Accuracy of Trauma Surgeons Prospective Estimation of the Injury Severity Score: A Pilot Study

Injury Severity Score (ISS) has limited utility as a prospective predictor of trauma outcomes as it is currently scored by abstractors post-discharge. This study aimed to determine accuracy of ISS estimation at time of admission. Attending trauma surgeons assessed the Abbreviated Injury Scale of each body region for patients admitted during their call, from which estimated ISS (eISS) was calculated. The eISS was considered concordant to abstracted ISS (aISS) if both were in the same category: mild (<9), moderate (9-15), severe (16-25), or critical (>25). Ten surgeons completed 132 surveys. Overall ISS concordance was 52.2%; 87.5%, 30.8%, 34.8%, and 61.7% for patients with mild, moderate, severe, and critical aISS, respectively; unweighted k = .36, weighted k = .69. This preliminarily supports attending trauma surgeons' ability to predict severity of injury in real time, which has important clinical and research implications.

"Blunt adrenal injury does not affect outcomes in the pediatric population with isolated abdominal injury- a National Trauma Data Bank Review®."

BACKGROUND

The incidence of blunt abdominal injury (BAI) in the adult population has been estimated to be between 0.03% and 4.95%. However, the impact of BAI on the pediatric population remains unknown.

METHODS

We conducted a retrospective review of National Trauma Data Bank datasets for the years 2017-2019. We included patients under the age of 18 who experienced blunt trauma and had suffered a blunt abdominal injury with an Abbreviated Injury Scale (AIS) severity score of 2 or higher.

RESULTS

Out of the 8064 pediatric patients with isolated abdominal trauma, 134 patients also suffered from BAI. We found no difference in the outcomes of patients with blunt adrenal injury in terms of mortality, length of stay in the intensive care unit (ICU) and hospital, and the number of ventilator days. Within poly-trauma patients BAI was associated with worst patient outcomes.

CONCLUSIONS

This study demonstrates that BAI has minimal clinical impact on patient outcomes in isolation. However it is associated with worst outcomes in poly trauma patients suggesting correlation with increased trauma burden.

LEVEL OF EVIDENCE

III.

Comparison of injury severity scores derived from ICD-10-AM codes with trauma registry derived scores: A study from New Zealand

INTRODUCTION

Various attempts at automation have been made to reduce the administrative burden of manually assigning Abbreviated Injury Severity (AIS) codes to derive Injury Severity Scores (ISS) in trauma registry data. The accuracy of the resulting measures remains unclear, especially in the New Zealand (NZ) context. The aim of this study was to compare ISS derived from hospital discharge International Classification of Diseases Australian Modification (ICD-10-AM) codes with ISS recorded in the NZ Trauma Registry (NZTR).

METHODS

Individuals admitted to hospital and enrolled in the NZTR between 1 December 2016 and 30 November 2018 were included. ISS were calculated using a modified ICD to AIS mapping tool. The agreement between both methods for raw scores was assessed by the Intraclass Correlation Coefficient (ICC), and for categorical scores the Kappa and weighted Kappa index were used. Analysis was conducted by gender, age, ethnicity, and mechanism of injury.

RESULTS

3,156 patients fulfilled the inclusion criteria. The ICC for agreement between the methods was poor (0.40, 95 % CI: 0.37-0.43). The Kappa index indicated slight agreement between both methods when using a cut-off value of 12 (0.06; 95 % CI: 0.01-0.12) and 15 (0.13 6; 95 % CI: 0.09-0.17).

CONCLUSION

Although the overall agreement between NZTR-ISS and ICD-ISS was slight, ICD-derived scores may be useful to describe injury patterns and for body region-specific estimations when manually coded ISS are not available.

Investigation on the dynamic characteristic of occupant during the frontal collision between high-speed train and obstacle

High-speed train may collide with many obstacles, which can cause serious occupant injury. This study aims to investigate the dynamic characteristic of occupant during the frontal collision between high-speed train and obstacle. The finite element method was used to establish the collision model between the head vehicle of the train and obstacle. The frontal collision simulation tests under three collision conditions were established. The dynamic characteristics of occupants under different collision speeds and collision angles were explored. According to the above research, the influences of collision angle and speed on occupant injuries were systematically studied, and the risk boundaries for Railway Group Standard GMRT2100: Rail Vehicle Structures and Passive Safety (GM/RT2100) and Abbreviated injury scale ≥ 3 (AIS 3 + ) injury risk ≤ 5 % were finally proposed. The results show that the occupant injuries increased with the increase of collision speed, and most of the injury values at the collision angle of 20° were the minimum. The risk boundary for AIS 3 + injury risk ≤ 5 % was higher than that for GM/RT2100. The findings in this study are helpful to understand the occupant injury mechanism during the frontal collision between high-speed train and obstacle.

Adolescent Trauma Patients With Isolated Head Trauma and Glasgow Coma Scale 6-8: Routine Intubation?

BACKGROUND

Recent evidence suggests that routine intubation upon arrival for adults with isolated head trauma and a depressed Glasgow Coma Scale (GCS) score is associated with increased risk of morbidity and mortality. Whether these outcomes are similar within an adolescent trauma population has not been previously investigated. We hypothesized intubation upon arrival for adolescent trauma patients with isolated head trauma to be associated with a higher risk of death and prolonged length of stay (LOS).

