Trauma Related Injury Severity Score Research Articles

Serum levels of copeptin predict adverse outcomes and improve risk prediction of TRISS and MGAP scores in patients with multiple trauma: A single-center prospective cohort study.

Multiple trauma deserves early prognostication and stratification. Copeptin, a precursor of vasopressin, is produced in response to stress. We examined the association between serum levels of copeptin and mortality risk in patients with multiple trauma. We aimed to also enhance the previously established Trauma-Related Injury Severity Score (TRISS) and Mechanism, GCS, Age, and Arterial Pressure (MGAP) score with the additional consideration of copeptin levels. This single-center prospective cohort study enrolled patients who presented to the emergency department with potential major injuries. The serum levels of copeptin were measured, and the correlation to clinical severity in terms of 30-day mortality and requirement of intensive care management was analyzed. By combining copeptin levels with TRISS or MGAP, comparison between performance of the original models with the copeptin-enhanced models was performed via discrimination, calibration, and reclassification analyses. There was a significant increase in copeptin levels in patients who died within 30 days (median 644.4 pg/L, interquartile range [472.5, 785.9]) or were admitted to intensive care units (233.8 pg/L, [105.7, 366.4]), compared with those who survived (37.49 pg/L, [17.88, 77.68]). Adding the natural log of copeptin levels to the established TRISS and MGAP models improved the AUC of TRISS from 0.89 to 0.96, and that of MGAP from 0.82 to 0.95. Both calibrations as measured by Brier's scores and reclassification as measured by net reclassification improvement or integrated discrimination improvement demonstrated significant improvements. A Web-based calculator was built to generate predicted mortality rates of various models for convenient clinical use. Admission serum copeptin levels were correlated with clinical severity in multiple trauma. Coupling copeptin with preexisting trauma severity scores improved prediction accuracy. Copeptin shows promise as a novel biomarker for the prediction of trauma outcome. Prognostic and Epidemiologic; Level III.

Interest of the MGAP score on in-hospital trauma patients: Comparison with TRISS, ISS and NISS scores

Trauma scoring systems were created to predict mortality and enhance triage capabilities. However, efficacy of scoring systems to predict mortality and accuracy of originally reported severity thresholds remains uncertain. A single-center, retrospective study was conducted at University of Virginia (UVA), an American College of Surgeons verified Level I trauma center. We compared four scoring systems: MGAP (Mechanism, Glasgow Coma Scale, Age, and arterial pressure), Injury Severity Score (ISS), New Injury Severity Score (NISS), and Trauma Related Injury Severity Score (TRISS) to predict in-hospital mortality and disposition from the emergency department to higher acuity level of care including mortality (i.e. operating room, intensive care unit, morgue) versus standard floor admission using area under the curve (AUC) for receiver operating characteristic analysis. Second, we examined sensitivity of these scores at standard thresholds to determine if adjustments were needed to minimize under-triage (sensitivity ≥95%). TRISS was the best predictor of mortality in a cohort of n=16,265 with AUC of 0.920 (95% CI: 0.911-0.929, p<0.0001), followed by MGAP with AUC of 0.900 (95% CI: 0.889-0.911, p<0.0001), and finally ISS and NISS (0.830 (95% CI: 0.814-0.847) and 0.827 (95% CI: 0.809-0.844) respectively). NISS was the best predictor of high acuity disposition with an AUC of 0.729 (95% CI: 0.721-0.736, p<0.0001), followed by ISS with AUC of 0.714 (95% CI: 0.707-0.722, p<0.0001), and finally TRISS and MGAP (0.673 (95% CI: 0.665-0.682) and 0.613 (95% CI: 0.604-0.621) respectively (p<0.0001). At historic thresholds, no scoring system displayed adequate sensitivity to predict mortality, with values ranging from 73% for ISS to 80% for NISS. In conclusion, in the reported study cohort, TRISS was the best predictor of mortality while NISS was the best predictor of high acuity disposition. We also stress updating scoring system thresholds to achieve ideal sensitivity, and investigating how scoring systems derived to predict mortality perform when predicting indicators of morbidity such as disposition from the emergency department.

