Revised Injury Severity Classification Research Articles

Discrimination and calibration of a prediction model for mortality is decreased in secondary transferred patients: a validation in the TraumaRegister DGU

IntroductionThe Revised Injury Severity Classification II (RISC II) score represents a data-derived score that aims to predict mortality in severely injured patients. The aim of this study was to assess...

Does the time of the day affect multiple trauma care in hospitals? A retrospective analysis of data from the TraumaRegister DGU\xae

BackgroundOptimal multiple trauma care should be continuously provided during the day and night. Several studies have demonstrated worse outcomes and higher mortality in patients admitted at night. This study involved the analysis of a population of multiple trauma patients admitted at night and a comparison of various indicators of the quality of care at different admission times.MethodsData from 58,939 multiple trauma patients from 2007 to 2017 were analyzed retrospectively. All data were obtained from TraumaRegister DGU®. Patients were grouped by the time of their admission to the trauma center (6.00 am–11.59 am (morning), 12.00 pm–5.59 pm (afternoon), 6.00 pm–11.59 pm (evening), 0.00 am–5.59 am (night)). Incidences, patient demographics, injury patterns, trauma center levels and trauma care times and outcomes were evaluated.ResultsFewer patients were admitted during the night (6.00 pm–11.59 pm: 18.8% of the patients, 0.00–5.59 am: 4.6% of the patients) than during the day. Patients who arrived between 0.00 am–5.59 am were younger (49.4 ± 22.8 years) and had a higher injury severity score (ISS) (21.4 ± 11.5) and lower Glasgow Coma Scale (GCS) score (11.6 ± 4.4) than those admitted during the day (12.00 pm–05.59 pm; age: 55.3 ± 21.6 years, ISS: 20.6 ± 11.4, GCS: 12.6 ± 4.0). Time in the trauma department and time to an emergency operation were only marginally different. Time to imaging was slightly prolonged during the night (0.00 am–5.59 am: X-ray 16.2 ± 19.8 min; CT scan 24.3 ± 18.1 min versus 12.00 pm- 5.59 pm: X-ray 15.4 ± 19.7 min; CT scan 22.5 ± 17.8 min), but the delay did not affect the outcome. The outcome was also not affected by level of the trauma center. There was no relevant difference in the Revised Injury Severity Classification II (RISC II) score or mortality rate between patients admitted during the day and at night. There were no differences in RISC II scores or mortality rates according to time period. Admission at night was not a predictor of a higher mortality rate.ConclusionThe patient population and injury severity vary between the day and night with regard to age, injury pattern and trauma mechanism. Despite the differences in these factors, arrival at night did not have a negative effect on the outcome.

Evaluation of Pelvic Circular Compression Devices in Severely Injured Trauma Patients with Pelvic Fractures

Background: The role of pelvic circumferential compression devices (PCCD) is to temporarily stabilize the pelvic ring, reduce its volume and to tamponade bleeding. The purpose of this study was to evaluate the effect of PCCDs on mortality and bleeding in severely injured trauma patients, using a large registry database. Methods: We performed a retrospective analysis of all patients registered in the Trauma Register DGU® between 2015 and 2016. The study was limited to directly admitted patients who were alive on admission, with an injury severity score (ISS) of 9 or higher, with an Abbreviated Injury Scale AISpelvis of 3–5, aged at least 16, and with complete status documentation on pelvic circular compression devices (PCCD) and mortality. A cohort analysis was undertaken of patients suffering from relevant pelvic fractures. Data were collected on mortality and requirements for blood transfusion. The observed outcome was compared with the expected outcome as derived from version II of the Revised Injury Severity Classification (RISC II) and adjusted accordingly. A Standardized Mortality Ratio (SMR) was also calculated. Results: A total of 9,910 patients were included. 1,103 of 9,910 patients suffered from a relevant pelvic trauma (AISpelvis = 3–5). Only 41% (454 cases) of these received a PCCD. PCCD application had no significant effect on mortality and did not decrease the need for blood transfusion in the multivariate regression analysis. However, in this cohort, the application of a PCCD is a general indicator for a critical patient with increased mortality (12.0% no PCCD applied vs. 23.2% PCCD applied prehospital vs. 27.1% PCCD applied in the emergency department). The ISS was higher in patients with PCCD (34.12 ± 16.4 vs. 27.9 ± 13.8; p < 0.001). Conclusion: PCCD was applied more often in patients with severe pelvic trauma according to ISS and AISpelvis as well with deterioration in circulatory status. PCCDs did not reduce mortality or reduce the need for blood transfusion. Trial registration: TR-DGU ID 2017-003, March 2017; German clinical trial register DRKS00024948

RISC II is superior to TRISS in predicting 30-day mortality in blunt major trauma patients in Hong Kong

Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK. This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models. 1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant. RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong.