METHODS

The 2017-2019 TQIP was queried for adolescents (age 12-16) presenting after isolated blunt head trauma (abbreviated injury scale [AIS] <1 spine/chest/abdomen/upper-extremity/lower-extremity) and GCS 6-8 on arrival. Transferred patients, dead-on-arrival, and those undergoing emergent operation from the emergency department were excluded. Patients intubated within one-hour were compared to patients not intubated within one-hour. A multivariable logistic regression analysis was performed adjusting for age, sex, GCS, and AIS-grade for the head.

RESULTS

From 141 patients, 73 (51.8%) were intubated upon arrival. Intubated patients had a low complication rate (5.6%). Intubated and non-intubated patients had a similar rate and mortality risk (6.8% vs 1.5%, P = .11) (OR 1.84, CI .08-43.69, P = .71) and median length of stay (LOS) (2 days vs 2 days, P = .13).

DISCUSSION

Unlike adult patients, adolescents with isolated head trauma and a depressed GCS have similar outcomes if they are intubated upon arrival. Utilizing initial GCS score to determine which adolescent trauma patients with isolated head trauma should be intubated appears to be a safe practice.

Utilizing ultra-early continuous physiologic data to develop automated measures of clinical severity in a traumatic brain injury population

Determination of prognosis in the triage process after traumatic brain injury (TBI) is difficult to achieve. Current severity measures like the Trauma and injury severity score (TRISS) and revised trauma score (RTS) rely on additional information from the Glasgow Coma Scale (GCS) and the Injury Severity Score (ISS) which may be inaccurate or delayed, limiting their usefulness in the rapid triage setting. We hypothesized that machine learning based estimations of GCS and ISS obtained through modeling of continuous vital sign features could be used to rapidly derive an automated RTS and TRISS. We derived variables from electrocardiograms (ECG), photoplethysmography (PPG), and blood pressure using continuous data obtained in the first 15 min of admission to build machine learning models of GCS and ISS (ML-GCS and ML-ISS). We compared the TRISS and RTS using ML-ISS and ML-GCS and its value using the actual ISS and GCS in predicting in-hospital mortality. Models were tested in TBI with systemic injury (head abbreviated injury scale (AIS) ≥ 1), and isolated TBI (head AIS ≥ 1 and other AIS ≤ 1). The area under the receiver operating characteristic curve (AUROC) was used to evaluate model performance. A total of 21,077 cases (2009-2015) were in the training set. 6057 cases from 2016 to 2017 were used for testing, with 472 (7.8%) severe TBI (GCS 3-8), 223 (3.7%) moderate TBI (GCS 9-12), and 5913 (88.5%) mild TBI (GCS 13-15). In the TBI with systemic injury group, ML-TRISS had similar AUROC (0.963) to TRISS (0.965) in predicting mortality. ML-RTS had AUROC (0.823) and RTS had AUROC 0.928. In the isolated TBI group, ML-TRISS had AUROC 0.977, and TRISS had AUROC 0.983. ML-RTS had AUROC 0.790 and RTS had AUROC 0.957. Estimation of ISS and GCS from machine learning based modeling of vital sign features can be utilized to provide accurate assessments of the RTS and TRISS in a population of TBI patients. Automation of these scores could be utilized to enhance triage and resource allocation during the ultra-early phase of resuscitation.

Hemorrhagic Shock in Isolated and Non-Isolated Pelvic Fractures: A Registries-Based Study

BACKGROUND

Pelvic fractures resulting from high-energy trauma can frequently present with life-threatening hemodynamic instability that is associated with high mortality rates. The role of pelvic exsanguination in causing hemorrhagic shock is unclear, as associated injuries frequently accompany pelvic fractures. This study aims to compare the incidence of hemorrhagic shock and in-hospital outcomes in patients with isolated and non-isolated pelvic fractures.

METHODS

Registries-based study of trauma patients hospitalized following pelvic fractures. Data from 1997 to 2021 were cross-referenced between the Israel Defense Forces Trauma Registry (IDF-TR), documenting prehospital care, and Israel National Trauma Registry (INTR) recording hospitalization data. Patients with isolated pelvic fractures were defined as having an Abbreviated Injury Scale (AIS) <3 in other anatomical regions, and compared with patients sustaining pelvic fracture and at least one associated injury (AIS ≥ 3). Signs of profound shock upon emergency department (ED) arrival were defined as either a systolic blood pressure <90 mmHg and/or a heart rate >130 beats per min.

RESULTS

Overall, 244 hospitalized trauma patients with pelvic fractures were included, most of whom were males (84.4%) with a median age of 21 years. The most common injury mechanisms were motor vehicle collisions (64.8%), falls from height (13.1%) and gunshot wounds (11.5%). Of these, 68 (27.9%) patients sustained isolated pelvic fractures. In patients with non-isolated fractures, the most common regions with a severe associated injury were the thorax and abdomen. Signs of shock were recorded for 50 (20.5%) patients upon ED arrival, but only four of these had isolated pelvic fractures. In-hospital mortality occurred among 18 (7.4%) patients, all with non-isolated fractures.