Beyond Mortality: Does Trauma-related Injury Severity Score Predict Complications or Lengths of Stay Using a Large Administrative Dataset.

Introduction:Despite its shortcomings, trauma-related injury severity score (TRISS) correlates well with mortality in large trauma datasets. The aim of this study was to determine if TRISS correlates with morbidity and hospital lengths of stay using data from an institutional registry at a Level I Trauma Center. We hypothesized that higher TRISS correlates with increased complications and longer hospital stays.Methods:A retrospective review of our institutional registry was performed, examining all trauma admissions between January 1999 and June 30, 2015. Out of a total of 32,026 patient records, TRISS data were available in 23,205 cases. ed data included patient age, gender, ISS, TRISS, presence of complication, Glasgow Coma Scale (GCS), hospital length of stay, intensive care unit LOS, step-down unit LOS, functional independence measure, and 30-day mortality.Results:TRISS was highly predictive of mortality, with the AUC value of 0.95 (95% confidence interval 0.936–0.954, P < 0.01) compared to ISS (AUC 0.794), GCS (AUC 0.827), and age (AUC 0.650). TRISS also performed better than the other variables in terms of the ability to predict morbidity events (AUC 0.813). TRISS was comparable to ISS in terms of prediction of ICU admission (AUC 0.801 versus 0.811, respectively). After correcting for patient age and gender, higher TRISS significantly correlated with longer hospital stays .Conclusions:Despite previous criticisms, we found that TRISS is superior to ISS for mortality and morbidity prediction. TRISS correlated significantly with a hospital, step down, and ICU lengths of stay using a large administrative dataset.

Development of a modified trauma and injury severity score to predict disability in acute trauma patients.

ObjectiveThe Trauma and Injury Severity Score (TRISS) has been used to predict trauma patient mortality and to assess the quality of trauma care systems. The goal of this investigation was to develop a modified trauma-related injury severity score (termed the TRISS-D) for predicting disability in acute trauma patients.MethodsWe used data collected by emergency medical services and entered into the Korea Centers for Disease Control and Prevention severe trauma database. The TRISS-D was based on age category (0–14, 15–54, ≥55 years), the Revised Trauma Score, and the Injury Severity Score. The outcome measures were severe disability and worsening disability. Worsening disability was defined as a lower Glasgow Outcome Scale score at hospital discharge than before the traumatic incident. Two types of cases were examined: those with penetrating or blunt injuries (group 1) and those with severe head injuries (group 2). We assessed the discriminatory power of the TRISS-D by calculating the area under a receiver operating characteristic curve (AUROC).ResultsThe database comprised 14,791 patients; overall, 3,757 (25%) had severe disability and 6,018 (41%) had worsening disability. For severe disability, the AUROC (95% confidence interval) for the TRISS-D was 0.948 (0.944–0.952) in group 1 and 0.950 (0.946–0.954) in group 2. The corresponding values for worsening disability were 0.810 (0.803–0.817) and 0.816 (0.809–0.823), respectively.ConclusionThe TRISS-D showed excellent discriminatory power for severe disability and very good discriminatory power for worsening disability.

Lactate Measurement in Critically Injured—Prognostic Importance

Trauma-related deaths are one of the top 10 causes of death. The diagnosis of occult hypoperfusion in patients who have suffered trauma is indeed challenging. The initial surge in lactate values is known to clear over time, and numerous studies have evaluated 6-h and 12-h lactate clearance. However, the trauma surgeon needs an objective indicator of his resuscitation efforts in record time. To find if blood lactate and a 2-h lactate clearance can predict mortality in trauma and to compare these with the available scores in trauma, namely, the revised trauma score (RTS), injury severity score (ISS) and the trauma-related injury severity score (TRISS). This was a prospective, descriptive study with a sample size of 200 patients. Patients with acute trauma presented to the emergency department between October 2016 and December 2018 who fit the inclusion criteria were chosen. Demographics were collected and the variables were compared. Out of the 200 patient studies, 15 expired during the 30-day period post-trauma. Admission serum lactate was found to be a good indicator for mortality (for values > 2.7 mmol/l) (sensitivity of 86.67 and specificity of 72.43). Independently, collected 2-h lactate predicts mortality (values > 2.5 mmol/L) (sensitivity of 60 and specificity of 87.57). Two-hour lactate clearance had no statistical significance in predicting mortality in trauma patients but maybe considered to be an important prognostic aid to predict adequacy of resuscitation efforts. Injury severity score was found to be a comparable triage scoring system. Lactate values at admission is a good indicator for mortality in trauma patients, as also independently measured lactate at 2 h; however, further studies may be required to prove benefit of lactate clearance in trauma patients. Injury severity score is comparable to lactate as a triage score.

