Trauma Revised Injury Severity Score Research Articles

Revised Trauma Score, Injury Severity Score, New Injury Severity Score and Trauma Revised Injury Severity Score among Trauma Patients in a Tertiary Care Hospital: A Comparative Study

Introduction: Injury severity scoring can provide objective correlations with resource utilisation, such as length of stay and treatment costs, and inform clinical decisions regarding managing injuries of specific severity. The ability to predict survival after trauma is perhaps the most fundamental use of injury severity scoring. Aim: To compare the efficacy of the Injury Severity Score (ISS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), and Trauma Revised Injury Severity Score (TRISS) in the prediction of mortality in trauma patients. Materials and Methods: In this comparative prospective observational study conducted in the Department of General Surgery, SRM Medical College Hospital and Research Centre, Chennai, Tamil Nadu, India from April 2021 to September 2022 in 400 trauma patients who were clinically assessed and managed per the latest Advanced Trauma Life Support (ATLS) guidelines (10th edition). After the stabilisation of the patient, RTS, ISS, NISS and TRISS was obtained from the trauma chart, imaging studies and intraoperative findings. Statistical analysis was done using the statistical software Statistical Package for the Social Sciences (SPSS) version 16.0. Results: Most trauma patients showed more blunt injuries 284 (71.0%) than penetrating injuries 116 (29.0%). The major trauma region was external 161 (40.3%), followed by extremity 124 (31.0%). The mortality rate in this study was 17 (4.3%). The cut-off points for predicting mortality in trauma patients in ISS, RTS, NISS and TRISS systems were 22, 6.8, 28.5, 87.95 with sensitivity of 94.12%, 88.24%, 88.24%, 100.00% and specificity of 94.78%, 94.52%, 92.95%, 95.56%, respectively. Conclusion: According to the current study’s findings, TRISS was a more accurate prognosticator among trauma patients.

IBM WATSON Trauma Pathway Explorer outperforms the TRISS score to predict early death after polytrauma

Abstract Objective In recent years, several big data-based artificial intelligence (AI) systems have found its way in health care, one of which we present here: The IBM WATSON Trauma Pathway Explorer, a visual analytics tool to predict early death in polytrauma patients. The aim of this study was to compare the predictive performance of the Trauma Pathway Explorer for early in-hospital mortality with an established trauma scoring system, the Trauma Revised Injury Severity Score (TRISS). Methods A retrospective comparative accuracy study in a level I trauma center including patients with an Injury Severity Score (ISS) ≥16 and age ≥16 was performed. The compared outcome was early death within 72 hours since admission of the patient. The area under the receiver operating characteristic curve (AUC) was used to measure discrimination. Hosmer-Lemeshow statistics was calculated to analyse calibration of the two predictive models. The Brier score assessed the overall performance of the two models. Results The cohort included 107 polytrauma patients with a death rate of 10.3% at 72 hours since patient admission. The Trauma Pathway Explorer and TRISS showed similar AUCs to predict early death (AUC 0.90, 95% CI 0.79-0.99 vs. AUC 0.88, 95% 0.77-0.97; p = 0.75). The calibration of the Trauma Pathway Explorer was superior to that of TRISS (chi-squared 8.19, Hosmer-Lemeshow p = 0.42 vs. chi-squared 31.93, Hosmer-Lemeshow p < 0.05). The Trauma Pathway Explorer had a lower Brier score than TRISS (0.06 vs. 0.11). Conclusion The IBM WATSON Trauma Pathway Explorer showed equal results in discrimination as TRISS but outperformed in calibration. In addition to being able to provide a prediction of early death, this visual analytics tool for polytrauma patients can also show the quantitative flow of patient sub-cohorts through different events, such as coagulopathy, hemorrhagic shock class, surgical strategy and the above-mentioned outcome. Here, we can present an accurate and valid alternative to TRISS for predicting early death in polytrauma patients.