CONCLUSION

In young patients with pelvic fractures, severe associated injuries were common, but isolated pelvic fractures rarely presented with profound shock upon arrival. Prehospital management protocols for pelvic fractures should prioritize prompt evacuation and resuscitative measures aimed at addressing associated injuries.

A Lightweight Pre-Crash Occupant Injury Prediction Model Distills Knowledge From Its Post-Crash Counterpart

Accurate occupant injury prediction in near-collision scenarios is vital in guiding intelligent vehicles to find the optimal collision condition with minimal injury risks. Existing studies focused on boosting prediction performance by introducing deep-learning models but encountered computational burdens due to the inherent high model complexity. To better balance these two traditionally contradictory factors, this study proposed a training method for pre-crash injury prediction models, namely, knowledge distillation (KD)-based training. This method was inspired by the idea of knowledge distillation, an emerging model compression method. Technically, we first trained a high-accuracy injury prediction model using informative post-crash sequence inputs (i.e., vehicle crash pulses) and a relatively complex network architecture as an experienced "teacher". Following this, a lightweight pre-crash injury prediction model ("student") learned both from the ground truth in output layers (i.e., conventional prediction loss) and its teacher in intermediate layers (i.e., distillation loss). In such a step-by-step teaching framework, the pre-crash model significantly improved the prediction accuracy of occupant's head abbreviated injury scale (AIS) (i.e., from 77.2% to 83.2%) without sacrificing computational efficiency. Multiple validation experiments proved the effectiveness of the proposed KD-based training framework. This study is expected to provide reference to balancing prediction accuracy and computational efficiency of pre-crash injury prediction models, promoting the further safety improvement of next-generation intelligent vehicles.

History of airbag safety benefits and risks

OBJECTIVE

The history of airbags was reviewed for benefits and risks as they became a supplement to lap-shoulder belts. Sled and crash tests were evaluated and field data was analyzed for airbag effectiveness. Field data on airbag deaths and studies on mechanisms of deployment injury were analyzed. The history was reviewed as airbags evolved from the early 1970s to today.

METHODS

Airbag benefits were determined from NHTSA crash tests with unbelted and belted dummies in 40, 48, and 56 km/h (25, 30, and 35 mph) frontal impacts with and without airbags. The literature was reviewed for testing of passive restraints with and without airbags. Recent NCAP tests were compared with earlier tests to determine the change in occupant responses with seatbelts and supplemental airbags in modern vehicles. 1994-2015 NASS-CDS field data was analyzed for MAIS 4 + F injury. Risks were compared for belted and unbelted occupants in frontal impacts by delta V. Airbag risks were identified from field deployments and research. The 1973-76 GM fleet had two deaths due to the occupant being out-of-position (OOP). The mechanisms of injury were determined. From 1989-2003, NHTSA investigated 93 driver, 184 child passenger, and 13 adult passenger airbag deaths. The data was reviewed for injury mechanisms. Second generation airbags essentially eliminated OOP airbag deaths. More recently, three suppliers were linked to airbag rupture deaths. The circumstances for ruptures were reviewed.

RESULTS

The risk for serious head injury was 5.495% in drivers and 4.435% passengers in 40-48 km/h (25-30 mph) frontal crash tests without belts or airbags. It was 80.5% lower at 1.073% in drivers and 82.0% at 0.797% in passengers with belts and airbags in 35 mph NCAP crash tests of 2012-20 MY vehicles. NASS-CDS field data showed a 15.45% risk for severe injury (MAIS 4 + F) to unbelted occupants and 4.68% with belted occupants in 30-35 mph frontal crash delta V with airbags, as deployed. The reduction in risk was 69.7% with belt use and airbags deploying in 96.1% of crashes. There were benefits over the range of delta V. Two airbag deaths were studied from the 1970s GM fleet of airbags. The unbelted driver death was caused by punchout force with the airbag cover blocked by the occupant and membrane forces as the airbag wrapped around the head, neck or chest with the occupant close to the inflating airbag. The unbelted child death was from airbag inflation forces from pre-impact braking causing the child to slide forward into the deploying airbag. Research showed that unrestrained children may have 13 different positions near the passenger airbag at deployment. NHTSA investigation of first generation airbag deaths found most driver deaths were females (75.3%) sitting forward on the seat track, close to the driver airbag. Seatbelt use was only 30%. Most child deaths (138, 75.4%) involved no or improper use of the lap-shoulder belts. Of these, 115 deaths involved pre-impact braking. Only 37 (20.2%) children were in child seats with 29 in rear-facing and 8 in forward-facing child seats. Eight child deaths (4.4%) occurred with lap-shoulder belt use. Airbag designs changed. More recently, Takata airbags were related to at least 24 deaths by airbag rupture prompting a recall; the successor company Joyson had an airbag recall. ARC airbags have experienced a chunk of the inflator propelled into the driver during deployment with several deaths leading to a recall.

CONCLUSIONS

Airbags are effective in preventing death and injury in crashes. They provide the greatest protection in combination with seatbelt use. NHTSA estimated airbags saved 28,244 lives through 1-1-09 while causing at least 320 deployment deaths, which has prompted improved designs, testing, and recalls.

[Consistency of injury severity score in severe trauma patients]

OBJECTIVE

To determine the accuracy of injury severity score (ISS)in the assessment of patients with severe trauma by the consistency analysis of the patients'ISS with severe trauma scored by three clinicians, and to guide the allocation of medical resource.