Comparing the Clinical Features and Trauma Scores of Trauma Patients Aged Under 65 Years with Those of Patients Aged over 65 Years in the Intensive Care Unit: A Retrospective Study for Last Ten Years.

This retrospective study aimed to compare the clinical characteristics and trauma scores of Intensive Care Unit (ICU) trauma patients 65 years and older with the patients under 65 years old. Trauma patients (n=161) who stayed at least 24 hours in ICU were included. Patients younger than 65 years were included into Group 1 (n=109) and patients aged ≥65 years (n=52) were included into Group 2. Patient characteristics and trauma index scores (GCS; APACHE II score, ISS; TRISS and RTS) at ICU admission were calculated. The patients in Group 2 had more comorbid disease compared with Group 1 (61.5%, 6.4%) (p=0.001). The Trauma-related Injury Severity Score score were higher in Group 1 (49.76±33.75) compared with Group 2 (35.38±34.93) (p=0.006). The APACHE II score were higher in Group 2 (20.08±7.60) compared with Group 1 (17.00±6.90) (p=0.007). The need for invasive mechanical ventilation and tracheostomy were more frequent in Group 2 trauma patients compared with those of patients in Group 1 (92.3%, 73.4%; p=0.003; 26.9%, 8.3%; p=0.002; respectively). The need for transfusion of packed red blood cell suspension (PRBC) was more frequent in Group 2 compared with Group 1 (92.3%, 55.0%; respectively) (p=0.001). The mortality rate was found to be higher in Group 2 compared with Group 1 (48.1%, 19.3%; respectively) (p=0.001). The elderly trauma patients have more comorbid disease, higher scores for APACHE II and lower scores for TRISS, more mechanical ventilation and tracheostomy requirements and higher mortality rate compared with young trauma patients.

La codification PMSI identifie mal les traumatismes graves

BackgroundResource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims. MethodsWe studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient. ResultsDuring the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %). ConclusionDCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding.

Helicopter emergency medical services for adults with major trauma.

