcohol level ≥ 0.5‰ were compared to patients with a measured alcohol level of 0.0‰. The patients were matched according to age, gender, AIS body regions (head, thorax, abdomen, pelvis/extremities) and survival presumption (Revised Injury Severity Classification Score (RISC) II the TraumaRegister ervals). After matching, a total of 834 patients were enrolled, with 417 patients in group with positive blood alcohol levels (BAL +) with a median alcohol level of 1.82‰and 417 patients in the negative-alcohol group (BAL -). As a mechanism of injury, the BAL + group showed more often penetrating injuries, pedestrian accidents and low energy falls compared to car and motorcycle accidents in the BAL - group. BAL + patients were significantly less sedated (BAL -: 66.7% vs. BAL + : 56.2%, p = 0.002), less frequently transported by rescue helicopter, were more frequently hypotensive (BAL-: 42 patients (10.3%) vs. BAL + : 61 patients (15.2%), p = 0.045, Table2) and exhibited lower base excess levels associated with an acidotic metabolic status compared to sober patients (acidosis: BAL-: 24 patients (6.1%) vs. BAL + : 61 patients (17.2%), p < 0.001). There was no difference regarding in-hospital complications, length of stay or mortality rate. Our data demonstrate that alcohol exposure in trauma patients has no impact on complication or mortality rates. On the other hand, there are initially clear differences in the mechanism of injury, sedation, mode of transport and the acid-base balance.

Severe head injury in elderly: 6-year comparison of treatment and outcome between southern Finland and Navarra (Spain).

To compare the profile, treatment and outcome of elderly patients with severe traumatic brain injuries (TBI) between southern Finland and Navarra (Spain). Data collected from, 2010 to 2015, in the Major Trauma Registry of Navarra (MTR-N) and the Helsinki Trauma Registry (HTR) were compared. Patients with New Injury Severity Score (NISS) ≥ 16 and age ≥ 65 with isolated severe TBI were considered. Patients who had been admitted to the hospital ≥ 24h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded. Outcome was defined by 30-day hospital mortality. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II). Other compared data included demographics, injury mechanism, pre-hospital and hospital treatment, and time intervals. A total of 305 (MTR-N) and 137 (HTR) patients were included in the outcome analysis. The standardized mortality ratio with 95% confidence interval was for MTR-N 1.4 (1.1-1.6) and for HTR 0.8 (0.6-1.1). Patients in Navarra were older (average 79.7 vs. 75.0) while in southern Finland the percentage of pre-hospital intubation in patients with GCS ≤ 8 (75.0% vs 50.0%) and ICU admission (72.2% vs 22.0%) were higher. The better adjusted outcome of elderly patients with severe TBI in southern Finland in comparison to Navarra could be due to higher rate of pre-hospital intubation and/or higher rate of ICU admissions in southern Finland. Increasing number of elderly patients with severe TBI necessitate uniformly accepted protocols in pre- and in-hospital management.

Epidemiological comparison between the Navarra Major Trauma Registry and the German Trauma Registry (TR-DGU\xae)

BackgroundInternational benchmarking can help identify trauma system performance issues and determine the extent to which other countries also experience these. When problems are identified, countries can look to high performers for insight into possible responses. The objective of this study was to compare the treatment and outcome of severely injured patients in Germany and Navarra, Spain.MethodsData collected, from 2010 to 2013, in the Navarra Major Trauma Registry (NMTR) and the TraumaRegister DGU® (TR-DGU) were compared. Both registries followed the Utstein Trauma Template (European Core Dataset) for documentation of trauma patients. Adult patients (≥ 16 years) with New Injury Severity Score (NISS) being >15 points were included in this study. Patients who had been admitted to the hospital later than 24 h after the trauma, had been pronounced dead before hospital arrival, or had been injured by hanging, drowning or burns, were excluded.Demographic data, injury data, prehospital data, hospital treatment data, time intervals, and outcome were compared. The expected mortality was calculated using the Revised Injury Severity Classification score II (RISC II).ResultsA total of 646 and 43,110 patients were included in the outcome analysis from NMTR and TR-DGU, respectively. The difference between observed and expected mortality was −0.4% (standardized mortality ratio [SMR] 0.97; 95% CI 0.93–1.04) in Germany and 1.6% (SMR 1.08; 95% CI: 1.02–1.14) in Navarra. Differences in the characteristics of trauma patients and trauma systems between the regions were noted.ConclusionThe higher observed mortality in Navarra is consistent with the epidemiological characteristics of its population. However, to improve the quality of trauma care in the Navarra trauma system, certain improvements are necessary. There were less young adults with severe injuries in Navarra than in Germany. It is possible to compare data of severely injured patients from different countries if standardized registries are used.