METHODS

Through retrospective analysis of 100 patients with serious or severe trauma admitted to Peking University People's Hospital since September 2020 to December 2021 (ISS≥16 points), we conducted a consistency analysis of ISS within different evaluators. The general information (gender, age), vital signs, physical examination, imaging, laboratory examination and other associated data of the patients after admission were retrospectively diagnosed by 3 clinicians specializing in trauma surgery and ISS was determined. SPSS 22.0 software was used for statistical analysis, descriptive reports were made on the observed values of each set of data, and Fleiss kappa test was used for consistency analysis of the credibility of the ISS within three clinicians.

RESULTS

Through the consistency analysis of the ISS in 100 patients with severe trauma scored by 3 eva-luators, the total Fleiss kappa value was 0.581, and the overall consistency was medium. Consistency analysis of the different scores was conducted according to the calculation rules of ISS. Among the patients with single-site severe trauma, abbreviated injury scale (AIS) was 4 or 5 points, ISS was 16 or 25 points, and Fleiss kappa value was 0.756 and 0.712 within the three evaluators, showing a relatively high consistency. AIS of each part was more than 4 points, and total ISS was more than 41 points in the severe trauma patients, Fleiss kappa values are higher than 0.8 within the 3 evaluators, showing a high consistency.

CONCLUSION

According to the consistency analysis of severe trauma patients ISS within the three evaluators, when the severe trauma patients with ISS≥16 points are treated or transported, there is a certain accuracy error when the score is used for inter-department communication or inter-hospital transportation, and the consistency of different evaluators for the same injury is moderate. It may lead to misjudgment of the severity of trauma and misallocation of medical resources. However, for trauma patients with single or multiple site AIS≥4 points, ISS is highly consistent among different evaluators, which can accurately indicate the severity of the patient's condition.

Internal and external validation of an updated ICD-10-CA to AIS-2005 update 2008 algorithm

BACKGROUND

Administrative data are a powerful tool for population-level trauma research but lack the trauma-specific diagnostic and injury severity codes needed for risk-adjusted comparative analyses. The objective of this study was to validate an algorithm to derive Abbreviated Injury Scale (AIS-2005 update 2008) severity scores from Canadian International Classification of Diseases (ICD-10-CA) diagnostic codes in administrative data.

METHODS

This was a retrospective cohort study using data from the 2009 to 2017 Ontario Trauma Registry for the internal validation of the algorithm. This registry includes all patients treated at a trauma center who sustained a moderate or severe injury or were assessed by a trauma team. It contains both ICD-10-CA codes and injury scores assigned by expert abstractors. We used Cohen's kappa (𝜅) coefficient to compare AIS-2005 Update 2008 scores assigned by expert abstractors to those derived using the algorithm and the intraclass correlation coefficient to compare assigned and derived Injury Severity Scores. Sensitivity and specificity for detection of a severe injury (AIS score, ≥ 3) were then calculated. For the external validation of the algorithm, we used administration data to identify adults who either died in an emergency department or were admitted to hospital in Ontario secondary to a traumatic injury (2009-2017). Logistic regression was used to evaluate the discriminative ability and calibration of the algorithm.

RESULTS

Of 41,869 patients in the Ontario Trauma Registry, 41,793 (99.8%) had at least one diagnosis matched to the algorithm. Evaluation of AIS scores assigned by expert abstractors and those derived using the algorithm demonstrated a high degree of agreement in identification of patients with at least one severe injury (𝜅 = 0.75; 95% confidence interval [CI], 0.74-0.76). Likewise, algorithm-derived scores had a strong ability to rule in or out injury with AIS ≥ 3 (specificity, 78.5%; 95% CI, 77.7-79.4; sensitivity, 95.1; 95% CI, 94.8-95.3). There was strong correlation between expert abstractor-assigned and crosswalk-derived Injury Severity Score (intraclass correlation coefficient, 0.80; 95% CI, 0.80-0.81). Among the 130,542 patients identified using administrative data, the algorithm retained its discriminative properties.

CONCLUSION

Our ICD-10-CA to AIS-2005 update 2008 algorithm produces reliable estimates of injury severity and retains its discriminative properties with administrative data. Our findings suggest that this algorithm can be used for risk adjustment of injury outcomes when using population-based administrative data.

LEVEL OF EVIDENCE

Diagnostic Tests/Criteria; Level II.

Sex-based differences in odds of motor vehicle crash injury outcomes

OBJECTIVE

Several studies have documented the relative risk or odds of injury and fatality for females versus males in motor vehicle crashes (Parenteau et al. 2013, Forman et al. 2019, Brumbelow and Jermakian, 2022; Noh et al. 2022). Though, none combined National Automotive Sampling System-Crashworthiness Data System (NASS-CDS) and Crash Investigation Sampling System (CISS). The aim of this study was to document the relative odds of various injury outcomes for females versus males while considering a broad range of crash types, pre-crash and crash variables, and occupant characteristics.