Although helicopters are presently an integral part of trauma systems in most developed nations, previous reviews and studies to date have raised questions about which groups of traumatically injured people derive the greatest benefit. To determine if helicopter emergency medical services (HEMS) transport, compared with ground emergency medical services (GEMS) transport, is associated with improved morbidity and mortality for adults with major trauma. We ran the most recent search on 29 April 2015. We searched the Cochrane Injuries Group's Specialised Register, The Cochrane Library (Cochrane Central Register of Controlled Trials; CENTRAL), MEDLINE (OvidSP), EMBASE Classic + EMBASE (OvidSP), CINAHL Plus (EBSCOhost), four other sources, and clinical trials registers. We screened reference lists. Eligible trials included randomized controlled trials (RCTs) and nonrandomized intervention studies. We also evaluated nonrandomized studies (NRS), including controlled trials and cohort studies. Each study was required to have a GEMS comparison group. An Injury Severity Score (ISS) of at least 15 or an equivalent marker for injury severity was required. We included adults age 16 years or older. Three review authors independently extracted data and assessed the risk of bias of included studies. We applied the Downs and Black quality assessment tool for NRS. We analyzed the results in a narrative review, and with studies grouped by methodology and injury type. We constructed 'Summary of findings' tables in accordance with the GRADE Working Group criteria. This review includes 38 studies, of which 34 studies examined survival following transportation by HEMS compared with GEMS for adults with major trauma. Four studies were of inter-facility transfer to a higher level trauma center by HEMS compared with GEMS. All studies were NRS; we found no RCTs. The primary outcome was survival at hospital discharge. We calculated unadjusted mortality using data from 282,258 people from 28 of the 38 studies included in the primary analysis. Overall, there was considerable heterogeneity and we could not determine an accurate estimate of overall effect.Based on the unadjusted mortality data from six trials that focused on traumatic brain injury, there was no decreased risk of death with HEMS. Twenty-one studies used multivariate regression to adjust for confounding. Results varied, some studies found a benefit of HEMS while others did not. Trauma-Related Injury Severity Score (TRISS)-based analysis methods were used in 14 studies; studies showed survival benefits in both the HEMS and GEMS groups as compared with MTOS. We found no studies evaluating the secondary outcome, morbidity, as assessed by quality-adjusted life years (QALYs) and disability-adjusted life years (DALYs). Four studies suggested a small to moderate benefit when HEMS was used to transfer people to higher level trauma centers. Road traffic and helicopter crashes are adverse effects which can occur with either method of transport. Data regarding safety were not available in any of the included studies. Overall, the quality of the included studies was very low as assessed by the GRADE Working Group criteria. Due to the methodological weakness of the available literature, and the considerable heterogeneity of effects and study methodologies, we could not determine an accurate composite estimate of the benefit of HEMS. Although some of the 19 multivariate regression studies indicated improved survival associated with HEMS, others did not. This was also the case for the TRISS-based studies. All were subject to a low quality of evidence as assessed by the GRADE Working Group criteria due to their nonrandomized design. The question of which elements of HEMS may be beneficial has not been fully answered. The results from this review provide motivation for future work in this area. This includes an ongoing need for diligent reporting of research methods, which is imperative for transparency and to maximize the potential utility of results. Large, multicenter studies are warranted as these will help produce more robust estimates of treatment effects. Future work in this area should also examine the costs and safety of HEMS, since multiple contextual determinants must be considered when evaluating the effects of HEMS for adults with major trauma.

Prehospital Use of Blood and Plasma in Pediatric Trauma Patients

ObjectiveOur rural trauma center uses packed red blood cells (PRBCs) and plasma onboard our helicopter to offset the delay of transport. We summarize our initial experience with prehospital blood use in pediatric trauma patients. MethodsOur air ambulance service began carrying PRBCs in 1987 and plasma in 2009. We performed a 9-year retrospective review including patients (< 18 years) who received blood during helicopter transports. Only patients transported to our level 1 trauma center were included to ensure complete follow-up. ResultsSixteen patients (6 females) were identified with a mean age of 13 years. The mean transport time was 30 minutes with 75% transferred in from a referring center. Injuries were blunt in 9 patients and penetrating in 2 patients. The mean Injury Severity Score was 30. Fifteen patients received an average of 1.5 units of PRBCs during flight. Indications for PRBCs were severe anemia (6), known blood loss (5), and nonresponder to intravenous fluids (4). Average hemoglobin improved from 9.4 to 11.4 mg/dL at our center. Base deficit improved from −7 to −5.7 at arrival. Five patients received a mean of 1.4 units of plasma. The arrival international normalized ratio was 1.4. The average length of stay was 9.3 days. Four patients died. Trauma Related Injury Severity Score showed 3 patients were unexpected survivors (0.24, 0.24, and 0.38). ConclusionPrehospital use of blood in injured children is rare. However, when indicated, this initial review of our protocol showed increased hemoglobin, decreased acidosis, and unexpected survivors with our program. Because of the rarity of prehospital blood use in children, administration triggers require continued review and refinement.

Value of the Glasgow coma scale, age, and arterial blood pressure score for predicting the mortality of major trauma patients presenting to the emergency department.