The Effect of Evolving Fluid Resuscitation on the Outcome of Severely Injured Patients: An 8-year Experience at a Tertiary Trauma Center.

Fluid resuscitation of severely injured patients has shifted over the last decade toward less crystalloids and more blood products. Helsinki University trauma center implemented the massive transfusion protocol in the end of 2009. The aim of the study was to review the changes in fluid resuscitation and its influence on outcome of severely injured patients with hemodynamic compromise treated at the single tertiary trauma center. Data on severely injured patients (New Injury Severity Score > 15) from Helsinki University Hospital trauma center's trauma registry was reviewed over 2006-2013. The isolated head-injury patients, patients without hemodynamic compromise on admission (systolic blood pressure > 90 or base excess > -5.0), and those transferred in from another hospital were excluded. The primary outcome measure was 30-day in-hospital mortality. The study period was divided into three phases: 2006-2008 (pre-protocol, 146 patients), 2009-2010 (the implementation of massive transfusion protocol, 85 patients), and 2011-2013 (post massive transfusion protocol, 121 patients). Expected mortality was calculated using the Revised Injury Severity Classification score II. The Standardized Mortality Ratio, as well as the amounts of crystalloids, colloids, and blood products (red blood cells, fresh frozen plasma, platelets) administered prehospital and in the emergency room were compared. Of the 354 patients that were included, Standardized Mortality Ratio values decreased (indicating better survival) during the study period from 0.97 (pre-protocol), 0.87 (the implementation of massive transfusion protocol), to 0.79 (post massive transfusion protocol). The amount of crystalloids used in the emergency room decreased from 3870 mL (pre-protocol), 2390 mL (the implementation of massive transfusion protocol), to 2340 mL (post massive transfusion protocol). In these patients, the blood products' (red blood cells, fresh frozen plasma, and platelets together) relation to crystalloids increased from 0.36, 0.70, to 0.74, respectively, in three phases. During the study period, no other major changes in the protocols on treatment of severely injured patients were implemented. The overall awareness of damage control fluid resuscitation and introduction of massive transfusion protocol in a trauma center has a significant positive effect on the outcome of severely injured patients.

Update of the trauma risk adjustment model of the TraumaRegister DGU™: the Revised Injury Severity Classification, version II.

IntroductionThe TraumaRegister DGU™ (TR-DGU) has used the Revised Injury Severity Classification (RISC) score for outcome adjustment since 2003. In recent years, however, the observed mortality rate has fallen to about 2% below the prognosis, and it was felt that further prognostic factors, like pupil size and reaction, should be included as well. Finally, an increasing number of cases did not receive a RISC prognosis due to the missing values. Therefore, there was a need for an updated model for risk of death prediction in severely injured patients to be developed and validated using the most recent data.MethodsThe TR-DGU has been collecting data from severely injured patients since 1993. All injuries are coded according to the Abbreviated Injury Scale (AIS, version 2008). Severely injured patients from Europe (ISS ≥4) documented between 2010 and 2011 were selected for developing the new score (n = 30,866), and 21,918 patients from 2012 were used for validation. Age and injury codes were required, and transferred patients were excluded. Logistic regression analysis was applied with hospital mortality as the dependent variable. Results were evaluated in terms of discrimination (area under the receiver operating characteristic curve, AUC), precision (observed versus predicted mortality), and calibration (Hosmer-Lemeshow goodness-of-fit statistic).ResultsThe mean age of the development population was 47.3 years; 71.6% were males, and the average ISS was 19.3 points. Hospital mortality rate was 11.5% in this group. The new RISC II model consists of the following predictors: worst and second-worst injury (AIS severity level), head injury, age, sex, pupil reactivity and size, pre-injury health status, blood pressure, acidosis (base deficit), coagulation, haemoglobin, and cardiopulmonary resuscitation. Missing values are included as a separate category for every variable. In the development and the validation dataset, the new RISC II outperformed the original RISC score, for example AUC in the development dataset 0.953 versus 0.939.ConclusionsThe updated RISC II prognostic score has several advantages over the previous RISC model. Discrimination, precision and calibration are improved, and patients with partial missing values could now be included. Results were confirmed in a validation dataset.