The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients.

Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.

Revised Injury Severity Classification II (RISC II) is a predictor of mortality in REBOA-managed severe trauma patients.

The evidence supporting the use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) in severely injured patients is still debatable. Using the ABOTrauma Registry, we aimed to define factors affecting mortality in trauma REBOA patients. Data from the ABOTrauma Registry collected between 2014 and 2020 from 22 centers in 13 countries globally were analysed. Of 189 patients, 93 died (49%) and 96 survived (51%). The demographic, clinical, REBOA criteria, and laboratory variables of these two groups were compared using non-parametric methods. Significant factors were then entered into a backward logistic regression model. The univariate analysis showed numerous significant factors that predicted death including mechanism of injury, ongoing cardiopulmonary resuscitation, GCS, dilated pupils, systolic blood pressure, SPO2, ISS, serum lactate level and Revised Injury Severity Classification (RISCII). RISCII was the only significant factor in the backward logistic regression model (p < 0.0001). The odds of survival increased by 4% for each increase of 1% in the RISCII. The best RISCII that predicted 30-day survival in the REBOA treated patients was 53.7%, having a sensitivity of 82.3%, specificity of 64.5%, positive predictive value of 70.5%, negative predictive value of 77.9%, and usefulness index of 0.385. Although there are multiple significant factors shown in the univariate analysis, the only factor that predicted 30-day mortality in REBOA trauma patients in a logistic regression model was RISCII. Our results clearly demonstrate that single variables may not do well in predicting mortality in severe trauma patients and that a complex score such as the RISC II is needed. Although a complex score may be useful for benchmarking, its clinical utility can be hindered by its complexity.

Survival among patients with severe high cervical spine injuries \u2013 a TraumaRegister DGU\xae database study

BackgroundTrauma is a significant cause of death and impairment. The Abbreviated Injury Scale (AIS) differentiates the severity of trauma and is the basis for different trauma scores and prediction models. While the majority of patients do not survive injuries which are coded with an AIS 6, there are several patients with a severe high cervical spinal cord injury that could be discharged from hospital despite the prognosis of trauma scores. We estimate that the trauma scores and prediction models miscalculate these injuries. For this reason, we evaluated these findings in a larger control group.MethodsIn a retrospective, multi-centre study, we used the data recorded in the TraumaRegister DGU® (TR-DGU) to select patients with a severe cervical spinal cord injury and an AIS of 3 to 6 between 2002 to 2015. We compared the estimated mortality rate according to the Revised Injury Severity Classification II (RISC II) score against the actual mortality rate for this group.ResultsSix hundred and twelve patients (0.6%) sustained a severe cervical spinal cord injury with an AIS of 6. The mean age was 57.8 ± 21.8 years and 441 (72.3%) were male. 580 (98.6%) suffered a blunt trauma, 301 patients were injured in a car accident and 29 through attempted suicide. Out of the 612 patients, 391 (63.9%) died from their injury and 170 during the first 24 h. The group had a predicted mortality rate of 81.4%, but we observed an actual mortality rate of 63.9%.ConclusionsAn AIS of 6 with a complete cord syndrome above C3 as documented in the TR-DGU is survivable if patients get to the hospital alive, at which point they show a survival rate of more than 35%. Compared to the mortality prognosis based on the RISC II score, they survived much more often than expected.

Predictors of mortality of trauma patients admitted to the ICU: a retrospective observational study☆

Background and objectivesWorldwide, trauma is one of the leading causes of morbidity and mortality. The aim of the present study is to identify the predictors of mortality of trauma patients requiring Intensive Care Unit (ICU) admission. MethodsThis retrospective study was conducted in the ICU of our institution in Greece during a six-year period (2010–215). ResultsAmong 326 patients, trauma was caused by road traffic accidents in .5%, followed by falls (21.1%) and violence (7.4%). Thirty-day mortality was 27.3%. Multivariate analysis showed that higher New Injury Severity Score (NISS), severe head/neck injury, acute kidney injury, septic shock and hemorrhagic shock were significantly associated with mortality while higher Revised Injury Severity Classification, version II (RISC II) and the administration of enteral nutrition were associated with survival. NISS showed the higher accuracy in predicting 30-day mortality followed by RISC II, while scores based only in physiological variables had lower predictive ability. ConclusionsIncreased mortality was strongly associated with the severity of the injury upon admission. Traumatic brain injury, septic shock and acute kidney injury have also been found among the strongest predictors of mortality. NISS can be considered as a statistically superior score in predicting mortality of severely injured patients.

