Triage Revised Trauma Score Research Articles

Trauma Scores Show Limited Utility for Predicting In-Flight Deterioration in Air Medical Patients

ObjectiveThe aim of this study was to determine the utility of the Triage Revised Trauma Score (TRTS), Glasgow Coma Scale/Age/systolic Pressure (GAP) score, and Shock Index (SI) in predicting in-flight hypotension and the need for critical care interventions in air medical trauma patients. MethodsA retrospective review of 3,582 air medical trauma cases from a 3-year period in Queensland was conducted. An initial TRTS, GAP score, and SI were calculated for each patient, and the lowest in-flight mean arterial pressure and systolic blood pressure were determined. The institution of in-flight critical care interventions was also recorded, including fluid resuscitation, vasopressors, and surgical procedures. The utility of the TRTS, GAP score, and SI for predicting in-flight hypotension was then examined using receiver operating characteristic curves. ResultsAll 3 approaches showed minor predictive value, with the GAP score performing slightly better than TRTS and SI for predicting in-flight interventions. The GAP score had a receiver operating characteristic area under the curve of 0.76 compared with 0.74 for the TRTS and SI. ConclusionNo score demonstrated sufficient predictive ability for deterioration in transit to be used clinically.

The shock index predicts in-flight blood transfusion in aeromedical trauma patients.

To define the utility of the Triage Revised Trauma Score (TRTS), GCS/Age/arterial Pressure (GAP) score, and shock index (SI) in predicting the need for in-flight blood product administration in civilian trauma patients transported by an aeromedical platform. A retrospective chart review of 3582 aeromedical trauma cases was conducted. An initial TRTS, GAP score and SI were calculated for each patient, and the administration of in-flight blood products was also recorded. Receiver operating characteristic (ROC) curves were used to quantify the predictive discrimination of the TRTS, GAP score and SI on the need for in-flight blood product administration. The SI showed a superior predictive value compared to the TRTS and GAP score. The SI showed an area under the curve on the ROC curve of 0.85 in both primary and inter-hospital transfer cases, indicating reasonable predictive value. The SI demonstrates favourable test characteristics for predicting the need for in-flight blood product administration. Prospective validation of these results is warranted.

Reverse Shock Index multiplied by Glasgow Coma Scale score as a point-of-care severity assessment for initial trauma management: a nationwide cohort study

BackgroundSevere trauma patients often require emergent interventions, such as massive transfusion, resuscitative procedures, and surgical procedures, and consume considerable human and medical resources. However, few practical indices can be easily used for emergent interventions. In recent years, it has become clear that rSIG (Reverse Shock Index multiplied by Glasgow Coma Scale [GCS] score), which can be easily calculated from vital signs, is a promising predictor of mortality. However, it is unclear whether rSIG is useful for emergent interventions. MethodsData collected by the Japan Trauma Data Bank for adult patients admitted directly from the scene of trauma between April 2019 and December 2020 were analysed. The outcomes were massive transfusion, resuscitative procedures, surgical procedures and emergent interventions. Emergent interventions were defined as the composite outcome of massive transfusion, resuscitative procedures, and surgical procedures. The ability of rSIG to predict massive transfusion was compared with that of the ABC score and FASILA score by receiver-operating characteristic curve analysis. The ability of rSIG to predict resuscitative and surgical procedures was compared with that of the Shock Index (SI), GCS, Triage Revised Trauma score (T-RTS), and Previous Simple Prediction (PSP) score. The ability of rSIG to predict emergent interventions was compared with that of T-RTS, PSP, ABC, and FASILA. In addition to rSIG, rSIM (Reverse Shock Index multiplied by best motor response score) was also analysed as a supplement. ResultsThe study included 32,201 patients, 6,371 of whom required emergent interventions. The area under the receiver-operating characteristic curve (AUROC) for massive transfusion was highest for rSIG (0.846 [95% confidence interval 0.832–0.859]) and significantly higher for rSIG than for rSIM, ABC and FASILA (all p<0.0001). AUROCs for resuscitative and surgical procedures were highest for rSIG (0.777 [0.769–0.785] and 0.731 [0.720–0.741], respectively) and significantly higher than those for rSIM, SI, GCS, T-RTS, and PSP (all p<0.0001). The AUROC for emergent interventions was highest for rSIG (0.760 [0.753–0.768]) and significantly higher for rSIG than for rSIM, T-RTS, PSP, ABC, or FASILA (all p<0.0001). ConclusionsrSIG is a simple and effective point-of-care predictor of emergent interventions during initial management of trauma.