Validation of the revised injury severity classification score in patients with moderate-to-severe traumatic brain injury

IntroductionBy analysing risk-adjusted mortality ratios, weaknesses in the process of care might be identified. Traumatic brain injury (TBI) is the main cause of death in trauma, and thus it is crucial that trauma prediction models are valid for TBI patients. Accordingly, we assessed the validity of the RISC score in TBI patients by internal and external validation analyses. MethodsPatients with moderate-to-severe TBI admitted to the TraumaRegister DGU® (TR-DGU) and the trauma registry of Helsinki University Hospital (TR-THEL) in 2006–2011 were included in this retrospective open cohort study. Definition of moderate-to-severe TBI was head abbreviated injury scale of 3 or higher. Subgroup analysis for patients with isolated and polytrauma TBI was performed. The performance of the RISC score was evaluated by assessing its discrimination (area under the curve, AUC) and calibration (Hosmer–Lemeshow [H–L] test). ResultsAmong the 9106 and 809 patients with moderate-to-severe TBI admitted to TR-DGU and TR-THEL, unadjusted mortality was 26% and 23%, respectively. Internal and external validation of the RISC score showed good discrimination (TR-DGU AUC 0.89, 95% confidence interval [CI] 0.88–0.90 and TR-THEL AUC 0.84, 95% CI 0.81–0.87), but poor calibration (p<0.001) in patients with moderate-to-severe TBI. Subgroup analysis found the discrimination only to be modest in isolated TBI (AUC 0.76) and calibration to be particularly poor in polytrauma TBI (TR-DGU H–L=4356, p<0.001; TR-THEL H–L 112, p<0.001). ConclusionThe RISC score was found to be of limited predictive value in patients with moderate-to-severe TBI. A new general trauma scoring system that includes TBI specific prognostic factors is warranted.

Hypothermia for Prediction of Death in Severely Injured Blunt Trauma Patients

Hypothermia is considered an independent predictor of death after trauma. The aim of this study was to assess these premises based on data from the TraumaRegistry DGU® (TR-DGU) using its outcome predication tool, the Revised Injury Severity Classification (RISC) score, in comparison with three previously published regression models by Shafi, Martin, and Wang. We hypothesized that body temperature on admission would improve accuracy of the RISC score. Data of 5,197 patients with documented body temperature on admission (T) and complete data for RISC score prognosis were selected from TR-DGU. Hypothermia was defined as T of 35°C or less. Patients were divided into hypothermia and normothermia group. Differences were assessed using Mann-Whitney U and chi-squared tests. Statistical significance was accepted at P < 0.01(*). Moreover, we performed multivariate logistic regression analyses using TR-DGU data on the four models (including RISC) with hospital mortality as dependant variable. Results are given as mean or odds ratio (OR) with 95% confidence intervals (95% CIs). Hypothermic patients were more severely injured (Injury Severity Score, 35.0 vs. 29.2 points*) and had higher rates of shock (38.3 vs. 16.8%*), organ failure (71.8 vs. 46%*), and sepsis (17.5 vs. 10.6%*). Survival was worse (29.2 vs. 13.7%*). Comparison of the above models revealed hypothermia as an independent risk factor (Martin: OR, 1.43 [95% CI, 2.21-1.42*]; and Wang: OR, 1.77 [95% CI, 2.21-1.42*]) only, although it would drop out from the model (RISC: OR, 1.12 [95% CI, 1.41-0.89; P = 0.33] and Shafi: OR, 1,.21 [95% CI, 1.60-0.92; P = 0.17]) as long as parameters to indicate hemorrhage and/or coagulopathy were included in sufficient number, a finding confirmed by a subsequent sensitivity analysis. We conclude that hypothermia is a result of injury severity and therefore unlikely to be an independent predictor of mortality. Our data suggest that hypothermia belongs closely to the hemorrhage/coagulopathy group of predictors.

Trauma management incorporating focused assessment with computed tomography in trauma (FACTT) - potential effect on survival

BackgroundImmediate recognition of life-threatening conditions and injuries is the key to trauma management. To date, the impact of focused assessment with computed tomography in trauma (FACTT) has not been formally assessed. We aimed to find out whether the concept of using FACTT during primary trauma survey has a negative or positive effect on survival.MethodsIn a retrospective, multicentre study, we compared our time management and probability of survival (Ps) in major trauma patients who received FACTT during trauma resuscitation with the trauma registry of the German Trauma Society (DGU). FACTT is defined as whole-body computed tomography (WBCT) during primary trauma survey. We determined the probability of survival according to the Trauma and Injury Severity Score (TRISS), the Revised Injury Severity Classification score (RISC) and the standardized mortality ratio (SMR).ResultsWe analysed 4.817 patients from the DGU database from 2002 until 2004, 160 (3.3%) were from our trauma centre at the Ludwig-Maximilians-University (LMU) and 4.657 (96.7%) from the DGU group. 73.2% were male with a mean age of 42.5 years, a mean ISS of 29.8. 96.2% had suffered from blunt trauma. Time from admission to FAST (focused assessment with sonography for trauma)(4.3 vs. 8.7 min), chest x-ray (8.1 vs. 16.0 min) and whole-body CT (20.7 vs. 36.6 min) was shorter at the LMU compared to the other trauma centres (p < 0.001). SMR calculated by TRISS was 0.74 (CI95% 0.40-1.08) for the LMU (p = 0.24) and 0.92 (CI95% 0.84-1.01) for the DGU group (p = 0.10). RISC methodology revealed a SMR of 0.69 (95%CI 0.47-0.92) for the LMU (p = 0.043) and 1.00 (95%CI 0.94-1.06) for the DGU group (p = 0.88).ConclusionTrauma management incorporating FACTT enhances a rapid response to life-threatening problems and enables a comprehensive assessment of the severity of each relevant injury. Due to its speed and accuracy, FACTT during primary trauma survey supports rapid decision-making and may increase survival.