METHODS

Multivariable logistic regression was carried out to study the odds of injury for females versus males. A select imputation method (Hot Deck, Approximate Bayesian Bootstrap) was applied as part of efforts to create multivariable logistic regression models for 25 different injury outcomes associated with occupants (age 13 years and older) involved in passenger vehicle crashes published in NASS-CDS (2000 to 2015) and CISS (2017-2021). Both pre-crash (n=7) and crashworthiness (n=22) predictor variables were considered, but only significant variables at p≤0.10 level were retained in final models. Six crash-type models were produced for each injury outcome; one that included all crashes, one for each of four different planar crash types (frontal, near-side, far-side, rear), and one for crashes involving rollover. These six sets of crash-type models were expanded further to include a model version that included both pre-crash/environment and crashworthiness predictor variables and one model limited to crashworthiness predictors only. Different than other recent studies, all crash types, occupant restraint conditions, and seating positions were considered. Occupant sex was retained in all models to facilitate female versus male injury outcome odds ratio (OR) assessments.

RESULTS

Female versus male injury OR estimates for 300 unique models are presented. Females had significantly higher odds of injury than males in 36 models (OR>1.0, p-value ≤0.05). This contrasts with 43 models where females had significantly lower odds (OR<1.0, p≤0.05). For the remaining 221 models, there was a near even split in how often the odds of injury were non-significantly higher (n=103) and non-significantly lower (n=114) for females as compared to males (p>0.05). In four cases, the OR estimate was 1.00. Amongst the results, there was a trend for females to have higher odds of AIS 2+ injuries (MAIS 2+ OR=1.75 and 1.69 for Full and Crashworthiness models, respectively for the All Crashes dataset). These increases included higher estimates for lower extremity injuries in frontal crashes, consistent with earlier studies (e.g., Forman et al. 2019). However, for certain AIS 2+ (neck, thorax) and AIS 3+ injuries (head, neck, thorax), females had significantly lower odds of injury (p≤0.05). The trends for reduced odds of injury for females were most prevalent in non-frontal crash models.

Reality of treatment for severely injured patients: are there age-specific differences?

BACKGROUND

Major trauma and its consequences are one of the leading causes of death worldwide across all age groups. Few studies have conducted comparative age-specific investigations. It is well known that children respond differently to major trauma than elderly patients due to physiological differences. The aim of this study was to analyze the actual reality of treatment and outcomes by using a matched triplet analysis of severely injured patients of different age groups.

METHODS

Data from the TraumaRegister DGU® were analyzed. A total of 56,115 patients met the following inclusion criteria: individuals with Maximum Abbreviated Injury Scale > 2 and < 6, primary admission, from German-speaking countries, and treated from 2011-2020. Furthermore, three age groups were defined (child: 3-15 years; adult: 20-50 years; and elderly: 70-90 years). The matched triplets were defined based on the following criteria: 1. exact injury severity of the body regions according to the Abbreviated Injury Scale (head, thorax, abdomen, extremities [including pelvis], and spine) and 2. level of the receiving hospital.

RESULTS

A total of 2,590 matched triplets could be defined. Traffic accidents were the main cause of severe injury in younger patients (child: 59.2%; adult: 57.9%). In contrast, low falls (from < 3 m) were the most frequent cause of accidents in the elderly group (47.2%). Elderly patients were least likely to be resuscitated at the scene. Both children and elderly patients received fewer therapeutic interventions on average than adults. More elderly patients died during the clinical course, and their outcome was worse overall, whereas the children had the lowest mortality rate.

CONCLUSIONS

For the first time, a large patient population was used to demonstrate that both elderly patients and children may have received less invasive treatment compared with adults who were injured with exactly the same severity (with the outcomes of these two groups being opposite to each other). Future studies and recommendations should urgently consider the different age groups.

Injury comparisons between paired drivers and front-seat passengers in frontal collisions using publicly available crash and injury data

Forensic engineers and crash safety researchers sometimes use the injuries of a seatbelted occupant to infer the injury risk of an unbelted occupant in the same crash, had they instead been wearing a seatbelt. It is unclear, however, whether this inference is valid or how often two occupants in the same collision have similar injuries. Here, we sought to compare the injury outcomes between drivers and front-seat passengers in frontal collisions using real-world collision data. We compared the injury severity, quantified using the Abbreviated Injury Scale (AIS), of 22 injury categories between front-seat occupants with matching seatbelt use and airbag deployment in single-event frontal collisions recorded in the publicly available National Automotive Sampling System, Crashworthiness Data System (years 1993-2015) database to assess whether they had similar severity injuries. We analyzed the four combinations of seatbelt use and airbag deployment and all seatbelt/airbag conditions combined. In only 3 of 88 combinations of injuries and seatbelt/airbag conditions did more than 50% of occupant pairs have the same AIS score, although the related confidence intervals showed these proportions were not significantly greater than 50%. In contrast, we found 19 combinations of injuries and seatbelt/airbag conditions where one occupant was consistently injured more severely than the other. Our findings show that injury outcome is not similar for both front-seat occupants in the same frontal collision with similar seatbelt and airbag conditions; however, one may be able to predict that one occupant would be more severely injured than their fellow occupant.

Risk factors affecting severe thoracic injuries in motor vehicle collisions based on age group and collision directions

OBJECTIVE

This study aimed to investigate the effect of age and collision direction on the severity of thoracic injuries based on a real-world crash database.