Assessment of earthquake casualties and comparison of accuracy of five injury triage methods: evidence from a retrospective study

ObjectiveThe use of an injury triage method among earthquake injury patients can facilitate the reasonable allocation of resources, but the various existing injury triage methods need further confirmation. This study...

Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma.

This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma. This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient's death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score. Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001. Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.

Validation of the Pediatric Physiological and Anatomical Triage Score in Injured Pediatric Patients.

Triaging plays an important role in providing suitable care to a large number of casualties in a disaster setting. A Pediatric Physiological and Anatomical Triage Score (PPATS) was developed as a new secondary triage method. This study aimed to validate the accuracy of the PPATS in identifying injured pediatric patients who are admitted at a high frequency and require immediate treatment in a disaster setting. The PPATS method was also compared with the current triage methods, such as the Triage Revised Trauma Score (TRTS). A retrospective review of pediatric patients aged ≤15 years, registered in the Japan Trauma Data Bank (JTDB) from 2012 through 2016, was conducted and PPATS was performed. The PPATS method graded patients from zero to 22, and was calculated based on vital signs, anatomical abnormalities, and the need for life-saving interventions. It categorized patients based on their priority, and the intensive care unit (ICU)-indicated patients were assigned a PPATS ≥six. The accuracy of PPATS and TRTS in predicting the outcome of ICU-indicated patients was compared. Of 2,005 pediatric patients, 1,002 (50%) were admitted to the ICU. The median age of the patients was nine years (interquartile range [IQR]: 6-13 years). The sensitivity and specificity of PPATS were 78.6% and 43.7%, respectively. The area under the receiver-operating characteristic (ROC) curve (AUC) was larger for PPATS (0.61; 95% confidence interval [CI], 0.59-0.63) than for TRTS (0.57; 95% CI, 0.56-0.59; P &lt;.01). Regression analysis showed a significant correlation between PPATS and the Injury Severity Score (ISS; r2 = 0.353; P &lt;.001), predicted survival rate (r2 = 0.396; P &lt;.001), and duration of hospital stay (r2 = 0.252; P &lt;.001). The accuracy of PPATS for injured pediatric patients was superior to that of current secondary triage methods. The PPATS method is useful not only for identifying high-priority patients, but also for determining the priority ranking for medical treatments and evacuation.

Validation of the Pediatric Physiological and Anatomical Triage Score in Pediatric Patients with Burn Injuries

Introduction:Triaging plays an important role in providing suitable care to the largest number of casualties in a disaster setting. We developed the Pediatric Physiological and Anatomical Triage score (PPATS) as a new secondary triage method.Aim:This study was performed to validate the accuracy of the PPATS in pediatric patients with burn injuries.Methods:A retrospective review of pediatric patients with burn injuries younger than 15 years old registered in the Japan Trauma Databank from 2004 to 2016 was conducted. The PPATS, which was assigned scores from 0 to 22, was calculated based on vital signs, anatomical abnormalities, and need for life-saving intervention. The PPATS categorized the patients by their priority and defined the intensive care unit (ICU)-indicated patients as those with PPARSs more than 6. This study compared the accuracy of prediction of ICU-indicated patients between the PPATS and Triage Revised Trauma Score (TRTS).Results:Among 87 pediatric patients, 62 (71%) were admitted to the ICU. The median age was 3 years (interquartile range: 1 to 9 years old). The sensitivity and specificity of the PPATS were 74% and 36%, respectively. The area under the receiver-operating characteristic curve was not different between the PPTAS [0.51 (95% confidence interval: -0.51–1.48) and the TRTS [0.51 (-1.17–1.62), p=0.57]. Regression analysis showed a significant association between the PPATS and the Injury Severity Score (ISS) (r2=0.39, p&lt;0.01). On the other hand, there is no association between the TRTS and the ISS (r2=0.00, p=0.79).Discussion:The accuracy of the PPATS was not superior to that of current secondary-triage methods. However, the PPATS had the advantage of objectively determining the triage priority ranking based on the severity of the pediatric patients with burn injuries.