The purpose of this study is to detect the mortality predictive power of new Glasgow coma scale, age, and arterial pressure (GAP) scoring system in major trauma patients admitted to the emergency department (ED). A total of 100 major trauma patients admitted to Uludağ University Faculty of Medicine ED who were 18 years of age or more were included in the study. In this prospective study, revised trauma score (RTS), injury severity score (ISS), trauma-related ISS (TRISS), Mechanism, GAP (MGAP) and GAP scores of the patients were calculated. A significant positive correlation was established between ISS, TRISS, MGAP, and GAP in predicting in-hospital mortality (p<0.0001). Short-term (24 hours) and long-term (4-week) mortality prediction rates and area under the curve in receiver operating characteristics analysis were 0.727-0.680 for RTS, 0.863-0.816 for ISS, 0.945-0,911 for TRISS, 0.970-0.938 for MGAP, and 0.910-0.904 for GAP. All calculated trauma scoring systems revealed a significant mortality prediction power (p<0.001). GAP score was found statistically and significantly selective and sensitive in predicting both in-ED and in-hospital mortality (p=0.0001). In major trauma patients, GAP score is an easily calculable system both in the field and at the time of admission in the EDs by providing emergency physicians with future decision-making schemes by means of mortality prediction of the patients.

Influence of In-House Attending Presence on Trauma Outcomes and Hospital Efficiency

The influence of in-house (IH) attendings on trauma patient survival and efficiency measures, such as emergency department length of stay (LOS), ICU LOS, and hospital LOS, has been debated for more than 20 years. No study has definitively shown improved outcomes with IH vs home-call attendings. This study examines trauma outcomes in a single, Level I trauma center before and after the institution of IH attending call. Patient data were collected from the University of Kentucky's trauma registry. Based on the Trauma-Related Injury Severity Score, survival rates were compared between the IH and home-call groups. To evaluate efficiency, emergency department LOS, ICU LOS, and hospital LOS were compared. A separate subanalysis for the most severely injured patients (trauma alert red) was also performed. The home-call group (n = 4,804) was younger (p = 0.018) and had a higher Injury Severity Score (p = 0.003) than the IH group (n = 5259), but there was no difference in Trauma-Related Injury Severity Score (p = 0.205) between groups. In-house attending presence did not reduce mortality. Emergency department LOS, ICU LOS, and hospital LOS were shorter during the IH period. Emergency department to operating room time was not different. There was no change in trauma alert red mortality with an attending present (20.7% vs 18.2%, p = 0.198). In-house attending presence does not improve trauma patient survival. For the most severely injured patients, attendings presence does not reduce mortality. In-house coverage can improve hospital efficiency by decreasing emergency department LOS, hospital LOS, and ICU LOS.

Prognostic Significance of Blood Lactate and Lactate Clearance in Trauma Patients

Lactate has been shown to be a prognostic biomarker in trauma. Although lactate clearance has already been proposed as an intermediate endpoint in randomized trials, its precise role in trauma patients remains to be determined. Blood lactate levels and lactate clearance (LC) were calculated at admission and 2 and 4 h later in trauma patients. The association of initial blood lactate level and lactate clearance with mortality was tested using receiver-operating characteristics curve, logistic regression using triage scores, Trauma Related Injury Severity Score as a reference standard, and reclassification method. The authors evaluated 586 trauma patients (mean age 38±16 yr, 84% blunt and 16% penetrating, mortality 13%). Blood lactate levels at admission were elevated in 327 (56%) patients. The lactate clearance should be calculated within the first 2 h after admission as LC0-2 h was correlated with LC0-4 h (R=0.55, P<0.001) but not with LC2-4 h (R=0.04, not significant). The lactate clearance provides additional predictive information to initial blood lactate levels and triage scores and the reference score. This additional information may be summarized using a categorical approach (i.e., less than or equal to -20 %/h) in contrast to initial blood lactate. The results were comparable in patients with high (5 mM/l or more) initial blood lactate. Early (0-2 h) lactate clearance is an important and independent prognostic variable that should probably be incorporated in future decision schemes for the resuscitation of trauma patients.

Predicting mortality in trauma patients: The discriminative accuracy of pre-hospital physiological variables vs. the current registry standard Trauma-Related Injury Severity Score (TRISS)

Predicting mortality in trauma patients: The discriminative accuracy of pre-hospital physiological variables vs. the current registry standard Trauma-Related Injury Severity Score (TRISS)

The motor component does not convey all the mortality prediction capacity of the Glasgow Coma Scale in trauma patients