METHODS

This was a retrospective, observational study. We used the Korean In-Depth Accident Study (KIDAS) database, which was collected from crash injury patients who visited emergency medical centers between January 2011 and February 2022 in Korea. Among the 4520 patients enrolled in the database, we selected 1908 adult patients with abbreviated injury scale (AIS) scores between 0 and 6 in the thoracic region. We classified patients with an AIS score of 3 or higher into the severe injury group.

RESULTS

The incidence rate of severe thoracic injuries due to motor vehicle accidents was 16.4%. Between the severe and non-severe thoracic injury groups, there were significant differences in sex, age, collision direction, crash object, seatbelt use, and delta-V parameters. Among the age groups, over 55 years occupants had a higher risk in the thoracic regions than those under 54 years occupants. The risk of severe thoracic injury was highest in near-side collisions in all collision directions. Far-side and rear-end collisions showed a lower risk than frontal collisions. Occupants with unfastened seatbelts were at greater risk.

CONCLUSIONS

The risk of severe thoracic injury is high in near-side collisions among elderly occupants. However, the risk of injury for elderly occupants increases in a super-aging society. To reduce thoracic injury, safety features made for elderly occupants in near-side collisions are required.

Undertriage of Severely Injured Trauma Patients

INTRODUCTION

The American College of Surgeons (ACS) delineates trauma team activation (TTA) criteria to identify seriously injured trauma patients in the field. Patients are deemed to be severely undertriaged (SU), placing them at risk for adverse outcomes, when they do not meet TTA criteria but nonetheless sustain significant injuries (Injury Severity Score [ISS] ≥25).

OBJECTIVES

Delineate patient demographics, injuries, and outcomes after SU.

PARTICIPANTS

Trauma patients presenting to our ACS-verified Level 1 trauma center with ISS ≥25 were included (11/2015-03/2022). Transfers and private vehicle transports were excluded. Patients were dichotomized and compared by trauma arrival level: TTA (Appropriately Triaged, AT) vs routine consults (SU).

RESULTS

Study criteria were satisfied by 1653 patients: 1375 (83%) AT and 278 (17%) SU. Severely undertriaged patients were older than AT patients (47 vs 36 years, P < .001). Severely undertriaged occurred almost exclusively following blunt trauma (96% vs 71%, P < .001). Injury Severity Score was lower following SU than AT (29 vs 32, P < .001). The most common severe injuries (Abbreviated Injury Scale score [AIS] ≥3) among the SU group were in the Chest (n = 179, 64%). Severely undertriaged patients necessitated emergent intubation (n = 34, 12%), surgery (n = 59, 21%), and angioembolization (n = 22, 8%) at high rates. Severely undertriaged mortality was n = 40, 14%.

CONCLUSION

Severely undertriaged occurred among a substantial proportion of ISS ≥25 patients, predominately following blunt trauma. Severe chest injuries were most likely to evade capture. Rates of intubation, emergent intervention, and in-hospital mortality were high after SU. Efforts should be made to identify such patients in the field as they may benefit from TTA.

Evaluation of Neural Machine translation for conversion of International Classification of disease codes to the Abbreviated injury Scale

The Abbreviated Injury Scale (AIS) is an essential tool for injury research since it allows for comparisons of injury severity among patients, however, the International Classification of Diseases (ICD) is more widely used to capture medical information. The problem of conversion between these two medical coding systems has similarities to the challenges encountered in language translation. We therefore hypothesize that neural machine translation (NMT), a deep learning technique which is commonly used for human language translation, could be used to convert ICD codes to AIS. The objective of this study was to compare the accuracy of a NMT model for determining injury severity compared to two established methods of conversion. The injury severity classifications used for this study were Injury Severity Score (ISS) ≥ 16, Maximum AIS severity (MAIS) ≥ 3, and MAIS ≥ 2. Data from a US national trauma registry, which has patient injuries coded in both AIS and ICD, was used to train a NMT model. Testing data from a separate year was used to determine the accuracy of the NMT model predictions against the actual ISS recorded in the registry. The prediction accuracy of the NMT model was compared to that of the official Association for the Advancement of Automotive Medicine (AAAM) ICD-AIS map and the R package 'ICD Program for Injury Categorization in R' (ICDPIC-R). The results show that the NMT model was the most accurate across all injury severity classifications, followed by the ICD-AIS map and then ICDPIC-R package. The NMT model also showed the highest correlation between the predicted and observe ISS scores. Overall, NMT appears to be a promising method for predicting injury severity from ICD codes, however, validation in external databases is needed.

Risk of permanent medical impairment after road traffic crashes: A systematic review

PURPOSE

To systematically review the risk of permanent disability related to road traffic injuries (RTIs) and to determine the implications for future research regarding permanent impairment following road traffic crashes.

METHODS

We conducted this systematic review according to the preferred reporting items for systematic reviews and meta-analysis statement. An extended search of the literature was carried out in 4 major electronic databases for scientific research papers published from January 1980 to February 2020. Two teams include 2 reviewers each, screened independently the titles/abstracts, and after that, reviewed the full text of the included studies. The quality of the studies was assessed using the strengthening the reporting of observational studies in epidemiology (STROBE) checklist. A third reviewer was assessed any discrepancy and all data of included studies were extracted. Finally, the data were systematically analyzed, and the related data were interpreted.