Evaluation and Comparison of Different Prehospital Triage Scores of Trauma Patients on In-Hospital Mortality

Introduction: Several prehospital major trauma patient triage scores have been developed, the triage revised trauma score (T-RTS), Vittel criteria, Mechanism/Glasgow Coma Scale/Age/Systolic blood pressure score (MGAP), and the new trauma score (NTS). These scoring schemes allow a rapid and accurate prognostic assessment of the severity of potential lesions. The aim of our study was to compare these scores with in-hospital mortality predictions in a cohort of consecutive trauma patients admitted in a Level 1 trauma center. Materials: Between 2013 and 2016, 1,112 patients were admitted to the "major trauma" spinneret of a Level 1 trauma center in the south of France. All prehospital data needed to calculate the T-RTS, Vittel criteria, the MGAP score, and the NTS were collected. The main evaluation criterion was in-hospital mortality at 30 days for all causes. The predictive performances of these scores were evaluated and compared with each other using the analysis of the receiver operating curves. Results: A total of 1,001 patients were included in the analysis, 238 (24%) females, aged 43 ± 19 years with ISS 15 ± 13. The area under the curve was for each score: T-RTS, AUC = 0.84, [0.82–0.87]; Vittel criteria, AUC = 0.87 [0.85–0.89]; MGAP score, AUC = 0.91 [0.89–0.92] and NTS, AUC = 0.90 [0.88–0.92]. By comparing the ROC curves of these scores, the MGAP and NTS scores were statistically higher than the T-RTS. With the current thresholds, the sensitivity, specificity, positive and negative predictive values of these scores were 91%, 35%, 10%, 98% for T-RTS, 100%, 2%, 8%, 100% for Vittel criteria, 91%, 71%, 24%, 99% for MGAP score, 82%, 86%, 33%, 98% for NTS. Only Vittel's criteria allowed undertriage below 5% as recommended by the American College of Surgeons Committee on Trauma (ACSCOT). Conclusion: The comparison of these different triage scores concluded with a superiority of the MGAP and NTS scores compared with the T-RTS. Including the calculation of MGAP or NTS scores with the Vittel criteria would reduce the risk of overtriage in the Level 1 trauma centers by further directing patients at low risk of death to a lower-level trauma facility.

A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services.

This is a retrospective study of patients who sustained a midshaft femur fracture in the absence of multiple other severe injuries or severe physiologic derangement, as defined by an injury severity score (ISS) <20 and a triage revised trauma score (T-RTS)≥10, who presented to an urban, Level 1 trauma center between September 2008 and September 2013. The EMS patient care reports were assessed for physical exam findings and treatment modality. Data were analyzed descriptively and statistical differences were assessed using odds ratios and Z-score with significance set at P≤.05. There were 170 patients studied in the cohort. The most common physical exam finding was a deformity +/- shortening and rotation in 136 patients (80.0%), followed by gunshot wound (GSW) in 22 patients (13.0%), pain or tenderness in four patients (2.4%), and no findings consistent with femur fracture in three patients (1.7%). The population was dichotomized between trauma type: blunt versus penetrating. Of 134 blunt trauma patients, 50 (37.0%) were immobilized in traction, and of the 36 penetrating trauma victims, one (2.7%) was immobilized in traction. Statistically significant differences were found in the application of a TS in blunt trauma when compared to penetrating trauma (OR=20.83; 95% CI, 2.77-156.8; P <.001). Intravenous analgesia was administered to treat pain in only 35 (22.0%) of the patients who had obtainable IV access. Of these patients, victims of blunt trauma were more likely to receive IV analgesia (OR=6.23; 95% CI, 1.42-27.41; P=.0067). Although signs of femur fracture are recognized in the majority of cases of midshaft femur fracture, only 30% of patients were immobilized using a TS. Statistically significant differences were found in the utilization of a TS and IV analgesia administration in the setting of blunt trauma when compared to penetrating trauma. Nackenson J , Baez AA , Meizoso JP . A descriptive analysis of traction splint utilization and IV analgesia by Emergency Medical Services.Prehosp Disaster Med. 2017;32(6):631-635.