Correlating injury severity scores and major trauma volume using a state-wide in-patient administrative dataset linked to trauma registry data—A retrospective analysis from New South Wales Australia

IntroductionTrauma registries are used to analyse and report activity and benchmark quality of care at designated facilities within a trauma system. These capabilities may be enhanced with the incorporation of administrative and electronic medical record datasets, but are currently limited by the use of different injury coding systems between trauma and administrative datasets. ObjectivesUse an Abbreviated Injury Scale to International Classification of Disease (AIS-ICD) mapping tool to correlate estimated injury severity scores and major trauma volume based on administrative data collections with trauma registry data. MethodsAdult trauma cases were identified from the New South Wales Trauma Registry between 2012 and 2016 and linked probabilistically using age, facility and date of facility arrival to the Admitted Patient Data Collection (APDC). Estimated Injury Severity Scores (ISS) were derived using the AIS-ICD mapping tool applied to diagnoses contained in the APDC. ResultsA total of eligible 13,439 cases were analysed. The overall correlation between trauma registry ISS and ISS estimated from APDC using the AIS-ICD mapping tool was low to moderate (Spearman Rho 0.41 95%CI 0.40, 0.43). Based on an estimated ISS cut-off value of 8, there was high correlation between estimated trauma volume and the number of major trauma cases at each facility (Spearman Rho 0.98, 95%CI 0.95, 0.99). Trauma Revised Injury Severity Score (TRISS) was associated with only slightly higher mortality prediction performance compared to estimated ISS (AUROC 0.76 95%CI 0.75, 0.78 versus AUROC 0.74 95%CI 0.73, 0.76). ConclusionA low to moderate correlation exists between individual patient ISS scores based on AIS to ICD mapping of in-patient data collection, but a high correlation for overall major trauma volume using the AIS-ICD mapping at facility level with comparable TRISS mortality prediction.

The effect of socioeconomic status on severe traumatic injury: a statistical analysis.

PurposeThe amount of studies performed regarding a link between socioeconomic status (SES) and fatal outcome after traumatic injury is limited. Most research is focused on work-related injuries without taking other important characteristics into account. The aim of this study is to examine the association between SES and outcome after traumatic injury.MethodsThe study involved polytrauma patients [Injury Severity Score (ISS) ≥ 16] admitted to the Amsterdam University Medical Center (location VUmc) and Northwest Clinics Alkmaar (level 1 trauma centers). The SES of every patient was based on their postal code and represented with a “status score”. Univariate and multivariable analyses were performed to estimate the association between SES and mortality, length of stay at the hospital and length of stay at the Intensive Care Unit (ICU). Z-statistics were used to determine the difference between the expected and actual survival, based on Trauma Revised Injury Severity Score (TRISS) and PSNL15 (probability of survival based on the Dutch population).ResultsA total of 967 patients were included in this study. The lowest SES group was significantly associated with more penetrating injuries and a younger age (45 years versus 55 years). Additionally, severely injured patients with lower SES were noted to have a prolonged stay at the ICU. Furthermore, differences were found in the expected and observed survival, especially for the lower SES groups.ConclusionPolytrauma patients with lower SES have more often penetrating injuries, are younger and have a longer stay at the ICU. No association was found between SES and length of hospital stay and neither between SES and mortality.

A study of mortality risk factors among trauma referrals to trauma center, Shiraz, Iran, 2017

PurposeTrauma is well known as one of the main causes of death and disability throughout the world. Identifying the risk factors for mortality in trauma patients can significantly improve the quality of care and patient outcomes, as well as reducing mortality rates. MethodsIn this retrospective cohort study, systematic randomization was used to select 849 patients referred to the main trauma center of south of Iran during a period of six months (February 2017–July 2017); the patients’ case files were evaluated in terms of demographic information, pre- and post-accident conditions, clinical conditions at the time of admission and finally, accident outcomes. A logistic regression model was used to analyze the role of factors affecting mortality among subjects. ResultsAmong subjects, 60.4% were in the age-group of 15–39 years. There was a 10.4% mortality rate among patients and motor-vehicle accidents were the most common mechanism of injury (66.7%). Aging led to increased risk of fatality in this study. For each unit increase in Glasgow coma scale (GCS), risk of death decreased by about 40% (odds ratio (OR) = 0.63, 95% confidence interval (CI): 0.59–0.67). For each unit increase in injury severe score (ISS), risk of death increased by 10% (OR = 1.11%, 95% CI: 1.08–1.14) and for each unit increase in trauma revised injury severity score (TRISS), there was 18% decrease in the risk of fatality (OR = 0.82, 95% CI: 0.71–0.88). ConclusionThe most common cause of trauma and the most common cause of death from trauma was traffic accidents. It was also found that an increase in the ISS index increases the risk of death in trauma patients, but the increase in GCS, revised trauma score (RTS) and TRISS indices reduces the risk of death in trauma patients. The TRISS indicator is better predictor of traumatic death than other indicators.