RESULTS

Five out of 16 studies were evaluated as high-quality according to the STROBE checklist. Fifteen studies ranked the initial injuries according to the abbreviated injury scale 2005. Five studies reported the total risk of permanent medical impairment following RTIs which varied from 2% to 23% for car occupants and 2.8% to 46% for cyclists. Seven studies reported the risk of permanent medical impairment of the different body regions. Eleven studies stated the most common body region to develop permanent impairment, of which 6 studies demonstrated that injuries of the cervical spine and neck were at the highest risk of becoming permanent injured.

CONCLUSION

The finding of this review revealed the necessity of providing a globally validated method to evaluate permanent medical impairment following RTIs across the world. This would facilitate decision-making about traffic injuries and efficient management to reduce the financial and psychological burdens for individuals and communities.

The association between lactate to albumin ratio and outcomes at early phase in patients with traumatic brain injury

BACKGROUND

The majority of traumatic brain injury (TBI) cases result in death in the early phase; predicting short-term progno-sis of affected patients is necessary to prevent this. This study aimed to examine the association between the lactate-to-albumin ratio (LAR) on admission and outcomes in the early phase of TBI.

METHODS

This retrospective observational study included patients with TBI who visited our emergency department between January 2018 and December 2020. TBI was considered as an head abbreviated injury scale (AIS) score of 3 or higher and other AIS of 2 or lower. The primary and secondary outcomes were 24-h mortality and massive transfusion (MT), respectively.

RESULTS

In total, 460 patients were included. The 24-h mortality was 12.6% (n=28) and MT was performed in 31 (6.7%) patients. In the multivariable analysis, LAR was associated with 24-h mortality (odds ratio [OR], 2.021; 95% confidence interval [CI], 1.301-3.139) and MT (OR, 1.898; 95% CI, 1.288-2.797). The areas under the curve of LAR for 24-h mortality and MT were 0.805 (95% CI, 0.766-0.841) and 0.735 (95% CI, 0.693-0.775), respectively.

CONCLUSION

LAR was associated with early-phase outcomes in patients with TBI, including 24-h mortality and MT. LAR may help predict these outcomes within 24 h in patients with TBI.

Inter-rater reliability of the Abbreviated Injury Scale scores in patients with severe head injury shows good inter-rater agreement but variability between countries. An inter-country comparison study

INTRODUCTION

Substantial difference in mortality following severe traumatic brain injury (TBI) across international trauma centers has previously been demonstrated. This could be partly attributed to variability in the severity coding of the injuries. This study evaluated the inter-rater and intra-rater reliability of Abbreviated Injury Scale (AIS) scores of patients with severe TBI across three international level I trauma centers.

METHODS

A total 150 patients (50 per center) were randomly selected from each respective trauma registry: University Medical Center Utrecht (UMCU), the Netherlands; John Hunter Hospital (JHH), Australia; and Harborview Medical Center (HMC), the United States. Reliability between coders and trauma centers was measured with the intraclass correlation coefficient (ICC).

RESULTS

The reliability between the coders and the original trauma registry scores was 0.50, 0.50, and 0.41 in, respectively, UMCU, JHH, and HMC. The AIS coders at UMCU scored the most AIS codes of ≥ 4. Reliability within the trauma centers was substantial in UMCU (ICC = 0.62) and HMC (ICC = 0.78) and almost perfect in JHH (ICC = 0.85). Reliability between trauma centers was 0.70 between UMCU and JHH, 0.70 between JHH and HMC, and 0.59 between UMCU and HMC.

CONCLUSION

The results of this study demonstrated a substantial and almost perfect reliability of the AIS coders within the same trauma center, but variability across trauma centers. This indicates a need to improve inter-rater reliability in AIS coders and quality assessments of trauma registry data, specifically for patients with head injuries. Future research should study the effect of differences in AIS scoring on outcome predictions.

Angioembolization in Severe Pelvic Trauma is Associated with Venous Thromboembolism

INTRODUCTION

Management of hemorrhage from pelvic fractures is complex and requires multidisciplinary attention. Pelvic angioembolization (AE) has become a key intervention to aid in obtaining definitive hemorrhage control. We hypothesized that pelvic AE would be associated with an increased risk of venous thromboembolism (VTE).

METHODS

All adults (age >16) with a severe pelvic fracture (Abbreviated Injury Scale ≥ 4) secondary to a blunt traumatic mechanism in the 2017-2019 American College of Surgeons Trauma Quality Improvement Program database were included. Patients who did not receive VTE prophylaxis during their admission were excluded. Patients who underwent pelvic AE during the first 24 h of admission were compared to those who did not using propensity score matching. Matching was performed based on patient demographics, admission physiology, comorbidities, injury severity, associated injuries, other hemorrhage control procedures, and VTE prophylaxis type, and time to initiation of VTE prophylaxis. The rates of VTE (deep vein thrombosis and pulmonary embolism) were compared between the matched groups.