The effect of early psychological symptom severity on long-term functional recovery: A secondary analysis of data from a cohort study of minor injury patients

BackgroundThe mental health consequences of injuries can interfere with recovery to pre-injury levels of function and long term wellbeing. ObjectivesThe purpose of this study was to explore the relationship between psychological symptoms after minor injury and long-term functional recovery and disability. DesignThis exploratory study uses secondary data derived from a longitudinal cohort study of psychological outcomes after minor injury. SettingParticipants were recruited from the Emergency Department of an urban hospital in the United States. ParticipantsA cohort of 275 patients was randomly selected from 1100 consecutive emergency department admissions for minor injury. Potential participants were identified as having sustained minor injury by the combination of three standard criteria including: presentation to the emergency department for medical care within 24h of a physical injury, evidence of anatomical injury defined as minor by an injury severity score between 2 and 8 and normal physiology as defined by a triage-Revised Trauma Score of 12. Patients with central nervous system injuries, injury requiring medical care in the past 2 years and/or resulting from domestic violence, and those diagnosed with major depression or psychotic disorders were excluded. MethodsPsychological symptom severity was assessed within 2 weeks of injury, and outcome measures for functional limitations and disability were collected at 3, 6 and 12 months. A quasi-least squares approach was used to examine the relationship between psychological symptom scores at intake and work performance and requirement for bed rest in the year after injury. ResultsAdjusting for demographic and injury covariates, depression symptoms at the time of injury predicted (p≤0.05) both poorer work performance and increased number of days in bed due to health in the year after injury. Anxiety symptoms predicted (p≤0.05) bed days at 3, 6, and 12 months and work performance at 3 months. ConclusionsDepression and anxiety soon after minor injury may help predict important markers of long-term recovery. With further research, simple assessment tools for psychological symptoms may be useful to screen for patients who are at higher risk for poor long-term recoveries and who may benefit from targeted interventions.

Shock Index as a Triage Tool Compared with the Triage Revised Trauma Score

Shock Index as a Triage Tool Compared with the Triage Revised Trauma Score

Mortality among head trauma patients taking preinjury antithrombotic agents: a retrospective cohort analysis from a Level 1 trauma centre

BackgroundBleeding represents the most well-known and the most feared complications caused by the use of antithrombotic agents. There is, however, limited documentation whether pre-injury use of antithrombotic agents affects outcome after head trauma. The aim of this study was to define the relationship between the use of preinjury antithrombotic agents and mortality among elderly people sustaining blunt head trauma.MethodsA retrospective cohort analysis was performed on the hospital based trauma registry at Oslo University Hospital. Patients aged 55 years or older sustaining blunt head trauma between 2004 and 2006 were included. Multivariable logistic regression analyses were used to identify independent predictors of 30-day mortality. Separate analyses were performed for warfarin use and platelet inhibitor use.ResultsOf the 418 patients admitted with a diagnosis of head trauma, 137 (32.8 %) used pre-injury antithrombotic agents (53 warfarin, 80 platelet inhibitors, and 4 both). Seventy patients died (16.7 %); 15 (28.3 %) of the warfarin users, 12 (15.0 %) of the platelet inhibitor users, and two (50 %) with combined use of warfarin and platelet inhibitors, compared to 41 (14.6 %) of the non-users. There was a significant interaction effect between warfarin use and the Triage Revised Trauma Score collected upon the patients’ arrival at the hospital. After adjusting for potential confounders, warfarin use was associated with increased 30-day mortality among patients with normal physiology (adjusted OR 8,3; 95 % CI, 2.0 to 34.8) on admission, but not among patients with physiological derangement on admission. Use of platelet inhibitors was not associated with increased mortality.ConclusionsThe use of warfarin before trauma was associated with increased 30-day mortality among a subset of patients. Use of platelet inhibitors before trauma was not associated with increased mortality. These results indicate that patients on preinjury warfarin may need closer monitoring and follow up after trauma despite normal physiology on admission to the emergency department.