Tranexamic Acid: Promise or Panacea

The MATTERs and CRASH-2 studies demonstrate that tranexamic acid (TXA) reduces mortality in patients with traumatic hemorrhage. However, their results, conducted in foreign countries and with U.S. military soldiers, provoke concerns over generalizability to civilian trauma patients in the United States was reported. The evaluation of patient outcomes following treatment with TXA by a civilian air medical program. A retrospective chart review of trauma patients transported by air service to a Level 1 trauma center was conducted. For the purposes of intervention evaluation, patients meeting this criterion for the 2 years (2012-2014) prior to therapy implementation were compared with patients treated during the 2-year study period (2014-2016). Goals were to evaluate morbidity, mortality, and length of stay. During the review, 82 control and 49 study patients were identified as meeting inclusion criteria. Patients in the control group were found to be less acute, which correlated with shorter hospital stays and better discharge outcomes. Multiple patients in the study group who should have expired according to a significantly elevated Trauma Revised Injury Severity Score (TRISS) survived, whereas multiple patients in the control group expired despite a low TRISS calculation. This is the first outcome-based study conducted in a U.S. trauma system. The outcomes in civilian trauma patients in the United States do not follow that of the previous MATTERs and CRASH-2 studies. However, this study still shows benefit to TXA administration and reduced risk for administration to patients with head trauma and occurrence of venous thromboembolism. Randomized control trials are needed to evaluate the role of TXA administration in the United States.

Tracheobronchial injuries in chest trauma: a 17-year experience.

to discuss the clinical and therapeutic aspects of tracheobronchial lesions in victims of thoracic trauma. we analyzed the medical records of patients with tracheobronchial lesions treated at the São Paulo Holy Home from April 1991 to June 2008. We established patients' severity through physiological (RTS) and anatomical trauma indices (ISS, PTTI). We used TRISS (Trauma Revised Injury Severity Score) to evaluate the probability of survival. nine patients had tracheobronchial lesions, all males, aged between 17 and 38 years. The mean values ​​of the trauma indices were: RTS - 6.8; ISS - 38; PTTI - 20.0; and TRISS - 0.78. Regarding the clinical picture, six patients displayed only emphysema of the thoracic wall or the mediastinum and three presented with hemodynamic or respiratory instability. The time interval from patient admission to diagnosis ranged from one hour to three days. Cervicotomy was performed in two patients and thoracotomy, in seven (77.7%), being bilateral in one case. Length of hospitalization ranged from nine to 60 days, mean of 21. Complications appeared in four patients (44%) and mortality was nil. tracheobronchial tree trauma is rare, it can evolve with few symptoms, which makes immediate diagnosis difficult, and presents a high rate of complications, although with low mortality.