Comparative analysis of MGAP, GAP, and RISC2 as predictors of patient outcome and emergency interventional need in emergency room treatment of the injured.

Little is known about the capabilities of triage and risk scores to predict the outcomes of injured patients, other than mortality, or to determine the need for trauma center resources. Retrospective analysis of prospectively gathered monocenter data on consecutively admitted adult emergency room trauma patients. For each patient, the GAP (Glasgow Coma Scale, Age and Pressure), MGAP (mechanism + GAP) scores and the revised injury severity classification 2 (RISC2) were calculated. The predictive performance of these scores was compared for the assessment of trauma severity, hospital resource need and early patient outcomes (area under the receiver operator characteristics, AUROC). 2112 patients were evaluated [mean age 49.1years; Injury Severity Score (ISS) 9.5]. GAP, MGAP, and RISC2 worked best at predicting mortality (AUROC 93.2, 93.5 and 96.1%, respectively). Other endpoints such as ISS > 15, emergency interventions, disability status, and return-not-home were predicted less precisely by these three scores, better by RISC2 (AUROC range 66.2-88.8%) than by (M)GAP-scores (55.2-84.1%), except for preclinical interventions. Over- and undertriage rates for the (M)GAP scores varied between 27.5-53.4% and 10.4-30%, respectively. The almost comparable precision of the three risk scores in the prediction of outcome or interventional need following trauma, and the fact, that the RISC2 can only be calculated following extensive diagnostics, favor earlier applicable (M)GAP scoring in the emergency setting. Overall, due to its easier use, the GAP appears to be the most preferable for the early assessment and triage of the injured in a trauma setting based on this European trauma center experience (NCT02165137).

Pre-hospital CPR and early REBOA in trauma patients \u2014 results from the ABOTrauma Registry

BackgroundSeverely injured trauma patients suffering from traumatic cardiac arrest (TCA) and requiring cardiopulmonary resuscitation (CPR) rarely survive. The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) performed early after hospital admission in patients with TCA is not well-defined. As the use of REBOA increases, there is great interest in knowing if there is a survival benefit related to the early use of REBOA after TCA. Using data from the ABOTrauma Registry, we aimed to study the role of REBOA used early after hospital admission in trauma patients who required pre-hospital CPR.MethodsRetrospective and prospective data on the use of REBOA were collected from the ABOTrauma Registry from 11 centers in seven countries globally between 2014 and 2019. In all patients with pre-hospital TCA, the predicted probability of survival, calculated with the Revised Injury Severity Classification II (RISC II), was compared with the observed survival rate.ResultsOf 213 patients in the ABOTrauma Registry, 26 patients (12.2%) who had received pre-hospital CPR were identified. The median (range) Injury Severity Score (ISS) was 45.5 (25–75). Fourteen patients (54%) had been admitted to the hospital with ongoing CPR. Nine patients (35%) died within the first 24 h, while seventeen patients (65%) survived post 24 h. The survival rate to hospital discharge was 27% (n = 7). The predicted mortality using the RISC II was 0.977 (25 out of 26). The observed mortality (19 out of 26) was significantly lower than the predicted mortality (p = 0.049). Patients not responding to REBOA were more likely to die. Only one (10%) out of 10 non-responders survived. The survival rate in the 16 patients responding to REBOA was 37.5% (n = 6). REBOA with a median (range) duration of 45 (8–70) minutes significantly increases blood pressure from the median (range) 56.5 (0–147) to 90 (0–200) mmHg.ConclusionsMortality in patients suffering from TCA and receiving REBOA early after hospital admission is significantly lower than predicted by the RISC II. REBOA may improve survival after TCA. The use of REBOA in these patients should be further investigated.

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.