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.

Influence of prehospital response times in the survival of trauma patients in Navarre

The relation between response times and mortality of polytrauma patients in the so-called "golden hour" continues to be a subject of debate. The purpose of this study is to determine the variables related to mortality in these patients and the influence of response times of the Emergency Medical Services in this mortality. To this end, the data in the "Major Trauma of Navarre" Register (retrospective cohort of polytrauma patients attended to by the Navarre Health Service) were analyzed for the four year period between 2010 and 2013. Of the 217 trauma cases available for the analysis, 42 (19%) died. No significant association was found in the multi-variate analysis between the different response times and mortality: arrival at the scene (odds ratio (OR) 1.0; 95% confidence interval (CI) from 0.99 to 1.01), in the scenario (OR 1.00; 95% CI from 0.98 to 1.02) and total time (OR 1.00; 95% CI from 0.99 to 1.01). The variables that influenced mortality are patient age and severity of injuries measured by the prehospital Triage-Revised Trauma Score (T-RTS) and the New Injury Severity Score (NISS). The mortality of polytrauma patients attended to by the emergency system in our region is influenced by age and by the intensity of the aggression suffered, determined by the prehospital T-RTS and by the NISS. The response times of the hospital do not have a significant influence.

Injectable hemostatic adjuncts in trauma: Fibrinogen and the FIinTIC study.

F adequate hemostasis, sufficient amounts of thrombin and coagulable substrate are fundamental prerequisites. In addition to platelets, on whose surfaces most of the thrombin is generated, fibrinogen can be considered as the substrate of the coagulation process. If sufficient thrombin is formed, it converts fibrinogen into stable fibrin, which determines the firmness of the developing clot in the presence of activated coagulation factor XIII (Fig. 1). Under physiologic conditions, fibrinogen availability is regulated through dynamic changes in synthesis and breakdown to preserve coagulation function. As a consequence of blood loss, consumption of coagulation factors, dilutional coagulopathy, hypothermia and acidosis, as well as profibrinolytic activation, fibrinogen may reach critical levels earlier than any other procoagulant factor and also platelets even before packed red blood cell concentrate administration becomes necessary. Floccard et al. have described even significant drops in fibrinogen levels to occur already during the ultra early prehospital phase of care when comparing blood samples obtained from bleeding trauma patients at the scene and at the time point of arrival to the trauma bay (fibrinogen median, 2.6 g/L; interquartile range [IQR], 2.3Y3.1; 95% confidence interval [CI], 2.4Y2.9 vs. 2.1 g/L; IQR, 1.4Y2.5; 95% CI, 1.7Y2.3) (changes, j0.6 g/L; IQR, j1.1 to j0.3; 95%CI,j0.9 toj0.3;pG 0.001). In this study, fibrinogen levels decreased substantially as a function of injury severity reflected by Injury Severity Scores (ISSs). Recently, Kimura et al. have reported similar results when searching retrospectively for predictors of hypofibrinogenemia in 290 blunt traumapatients upon admission to aLevel 1 trauma center during a 3-year period. Their multivariate regression analysis identified patient’s age (odds ratio [OR], 0.97; p G 0.001), Triage Revised Trauma Score (T-RTS including Glasgow Coma Scale [GCS] score, respiratory rate, and systolic blood pressure; OR, 0.81; p = 0.003), and prehospital volume therapy (OR, 2.54; p = 0.01) as independent predictors for early hypofibrinogenemia. In contrast todisseminated intravascular coagulopathy, there is no generalized intravascular microcoagulation with increased consumption in trauma-induced coagulopathy. Instead, there is hemorrhage-related loss of coagulation factors and platelets with subsequent dilution of procoagulant factors due to (uncritical) volume resuscitation with direct effect on fibrinogen polymerization. Dilution of fibrinogen by crystalloid fluids and additional reduced fibrin interlinkage by synthetic colloids has been discussed. Recently, experimental data confirmed significant fibrinogen breakdown by acidosis following hypoperfusion with no effect on fibrinogen synthesis, while hypothermia decreased fibrinogen synthesis with no effect on fibrinogen degradation. Furthermore, synthesis and degradation seem to be regulated through different mechanisms, and a potential deficit in fibrinogen availability during hypothermia has been suggested.