Emergency thoracotomy: Experience of one year in a large tertiary trauma center

IntroductionEmergency thoracotomy (ET) can be a life-saving procedure in highly selected trauma patients, especially after penetrating chest trauma. The aim of this work was to evaluate the outcome in trauma patients who were admitted to the Alexandria Main University Hospital (AMUH) during 1 year period and underwent ET as a management and to compare our results with that documented in the literature. Patients and methodsThis is prospective clinical study included trauma patients who were admitted to AMUH during 1 year period (August 2013–August 2014) and underwent ET. Analysis of the cause of trauma, age, sex, different tools of investigations used, concomitant organ injuries, systolic blood pressure (SBP), Glasgow Coma Scale (GCS), Injury Severity Score (ISS), Trauma Revised Injury Severity Score (TRISS) and mortality rate were performed. ResultsTwenty-two patients who had ET were included in this study (All were males, Age range: 5–45 years; median: 23.5 ± 7.83 years). Twenty patients from twenty-two were survived. Two of them had blunt trauma while 18 had penetrating injuries. The most frequent injury encountered was isolated thoracic injury (n=13). Thoracotomy was performed in 20 patients, sternotomy in two, and one patient underwent additional laparotomy. Median ISS and TRISS were 10 (Range 9–29) and 0.98 (Range 0.54–0.99), respectively. Blood transfusion ranged between 1 and 13 units with a median of 2 units of packed red blood cells. The median time from admission to operating room was 37.50 min. Pre-operative (FAST & Thoracic Ultrasound) was done in 90.9% of patients. Most common indication for thoracotomy was shock (SBP < 90). The mortality rate was 9.1% for all patients and 10% for patients with penetrating trauma. Factors affecting mortality was ISS and the amount of blood transfusion. ConclusionET procedure is an important tool in management of selected trauma patients. Rapid assessment, multidisciplinary approach, good resuscitation and prompt surgical intervention reduce the mortality and improve the outcome.

Prediction of intra-hospital mortality after severe trauma: which pre-hospital score is the most accurate?

Computing trauma scores in the field allows immediate severity assessment for appropriate triage. Two pre-hospital scores can be useful in this context: the Triage-Revised Trauma Score (T-RTS) and the Mechanism, Glasgow, Age and arterial Pressure (MGAP) score. The Trauma Revised Injury Severity Score (TRISS), not applicable in the pre-hospital setting, is the reference score to predict in-hospital mortality after severe trauma. The aim of this study was to compare T-RTS, MGAP and TRISS in a cohort of consecutive patients admitted in the Trauma system of the Northern French Alps(TRENAU). From 2009 to 2011, 3260 patients with suspected severe trauma according to the Vittel criteria were included in the TRENAU registry. All data necessary to compute T-RTS, MGAP and TRISS were collected in patients admitted to one level-I, two level-II and ten level-III trauma centers. The primary endpoint was death from any cause during hospital stay. Discriminative power of each score to predict mortality was measured using receiver operating curve (ROC) analysis. To test the relevancy of each score for triage, we also tested their sensitivity at usual cut-offs. We expected a sensitivity higher than 95% to limit undertriage. The TRISS score showed the highest area under the ROC curve (0.95 [CI 95% 0.94-0.97], p<0.01). Pre-hospital MGAP score had significantly higher AUC compared to T-RTS (0.93 [CI 95% 0.91-0.95] vs 0.86 [CI 95% 0.83-0.89], respectively, p<0.01). MGAP score<23 had a sensitivity of 88% to detect mortality. Sensitivities of T-RTS<12 and TRISS<0.91 were 79% and 87%, respectively. Pre-hospital calculation of the MGAP score appeared superior to T-RTS score in predicting intra-hospital mortality in a cohort of trauma patients. Although TRISS had the highest AUC, this score can only be available after hospital admission. These findings suggest that the MGAP score could be of interest in the pre-hospital setting to assess patients' severity. However, its lack of sensitivity indicates that MGAP should not replace the decision scheme to direct the most severe patients to level-I trauma center.

Comparison of trauma scores for predicting mortality and morbidity on trauma patients.

In this study, we compared the anatomical, and physiological scoring systems trauma revised injury severity score (TRISS), revised trauma score (RTS), injury severity score (ISS), new injury severity score (NISS) to each other, to find out the most accurate and reliable trauma score for the risk classification of morbidity and mortality among the trauma patients. This is a cross-sectional study, which included 633 patients who admitted to our University Hospital Emergency Department during an 8-month period due to trauma. All blunt and penetrating traumas (traffic accident, assault, etc.) patients above 16 years were included. Arrival time trauma scores (ISS, NISS, RTS, and TRISS) of the patients was calculated. Mean trauma score for the mortality prediction was calculated, and the p value was equal for all (p=0.001). Trauma scores were also analyzed for the hospitalization time in intensive care unit (ICU). While NISS, RTS, and TRISS values were significant (p=0.048, p=0.048, and p=0.017, respectively), ISS value was not significant (p=0.257) for predicting the ICU hospitalization time. Only TRISS was a good predictor for the mechanically ventilation time in ICU patients (p=0.01). In conclusion, we determined that the anatomical trauma scores (NISS, ISS) predicted the hospitalization and ICU necessities better, whereas TRISS, an anatomo-physiological trauma score, defined the ICU hospitalization and mechanically ventilation time better.