Empirical evaluation of quality indicators for severely injured patients in the TraumaRegisterDGU®

Asystematic assessment of the quality of medical treatment by using key indicators has been required in Germany for many years. These quality indicators (QI) have to satisfy many requirements. Besides an expert review an empirical data-based evaluation is also necessary. The TraumaRegister DGU® (TR-DGU) has reported QI in the annual reports from the beginning. The objective of this study was to validate 40QI for the treatment of severely injured patients reviewed by experts using data from the TR-DGU. The association of the 40QI with hospital mortality was verified using healthcare data from the TR-DGU from a 5‑year period (2012-2016). Of these 26QI consider events while the remaining 14QI are key indicators, such as time spent in the trauma room. To compensate differences in injury severity, adjusted mortality rates were calculated using the revised injury severity classification (RISC)II score. For this two different approaches were chosen: the hospital-based approach classifies all hospitals into three categories and analyzes the grade of fulfilment of the indicator. The indicator-based approach considers the adjusted mortality depending on the grade of fulfilment of the indicator. The analysis was based on 111,656 cases documented in the TR-DGU (mean age 50years; 70 % male). The data analysis showed an obvious correlation with mortality for half of the QI, including only three procedural times. Aclear correlation in both approaches was shown for two QI: prehospital capnometry in intubated patients and sonography used for patients without whole body computed tomography (CT) scans. Of the 20QI with apositive result 15were also positively rated by the experts. Of the 14 QI reported annually since 2017 in the TR-DGU report, 8 (57%) showed aclear correlation with mortality. There is no doubt regarding the necessity of scientifically assessing QI. Approximately half of the evaluated QI showed an empirical association with mortality. Interventions and events showed better results than measurements of procedural times; however, many QI may require arefined definition. The interpretation of the results is still challenging due to differences in the patient groups. Secondary endpoints, such as hospital length of stay and quality of life after trauma were not considered here.

Quality of life after multiple trauma: results from a patient cohort treated in a certified trauma network.

Besides mortality, the patient-reported outcome (PRO) in survivors of multiple trauma is of increasing interest. So far, no data on patient-reported outcome measures (PROMs) after multiple trauma from an entire trauma network are available. Within this study, the course of the PRO over time and differences between level I and level II trauma centers within an entire trauma network was evaluated. Multiple injured patients, treated in a rural trauma network over 2years, were prospectively included in this study. After 6, 12 and 24months the results of the European Quality of Life (EuroQoL) EQ-5D outcome instrument were evaluated. To adjust for differences in trauma severity between level I and level II centers, the Revised Injury Severity Classification II (RISC II) and the Functional Capacity Index (FCI) were used to adjust the life-quality results of patients. 501 patients were included, 118 patients with an ISS < 16 points, 383 patients reached 16 points or more. Despite a steady increase of EQ-5D index over time (6months: 0.71 ± 0.31; 12months: 0.74 ± 0.28; 24months: 0.76 ± 0.27; p < 0.001), the values of a reference population could not be reached even 2 years after trauma (EQ-5D reference population: 0.9). After adjustment for trauma severity, no significant differences in PROMs between level I and level II centers could be detected (p = 0.188). The consistently low EQ-5D index relative the reference population and the lack of a difference between level I and II centers suggest that improved strategies for polytrauma aftercare are called for.

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.

The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients

Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured. Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis. The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. Atotal of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals aproportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to asmarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISCII) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset. The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at arelatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.

A trauma network with centralized and local health care structures: Evaluating the effectiveness of the first certified Trauma Network of the German Society of Trauma Surgery.

BackgroundTrauma is a global burden of disease and one of the main causes of death worldwide. Therefore, many countries around the world have implemented a wide range of different initiatives to minimize mortality rates after trauma. One of these initiatives is the bundling of treatment expertise in trauma centers and the establishment of trauma networks.Germany has a decentralized system of trauma care medical centers. Severely injured patients ought to receive adequate treatment in both level I and level II centers. This study investigated the effectiveness of a decentralized network and the question whether level I and level II centers have comparable patient outcome.Materials and methodsIn 2009, the first trauma network DGU® in Germany was certified in the rural area of Eastern Bavaria. All patients admitted to the 25 participating hospitals were prospectively included in this network in the framework of a study sponsored by the German Federal Ministry of Education and Research between March 2012 and February 2014. 2 hospitals were level I centers (maximal care centers), 8 hospitals were level II centers, and 15 hospitals were level III centers. The criterion for study inclusion was an injury severity score (ISS) ≥ 16 for patients´ primarily admitted to a level I or a level II center. Exclusion criteria were transferal to another hospital within 48 h, an unknown revised injury severity classification II score (RISC II), or primary admittance to a level III center (n = 52). 875 patients were included in the study.Univariate analyses were used regarding the preclinical and clinical parameters, the primary endpoint mortality rate, and the secondary endpoints length of stay, organ failure, and neurological outcome (GOS). The primary endpoint was additionally evaluated by means of multivariable analysis.ResultsIndices for injury severity (GCS, AISHead, ISS, and NISS) as well as the predicted probability of death (RISC II) were higher in level I centers than in level II centers.No significant differences were found between the mortality rate of the unadjusted analysis [level I: 21.6% (CI: 16.5, 27.9), level II: 18.1% (CI: 14.4, 22.5), p = 0.28] and that of the adjusted analysis [level I SMR: 0.94 (CI: 0.72, 1.21), level II SMR: 1.18 (CI 0.95, 1.48) SMR: expected vs. calculated mortality rate according to RISC II]. Multivariable analysis showed a survival advantage of patients admitted to a level I center with a probability of death of 13% (RISC II). The number need to treat was 10 patients.DiscussionThis study showed that a rural trauma network with centralized and local structures may achieve equivalent results with regard to mortality rates to those obtained in level I and level II centers. These results were furthered by a certain preclinical centralization (24/7 air rescue) of patients. The study also showed a survival advantage of patients admitted to a level I center with a probability of death of 13%. Preclinical and initial clinical evaluation with regard to probable mortality rates should be further improved to identify patients who would benefit from admittance to a level I center.