Predictors of hypofibrinogenemia in blunt trauma patients on admission.

Massive bleeding usually leads to critically low levels of clotting factors, including fibrinogen. Although reduced fibrinogen levels correlate with increased mortality, predictors of hypofibrinogenemia have remained poorly understood. We investigated whether findings available on admission can be used as predictors of hypofibrinogenemia. We retrospectively reviewed serum fibrinogen levels tested on arrival in 290 blunt trauma patients transported to a level I trauma center during a 3-year period. The primary outcome was prehospital predictors for hypofibrinogenemia. Covariates included age, sex, prehospital fluid therapy, prehospital anatomical and physiological scores, time from injury, base excess, and lactate on arrival. All variables with values of p<0.10 in univariate analysis were included in a multivariate logistic regression model. The relationships between the variables and the 7-day mortality rate were evaluated in a Cox proportional hazards model. Patient's age [odds ratio (OR): 0.97, p<0.001], Triage Revised Trauma Score (T-RTS) (OR: 0.81, p=0.003), and prehospital fluid therapy (OR: 2.54, p=0.01) were detected as independent predictors for hypofibrinogenemia in multivariate logistic regression analysis. Serum fibrinogen level [hazard ratio (HR): 0.99, p=0.01] and T-RTS (HR: 0.77, p<0.01) were associated with the 7-day mortality rate. T-RTS is considered to play an important role in predicting hypofibrinogenemia and 7-day mortality in blunt trauma patients.

Norwegian survival prediction model in trauma: modelling effects of anatomic injury, acute physiology, age, and co‐morbidity

IntroductionAnatomic injury, physiological derangement, age, and injury mechanism are well-founded predictors of trauma outcome. We aimed to develop and validate the first Scandinavian survival prediction model for trauma.MethodsEligible were patients admitted to Oslo University Hospital Ullevål within 24 h after injury with Injury Severity Score ≥ 10, proximal penetrating injuries or received by a trauma team. The derivation dataset comprised 5363 patients (August 2000 to July 2006); the validation dataset comprised 2517 patients (August 2006 to July 2008). Exclusion because of missing data was < 1%. Outcome was 30-day mortality. Logistic regression analysis incorporated fractional polynomial modelling and interaction effects. Model validation included a calibration plot, Hosmer–Lemeshow test and receiver operating characteristic (ROC) curves.ResultsThe new survival prediction model included the anatomic New Injury Severity Score (NISS), Triage Revised Trauma Score (T-RTS, comprising Glascow Coma Scale score, respiratory rate, and systolic blood pressure), age, pre-injury co-morbidity scored according to the American Society of Anesthesiologists Physical Status Classification System (ASA-PS), and an interaction term. Fractional polynomial analysis supported treating NISS and T-RTS as linear functions and age as cubic. Model discrimination between survivors and non-survivors was excellent. Area (95% confidence interval) under the ROC curve was 0.966 (0.959–0.972) in the derivation and 0.946 (0.930–0.962) in the validation dataset. Overall, low mortality and skewed survival probability distribution invalidated model calibration using the Hosmer–Lemeshow test.ConclusionsThe Norwegian survival prediction model in trauma (NORMIT) is a promising alternative to existing prediction models. External validation of the model in other trauma populations is warranted.