PurposeWe tested the hypothesis that the motor component of the Glasgow Coma Scale (GCS) conveys most of the predictive information of triage scores (Triage Revised Trauma Score [T-RTS] and the Mechanism, GCS, Age, arterial Pressure score [MGAP]) in trauma patients. MethodWe conducted a multicenter prospective observational study and evaluated 1690 trauma patients in 14 centers. We compared the GCS, T-RTS, MGAP, and Trauma Related Injury Severity Score (reference standard) using the full GCS or its motor component only using logistic regression model, area under the receiver operating characteristic curve, and reclassification technique. ResultsAlthough some changes were noted for the GCS itself and the Trauma Related Injury Severity Score, no significant change was observed using the motor component only for T-RTS and MGAP when considering (1) the odds ratio of variables included in the logistic model as well as their discrimination and calibration characteristics, (2) the area under the receiver operating characteristic curve (0.827 ± 0.014 vs 0.831 ± 0.014, P = .31 and 0.863 ± 0.011 vs 0.859 ± 0.012, P = .23, respectively), and (3) the reclassification technique. Although the mortality rate remained less than the predetermined threshold of 5% in the low-risk stratum, it slightly increased for MGAP (from 1.9% to 3.9%, P = .048). ConclusionThe use of the motor component only of the GCS did not change the global performance of triage scores in trauma patients. However, because a subtle increase in mortality rate was observed in the low-risk stratum for MGAP, replacing the GCS by its motor component may not be recommended in every situation.

Management of exsanguinating pelvic trauma: Do we still need the radiologist?

The hemodynamically unstable pelvic fracture are a diagnostic and therapeutic challenge. The current management is based on the control of pelvic bleeding by combining pelvic ring stabilization and embolization of pelvic arteries. The mortality of these patients, however, exceeds 30%. Recently the preperitoneal packing, based on the hemostatic tamponade of the pelvic cavity has been described. The objective of this study was to evaluate the interest of this new surgical procedure. The effectiveness of the standard algorithm is evaluated by analysis of pelvic injuries in 200 severe trauma treated at the Sainte-Anne Hospital. The results are then compared with literature data on the preperitoneal packing. The profile injury, management and morbidity and mortality was evaluated in 200 polytrauma. After an initial phase of resuscitation, unstable pelvic fractures were treated with a circumferential belt followed by the application of an external fixator. Arteriography was performed for all patients with persistent hemodynamic instability. The mean injury severity score (ISS) was 31 (4-75). The mean trauma-related injury severity score (TRISS) was 74% (3-99). The proportion of hemodynamically unstable patients was 47%. Fifteen patients (41%) had severe bleeding. The median number of blood transfusion was 10 (4-42); eight patients (22%) underwent embolization. For two patients, reducing the pelvic fracture with an external fixator resulted in permanent hemostasis. Two patients underwent a laparotomy first, for the control of a hemoperitoneum. The mortality rate of the group of patients with hemorrhage was 33% (5/15). This high mortality leads to reconsider the place of pelvic embolization as firstline treatment. Some major drawbacks are noted: its effectiveness in treating venous bleeding, availability and duration of the procedure. The preperitoneal packing is a fast and effective surgical alternative. It seems to improve hemodynamic status of patients and significantly reduce the use of embolization and massive transfusion. Embolization is still indicated for patients not responding to surgery. However survival is not significantly improved.

What Do Prehospital Trauma Scores Predict Besides Mortality?

Little information is available concerning the ability of prehospital triage scores to predict endpoints other than mortality. We evaluated two cohorts (a national cohort of 1,360 patients during 2002 and a single center cohort of 1,003 patients in 2003-2005) of trauma patients receiving care from a prehospital mobile intensive care unit (ICU). We tested the ability of prehospital triage scores (MGAP, Revised Trauma Score [RTS], and triage RTS [T-RTS]) to predict a severe injury, the need for a prolonged ICU period, the occurrence of massive hemorrhage, and the need for emergency procedures, and compared them with a reference score (Trauma-Related Injury Severity Score [TRISS]). The areas under the receiver operating characteristic (AUC(ROC)) curves were measured. The MGAP, RTS, and T-RTS scores were able to predict an Injury Severity Score >15 (AUC(ROC): 0.75, 0.75, and 0.74, respectively), the need for a stay in ICU >2 days or death (AUC(ROC) of 0.85, 0.83, and 0.83, respectively), and the massive hemorrhage (AUC(ROC): 0.70, 0.72, and 0.73, respectively). In contrast, MGAP, RTS, T-RTS, and TRISS scores were not predictors of the need of an emergency procedure (AUC(ROC): 0.53, 0.51, and 0.52, respectively). Four independent predictors of emergency procedure were noted: penetrating trauma, intravenous colloid administration >750 mL, systolic arterial blood pressure <100 mm Hg, and heart rate >100 bpm. Prehospital triage scores were predictors of Injury Severity Score >15, prolonged ICU stay, and massive hemorrhage but not of emergency procedure requirement.

Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP): A new simple prehospital triage score to predict mortality in trauma patients*

Prehospital triage of trauma patients is of paramount importance because adequate trauma center referral improves survival. We developed a simple score that is easy to calculate in the prehospital phase. Multicenter prospective observational study. Prehospital physician-staffed emergency system in university and nonuniversity hospitals. We evaluated 1360 trauma patients receiving care from a prehospital mobile intensive care unit in 22 centers in France during 2002. The association of prehospital variables with in-hospital death was tested using logistic regression, and a simple score (the Mechanism, Glasgow coma scale, Age, and Arterial Pressure [MGAP] score) was created and compared with the triage Revised Trauma Score, Revised Trauma Score, and Trauma Related Injury Severity Score. The model was validated in 1003 patients from 2003 through 2005. Four independent variables were identified, and each was assigned a number of points proportional to its regression coefficient to provide the MGAP score: Glasgow Coma Scale (from 3-15 points), blunt trauma (4 points), systolic arterial blood pressure (>120 mm Hg: 5 points, 60 to 120 mm Hg: 3 points), and age <60 yrs (5 points). The area under the receiver operating characteristic curve of MGAP was not significantly different from that of the triage Revised Trauma Score or Revised Trauma Score, but when sensitivity was fixed >0.95 (undertriage of 0.05), the MGAP score was more specific and accurate than triage Revised Trauma Score and Revised Trauma Score, approaching those of Trauma Related Injury Severity Score. We defined three risk groups: low (23-29 points), intermediate (18-22 points), and high risk (<18 points). In the derivation cohort, the mortality was 2.8%, 15%, and 48%, respectively. Comparable characteristics of the MGAP score were observed in the validation cohort. The MGAP score can accurately predict in-hospital death in trauma patients.

Comparison of conservative and operative treatment for blunt carotid injuries: Analysis of the National Trauma Data Bank

Blunt carotid injury (BCI) is uncommon but potentially devastating. The best treatment modality for this injury remains undetermined. We conducted this study to better understand the hospital course and treatment outcomes for patients with BCI who received different interventions. BCI and related vascular procedures were identified by ICD-9-CM codes from the National Trauma Data Bank(1) using data gathered from 2002 to 2006. Conservative and operative treatment groups were compared by variables of patient demographics, initial assessment in the emergency department (ED), hospital course, and treatment outcomes. Open surgical and endovascular interventions were further compared. A total of 842 BCI were identified from 1,633,126 discharged blunt trauma patients (0.05%). Of these, 762 (90.5%) were treated conservatively and 80 (9.5%) received operative intervention. No differences in demographics were observed between these treatment groups. On initial assessment, no differences between conservative and operative treatment groups were noted with regard to vital signs, Glasgow coma scale, presence of drugs or alcohol in blood, or Trauma Related Injury Severity Score survival probability. Significant differences were seen in terms of the presence of a base deficit (-3.1 +/- 6.8 vs -7.6 +/- 8.3; P = .01), likelihood of a positive head computed tomography (CT) scan (58.6% vs 26.1%; P = .003), and total Injury Severity Score (29.8 +/- 13.3 vs 26.1 +/- 14.1; P = .02). Hospital course and treatment outcomes were comparable, with no differences in hospital length of stay (13.4 +/- 15.3 days vs 13.7 +/- 13.6 days; P = .86), total Functional Independence Measure (8.8 +/- 3.3 vs 9.3 +/- 3.1; P = .38), progression of original neurologic insult (7.5% vs 4.6%; P = .61) or mortality (28.1% vs 19%; P = .08). When comparing open surgical to endovascular interventions (46 open, 34 endovascular, including 3 combined), the only significant differences were in the total Injury Severity Score (22.4 +/- 12.2 vs 31.4 +/- 15.4; P = .01) and length of intensive care unit (ICU) and hospital stay (5.0 +/- 6.0 days vs 10.7 +/- 10.4 days; P = .01, and 10.3 +/- 9.2 days vs 19.3 +/- 17.7 days; P = .01). Multivariate regression analysis confirmed that neither Functional Independence Measure (FIM) nor mortality was associated with conservative or operative treatment. BCI is rare and carries a poor prognosis. Operative intervention is not associated with functional improvement or a survival advantage. This study was unable to support that less invasive endovascular treatment improves treatment outcome when compared to open surgery.