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 Impact of Prehospital Intubation With and Without Sedation on Outcome in Trauma Patients With a GCS of 8 or Less.

Although unconsciousness (Glasgow Coma Scale [GCS] 3 to 8) necessitates intubation according national guidelines, there is a notable lack of evidence to support this approach. This study evaluates the impact on outcome of prehospital intubation with and without sedation in trauma patients with a GCS of ≤8. A retrospective cohort analysis of severely injured trauma patients registered in the TraumaRegister DGU of the German Trauma Society (DGU) from 2002 to 2013 was conducted. Only directly admitted patients alive on admission and with a GCS of ≤8 at the scene were included. The observed outcome was matched with the expected outcome deriving from the Revised Injury Severity Classification, version II (RISC-II). Furthermore, a Standardized Mortality Ratio (SMR) was calculated for various subgroups. Early neurological outcome was classified using the Glasgow Outcome Scale. A total of 21,242 patients fulfilled the study inclusion criteria. A total of 18,975 patients (89.3%) received prehospital intubation. Intubation rates were continuously increasing with decreasing GCS score values. Difference between observed and expected mortality was lower in intubated patients (42.2% [95% confidence interval (CI), 41.5%-42.9%]; RISC-II prognosis 41.4%; SMR 1.020 [95% CI, 1.003-1.037]) compared with nonintubated (30.0% [95% CI, 28.1-31.9%] RISC-II prognosis 26.6% and SMR 1.128 [95% CI, 1.057-1.199]). Patients being sedated before intubation presented significant (P<0.001) lower observed mortality (37.7% [95% CI, 36.7-38.7%], RISC-II prognosis 39.0%, SMR 0.967 [95% CI, 0.951-0.983]) associated with a less poor early neurological outcome compared with those being intubated without sedation. Observed outcome of prehospital intubated patients with a GCS of ≤8 seems less poor than predicted compared with nonintubated patients. Sedation before intubation might potentially decrease mortality and improve early neurological outcome. Further studies are required to clarify this issue.

Differences in the outcome of seriously injured children depending on treatment level

Many publications, mainly from other countries, suggest that the treatment of seriously injured children might be better in specialised paediatric trauma centres than in general trauma centres. Data from Germany are not available yet, but those from abroad were used for the recommendations made by the German Association for Trauma Surgery (DGU) on the topic of paediatric trauma in the "White Paper on Trauma Care". The goal of this study was to analyse whether the outcome of severely injured children is dependent on treatment level and on the availability of a paediatric surgeon based on the given data. Data from the "TraumaRegister DGU" between 2002 and 2012 were used. Children aged 1-15years treated during the period 2002-2012 were included. Severity had to reach a minimum Injury Severity Score (ISS) of 9 and the treatment had to involve astay at an Intensive Care Unit. Patients with an ISS ≥9 who died were also included to take into consideration children with particularly severe injuries. Hospitals without a paediatric surgeon transferred the patients significantly more frequently (p< 0.001). Mean hospital stay was shorter in centres with a paediatric surgeon, with slightly longer median stays at an Intensive Care Unit. Hospitals without a paediatric surgeon performed slightly more frequent surgical interventions on injured children (barely significant at p= 0.045). The death rate and the calculated Revised Injury Severity Classification (RISC)II prognosis were the same with or without the presence of apaediatric surgeon. No difference was found in the Glasgow Outcome Score (GOS) between the group with and the group without involvement of a paediatric surgeon. Overall, the medical care of seriously injured and polytraumatised children in Germany is good at all levels of treatment whether apaediatric surgeon is involved or not.