Prediction of mortality rate of trauma patients in emergency room at Cipto Mangunkusumo Hospital by several scoring systems

Background: Trauma management is well recognized as one of the main challenges in modern health care. Easy-to-use trauma scoring systems inform physicians of the severity of trauma and help them to decide the course of trauma management. The aim of this study was to find the most applicable trauma scoring system which can be used by physicians by comparing prediction of the mortality rate using: 1)triage-revised trauma score (T-RTS); 2) mechanism, Glasgow coma scale (GCS), age, and arterial pressure (MGAP); and GCS, age, and systolic blood pressure (GAP) scoring system on trauma patients in emergency room (ER) at Cipto Mangunkusumo Hospital. Methods: The data were collected retrospectively from medical records of trauma patients who came to the resuscitation area in ER at Cipto Mangunkusumo Hospital throughout 2011. As many as 185 patients were managed. The inclusion criteria were all trauma patients who came to the resuscitation area in ER. All referred patients, patients under eighteen, and uncompleted data were excluded. The data were calculated based on each scoring system. The outcome (death or alive) was collected on first 24 hours following admission. Results: There were 124 cases analyzed, with mean of age of 32.4 years and total mortality rate up to 23 cases (18.5%). The mortality rate of low risk group on T-RTS, MGAP, and GAP was 5%, 1.3%, and 1.4% respectively (p = 1.000). The mortality rate of intermediate risk group on T-RTS, MGAP, and GAP was 39.4%, 32.1%, and 36.3%, respectively (p = 0.841). Mortality rate of high risk group on T-RTS, MGAP, and GAP was 100%, 72.2%, and 85.7% respectively (p = 0.782). Conclusion: There was no difference on T-RTS, MGAP, and GAP scoring system in predicting mortality rate. T-RTS is the most applicable trauma scoring system since it does not differ the age and mechanism of trauma. (Med J Indones. 2013;22:227-31. doi: 10.13181/mji.v22i4.603) Keywords: GAP, MGAP, T-RTS, Trauma scoring system

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.

Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score.

IntroductionOur aim in this study was to assess whether the new Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) scoring system, which is a modification of the Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) scoring system, better predicts in-hospital mortality and can be applied more easily than previous trauma scores among trauma patients in the emergency department (ED).MethodsThis multicenter, prospective, observational study was conducted to analyze readily available variables in the ED, which are associated with mortality rates among trauma patients. The data used in this study were derived from the Japan Trauma Data Bank (JTDB), which consists of 114 major emergency hospitals in Japan. A total of 35,732 trauma patients in the JTDB from 2004 to 2009 who were 15 years of age or older were eligible for inclusion in the study. Of these patients, 27,154 (76%) with complete sets of important data (patient age, Glasgow Coma Scale (GCS) score, systolic blood pressure (SBP), respiratory rate and Injury Severity Score (ISS)) were included in our analysis. We calculated weight for the predictors of the GAP scores on the basis of the records of 13,463 trauma patients in a derivation data set determined by using logistic regression. Scores derived from four existing scoring systems (Revised Trauma Score, Triage Revised Trauma Score, Trauma and Injury Severity Score and MGAP score) were calibrated using logistic regression models that fit in the derivation set. The GAP scoring system was compared to the calibrated scoring systems with data from a total of 13,691 patients in a validation data set using c-statistics and reclassification tables with three defined risk groups based on a previous publication: low risk (mortality < 5%), intermediate risk, and high risk (mortality > 50%).ResultsCalculated GAP scores involved GCS score (from three to fifteen points), patient age < 60 years (three points) and SBP (> 120 mmHg, six points; 60 to 120 mmHg, four points). The c-statistics for the GAP scores (0.933 for long-term mortality and 0.965 for short-term mortality) were better than or comparable to the trauma scores calculated using other scales. Compared with existing instruments, our reclassification tables show that the GAP scoring system reclassified all patients except one in the correct direction. In most cases, the observed incidence of death in patients who were reclassified matched what would have been predicted by the GAP scoring system.ConclusionsThe GAP scoring system can predict in-hospital mortality more accurately than the previously developed trauma scoring systems.