Development and validation of the revised injury severity classification score for severely injured patients.

Trauma scores are often used for prognostication and the adjustment of mortality data. The appropriate consideration of identified prognostic factors is mandatory for a valid score with good outcome prediction properties. The Trauma Registry of the German Society for Trauma Surgery (TR-DGU) initially used the Trauma and Injury Severity Score (TRISS) but various reasons led to the development of a new scoring system, the Revised Injury Severity Classification (RISC). A total of 2,008 severely injured patients with complete data documented in the TR-DGU during the period 1993-2000 were used to develop a new score. Patients were split into a development sample (n = 1,206) and a validation sample (n = 802). Multivariate logistic regression analysis was applied, and the results were compared with existing score systems. The quality of prediction was determined regarding discrimination (disparity, sensitivity, specificity, receiver operating characteristic [ROC] curve), precision (predicted versus observed mortality), and calibration (Hosmer-Lemeshow goodness-of-fit). Existing score systems (ISS, NISS, RTS, ASCOT, TRISS, Rixen) revealed areas under the ROC curve ranging from 0.767 to 0.877. The RISC combines 11 different components: age, NISS, head injury, severe pelvic injury, Glasgow Coma Scale, partial thromboplastin time (PTT), base excess, cardiac arrest, and indirect signs of bleeding (shock, mass transfusion, and low hemoglobin). The new RISC score reached significantly higher values of above 0.90 for the area under the ROC curve in both development and validation samples. Application to data from 2001 confirmed these results. Outcome prediction including initial laboratory values was able to significantly improve the ability to discriminate between survivors and nonsurvivors. The adjustment of mortality rates should be based on the best available prediction model.

Association of Preexisting Medical Conditions with In-Hospital Mortality in Multiple-Trauma Patients

Mortality after trauma has been shown to be influenced by host factors, such as age and preexisting medical conditions (PMCs). The independent predictive value of specific PMCs for in-hospital mortality after adjustment for injury severity, injury pattern, age, and presence of other PMCs has not been fully elucidated. Records of 11,142 trauma patients (18 years of age or older, Injury Severity Score > or = 16, years 2002 to 2007) documented in the Trauma Registry of the German Society for Trauma Surgery were analyzed to assess the association of PMCs with in-hospital mortality. Multiple logistic regression models were used for this analysis. PMCs were affirmed for 3,836 of the 11,142 patients studied (34.4%). An independent statistical association with increased in-hospital mortality was found for 6 of 14 analyzed PMCs after adjustment for age and the Revised Injury Severity Classification score, respectively, ie, heart disease, obesity, hepatitis/liver cirrhosis, malignancies, coagulation disorder, and peripheral arterial occlusive disease stage IV. The association with mortality varied with different injury patterns. Specific PMCs were associated with increased mortality after trauma independent from injury severity and age. Knowledge of the identified relevant PMCs could help the medical team to be able to assess the mortality risk profile of trauma patients in a more detailed and quantifiable way.

Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study

The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing. There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not. In a retrospective, multicentre study, we used the data recorded in the trauma registry of the German Trauma Society to calculate the probability of survival according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardised mortality ratio (SMR, ratio of recorded to expected mortality) for 4621 patients with blunt trauma given whole-body or non-whole-body CT. 1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42.6 years (SD 20.7), 3364 (73%) were men, and mean injury-severity score was 29.7 (13.0). SMR based on TRISS was 0.745 (95% CI 0.633-0.859) for patients given whole-body CT versus 1.023 (0.909-1.137) for those given non-whole-body CT (p<0.001). SMR based on the RISC score was 0.865 (0.774-0.956) for patients given whole-body CT versus 1.034 (0.959-1.109) for those given non-whole-body CT (p=0.017). The relative reduction in mortality based on TRISS was 25% (14-37) versus 13% (4-23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p </= 0.002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation. Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma. None.