Genetic Variation in the Autonomic Nervous System Affects Mortality: A Study of 1,095 Trauma Patients

We have previously demonstrated an unappreciated link between the autonomic nervous system and mortality, heart rate variability, and physiologic complexity. Genetic variation in adrenergic receptors or key enzymes in catecholamine degradation could be associated with, and potentially explain, autonomic nervous system dysfunction and its impact on mortality after severe trauma. Three genetic polymorphisms critical to the adrenergic pathway were evaluated: beta-2 adrenergic receptor (ADBR2: Q27E), alpha-1a adrenergic receptor (ADRA1A:R347C), and catechol-O-methyl transferase (COMT: V158M). The study population consisted of 1,095 trauma admissions between April 2005 and April 2007. These patients all had genotyping performed using mass spectrometric analysis (Sequenom, Inc). The genetic data were linked with detailed demographic and clinical data. Trauma Related Injury Severity Score (TRISS) probability of survival was used as a composite measure of injury severity, admission physiology, and demographic factors in the multivariate logistic regression analyses of mortality outcomes data. The overall mortality rate for the study population was 14.2% (155 of 1,095). Univariate comparisons of genotypes with mortality revealed a significant association with the ADBR2 polymorphism: CC=15.9%, GC=14.8% and GG=7.6%, p=0.02. The apparently protective ADBR2 GG genotype was seen in 15.5% (170 of 1,095) of the study population. In multivariate analysis, which included adjustment for TRISS, the ADBR2 GG genotype was associated with reduced mortality (odds ratio 0.36, p=0.002). Genetic variation in the beta-2 adrenergic receptor (ADBR2:Q27E) associated with bronchial constriction appears protective (odds ratio 0.36), perhaps by making the receptor resistant to downregulation. These genetic data support the emerging understanding of critical role of the autonomic nervous system in the response to injury.

Use of Scene Vital Signs Improves TRISS Predicted Survival in Intubated Trauma Patients

The Trauma Related Injury Severity Score (TRISS) has been previously validated to predict outcomes in nonintubated, nonparalyzed trauma patients. The purpose of this study was to assess the impact of scene vital signs on predicting survival in intubated trauma patients. Our Trauma Registry of the American College of Surgeons was reviewed for all trauma patients admitted between 10/01/04 and 09/30/06, arriving by aeromedical transport. TRISS was evaluated for each patient based on their (1) scene vital signs and (2) arrival vital signs. Additionally, the "TRISS-like" score was calculated for each patient. Expected mortality for each score was measured against observed mortality. Four thousand four hundred ninety-nine Trauma Registry of the American College of Surgeons patients were admitted during the study period; 695 (15%) were transported by air; 163 patients (23%) arrived intubated; 480 arrived nonintubated. Observed survival in the intubated group was 76%. Observed survival in the nonintubated group was 100%. TRISS using scene vital signs more closely predicted mortality among intubated patients than the other scoring systems (69% versus 39% using TRISS-arrival versus 80% using TRISS-like). Scene vital signs with TRISS also resulted in fewer "unexpected" outcomes (survivors and deaths). Traditionally, patients arriving at trauma centers intubated are either excluded from the trauma registry or have their physiological score "modified" to account for pharmacologically altered respiratory rate and Glasgow Coma Scale. In intubated patients, TRISS using scene vital signs more reliably predicts survival and does so with far fewer "unexpected" outcomes than with other available scoring systems.