Impact de la mise en place d’un réseau de soins en traumatologie sur la mortalité des patients traumatisés graves du bassin

AimTo evaluate the impact of a regional trauma network on intra-hospital mortality rates of patients admitted with severe pelvic trauma. StudyRetrospective observational study. PatientsSixty-five trauma patients with serious pelvic fracture (pelvic abbreviated injury scale [AIS] score of 3 or more). MethodsDemographic, physiologic and biological parameters were recorded. Observed mortality rates were compared to predicted mortality according to the Trauma Revised Injury Severity Score methodology adjusted by a case mix variation model. ResultsTwenty-nine patients were admitted in a level I trauma centre (reference centre) and 36 in level II trauma centres (centres with interventional radiology facility and/or neurosurgery). Patients from the level I trauma centre were more severely injured than those who were admitted at the level II trauma centres (Injury Severity Score [ISS]: 30 [13–75] vs 22 [9–59]; P<0.01). Time from trauma to hospital admission was also longer in level I trauma centre (115 [50–290] min vs 90 [28–240] min, P <0.01). Observed mortality rates (14%; 95% confidence interval, 95% CI, [1–26%]) were lower than the predicted mortality (29%; 95% CI [13–44%]) in the level I trauma centre. No difference in mortality rates was found in the level II trauma centres. ConclusionThe regional trauma network could screen the most severely injured patients with pelvic trauma to admit them at a level I trauma centre. The observed mortality of these patients was lower than the predicted mortality despite increased time from trauma to admission.

Major trauma deaths at Perth secondary hospitals

Some major trauma (Injury Severity Score [ISS] >15) patients transported to a secondary hospital in Perth do not survive. We sought to describe this cohort and assess preventability. A cohort study from a previously developed cohort of trauma deaths in Western Australia from 1 July 1997 to 30 June 2006. A preformatted data sheet was used to collect a range of descriptive, time, physiological, and autopsy data. Trauma scores were calculated. Preventability was assessed using three approaches, based on ISS, Trauma Revised Injury Severity Score (TRISS) and individual case review. There were 74 major trauma deaths, mean age 55.6 ± 26.3 years (range 3-95). Thirty-seven (50%) were motor vehicle crashes. The mean Revised Trauma Score was 3.84 ± 3.09 (0-7.84), median ISS 31 (interquartile range [IQR] 25-51), median TRISS 0.127 (IQR 0.031-0.772) and median time to death was 80 min (IQR 20 min-10 h 8 min). Severe head and chest injuries were the most common. Almost half (36, 48.6%) were receiving CPR on arrival to the hospital. The crude proportion of potentially preventable deaths, based on ISS, TRISS and case review, were 16.2%, 32.4% and 6.7%, respectively. However, these were predominantly elderly patients and a decision against resuscitation was recorded in 54%. The proportion of potentially preventable major trauma deaths at Perth secondary hospitals is low. The most notable group were the elderly after falls, and trauma system efforts should be focused on this group. Primary prevention of major trauma represents the biggest opportunity for improvements in trauma survival.

Blood product use in trauma resuscitation: plasma deficit versus plasma ratio as predictors of mortality in trauma (CME)

Resuscitation of rapidly bleeding trauma patients with units of red blood cells (RBCs) and plasma given in a 1:1 ratio has been associated with improved outcome. However, demonstration of a benefit is confounded by survivor bias, and past work from our group has been unable to demonstrate a benefit. We identified 438 adult direct primary trauma admissions at risk for massive transfusion who received 5 or more RBC units in the first 24 hours and had a probability of survival of 0.010 to 0.975. We correlated survival with RBC and plasma use by hour, both as a ratio (units of plasma/units of RBC) and as a plasma deficit (units of RBC - units of plasma) in the group as a whole and among those using 5 to 9 and more than 9 units of RBCs. Resuscitation was essentially complete in 58.3% by the end of the third hour and 77.9% by the end of the sixth hour. Mortality by hour was significantly associated with worse plasma deficit status in the first 2 hours of resuscitation (p < 0.001 and p < 0.01) but not with plasma ratio. In a subgroup with a Trauma Revised Injury Severity Score of 0.200 to 0.800, early plasma repletion was associated with less blood product use independently of injury severity (p < 0.001). 1) The efficacy of plasma repletion plays out in the first few hours of resuscitation, 2) plasma deficit may be a more sensitive marker of efficacy in some populations, and 3) early plasma repletion appears to prevent some patients from going on to require massive transfusion.

High concentrations of circulating macrophage migration inhibitory factor in patients with severe blunt trauma: Is serum macrophage migration inhibitory factor concentration a valuable prognostic factor?

To determine serum concentrations of macrophage migration inhibitory factor and other cytokines in severe blunt trauma patients in critical settings and to evaluate their association with patient outcome. Prospective, observational study. Emergency department and surgical intensive care unit of a university hospital. Fifty-four severe blunt trauma patients with systemic inflammatory response syndrome requiring intensive care, emergency surgical intervention, or both were enrolled in the study. Forty-four patients with minor injuries were the controls. Serum macrophage migration inhibitory factor concentrations were measured in the emergency department <4 hrs postinjury (day 1) and the surgical intensive care unit 24 hrs later (day 2). Blood samples for determination of tumor necrosis factor-alpha, interleukin-6, interleukin-8, and interleukin-10 were measured both in patients with severe blunt trauma and in controls. The Acute Physiology and Chronic Health Evaluation II, Injury Severity Score, Revised Trauma Score, and Trauma Revised Injury Severity Score were used for clinical evaluation of trauma severity. Serum macrophage migration inhibitory factor concentrations were higher in severe blunt trauma patients than in controls; were significantly correlated with Acute Physiology and Chronic Health Evaluation II, Revised Trauma Score, and Trauma Revised Injury Severity Score scores in severe blunt trauma patients but not in controls; and were higher in nonsurvivors than in survivors. Our data suggest that the serum macrophage migration inhibitory factor concentration is higher in severe blunt trauma and that it reflects the severity of trauma. The serum macrophage migration inhibitory factor concentration might be a valuable predictor for the outcome of severe blunt trauma.

Correlation of serial blood lactate levels to organ failure and mortality after trauma

To define the value of serial measurements of blood lactate levels after trauma, the present study investigated the correlation between blood lactate, mortality, and organ failure in 129 trauma patients, including 100 intensive care unit (ICU) survivors and 29 ICU fatalities. On admission, injury severity score (ISS) was higher and Glasgow coma score (GCS), revised trauma score (RTS), and trauma revised ISS (TRISS) were lower in the nonsurvivors than in the survivors. Serial arterial blood lactate levels were measured on admission and at least three times a day until normalization. Both initial lactate and highest lactate levels were higher in the nonsurvivors than in the survivors. Organ failure developed in 84 (65%) of the 129 patients. Patients with organ failure had significantly lower RTS and TRISS. Initial lactate and highest lactate levels were significantly higher in patients with organ failure than without organ failure (3.4 [0.7 to 12.7] versus 2.4 [0.4 to 7.6] mEq/L and 4.1 [0.7 to 12.7] versus 2.8 [0.4 to 8.9] mEq/L, respectively, both P < .01). The duration of hyperlactatemia averaged 2.2 days in the former but 1.0 day in the latter patients ( P < .01). The data therefore indicate that not only the initial or the highest lactate value but also the duration of hyperlactatemia can be correlated with the development of organ failure. These observations stress the importance of the initial resuscitation in the prevention of organ failure. Serial blood lactate measurements are reliable indicators of morbidity and mortality after trauma.