RESULTS

Of 72,985 patients with a severe blunt pelvic fracture, 1887 (2.6%) underwent pelvic AE during the first 24 h of admission versus 71,098 (97.4%) who did not. Pelvic AE patients had a higher median Injury Severity Score and more often required other hemorrhage control procedures, with laparotomy being most common (24.7%). The median time to initiation of VTE prophylaxis in pelvic AE versus no pelvic AE patients was 60.1 h (interquartile range = 36.6-98.6) versus 27.7 h (interquartile range = 13.9-52.4), respectively. After propensity score matching, pelvic AE patients were more likely to develop VTE compared to no pelvic AE patients (11.8% versus 9.5%, P = 0.03).

CONCLUSIONS

Pelvic AE for control of hemorrhage from severe pelvic fractures is associated with an increased risk of in-hospital VTE. Patients who undergo pelvic AE are especially high risk for VTE and should be started as early as safely possible on VTE prophylaxis.

Evaluating the definition of severely injured patients: a Japanese nationwide 5-year retrospective study

OBJECTIVES

The definition of severely injured patients lacks universal consensus based on quantitative measures. The most widely used definition of severe injury is based on the Injury Severity Score (ISS), which is calculated using the Abbreviated Injury Scale in Japan. This study aimed to compare the prevalence, in-hospital mortality and OR for mortality in patients with ISS ≥16, ISS ≥18 and ISS ≥26 by age groups.

DESIGN

Retrospective cohort study.

SETTING

Japan Trauma Data Bank, which is a nationwide trauma registry with data from 280 hospitals.

PARTICIPANTS

We used data of 117 199 injured patients from a national database. We included injured patients who were transferred from the scene of injury by ambulance and/or physician.

PRIMARY AND SECONDARY OUTCOME MEASURES

Prevalence, in-hospital mortality and OR for mortality with respect to age and injury level (ISS group).

RESULTS

In all age categories, the in-hospital mortality of patient groups with an ISS ≥16, ISS ≥18 and ISS ≥26 was 13.3%, 17.4% and 23.5%, respectively. The in-hospital mortality for patients aged >75 years was the highest (20% greater than that of the other age groups). Moreover, in-hospital mortality for age group 5-14 years was the lowest (4.0-10.9%). In all the age groups, the OR for mortality for patients with ISS ≥16, ISS ≥18 and ISS ≥26 was 12.8, 11.0 and 8.4, respectively.

CONCLUSIONS

Our results revealed the lack of an acceptable definition, with a high in-hospital mortality and high OR for mortality for all age groups.

How does Injury Severity Score derived from International Classification of Diseases Programs for Injury Categorization using International Classification of Diseases, Tenth Revision, Clinical Modification codes perform compared with Injury Severity Score derived from Trauma Quality Improvement Program?

BACKGROUND

Injury Severity Score (ISS) is a measurement of injury severity based on the Abbreviated Injury Scale. Because of the difficulty and expense of Abbreviated Injury Scale coding, there have been recent efforts in mapping ISS from administrative International Classification of Diseases ( ICD ) codes instead. Specifically, the open source and freely available International Classification of Diseases Programs for Injury Categorization (ICDPIC) in R (Foundation for Statistical Computing, Vienna, Austria) converts International Classification of Diseases, Ninth Revision, codes to ISS. This study aims to compare ICDPIC calculations versus manually derived Trauma Quality Improvement Program (TQIP) calculations for International Classification of Diseases, Tenth Revision ( ICD-10 ), codes. Moderate concordance was chosen as the hypothetical relationship because of previous work by both Fleischman et al. ( J Trauma Nurs. 2017;24(1):4-14) who found moderate to substantial concordance between ICDPIC and ISS and Di Bartolomeo et al. ( Scand J Trauma Resusc Emerg Med. 2010;18(1):17) who found none to slight concordance. Given these very different findings, we thought it reasonable to predict moderate concordance with the use of more detailed ICD-10 codes.

METHODS

This was an observational cohort study of 1,040,728 encounters in the TQIP registry for the year 2018. International Classification of Diseases Programs for Injury Categorization in R was used to derive ISS from the ICD-10 codes in the registry. The resulting scores were compared with the manually derived ISS in TQIP.

RESULTS

The median difference between ISS calculated by ICDPIC-2021 using ICD-10, Clinical Modification (ISS-ICDPIC), and manually derived ISS was -3 (95% confidence interval, -5 to 0), while the mean difference was -2.09 (95% confidence interval, -2.10 to -2.07). There was substantial concordance between ISS-ICDPIC and manually derived ISS ( κ = 0.66). The ISS-ICDPIC was a better predictor of mortality (area under the curve, 0.853 vs. 0.836) but a worse predictor of intensive care unit admission (area under the curve, 0.741 vs. 0.757) and hospital stay ≥10 days (AUC, 0.701 vs. 0.743). The ICDPIC has substantial concordance with TQIP for the firearm ( κ = 0.69), motor vehicle trauma ( κ = 0.71), and pedestrian ( κ = 0.73) injury mechanisms.

CONCLUSION

When TQIP data are unavailable, ICDPIC remains a valid way to calculate ISS after transition to ICD-10 codes. The ISS-ICDPIC performs well in predicting a number of outcomes of interest but is best served as a predictor of mortality.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Age-based variability in the association between restraint use and injury type and severity in multi-occupant crashes

PURPOSE

Previous studies have shown older adults receive relatively less protection from seat belts against fatal injuries, however it is unknown how seat belt protection against severe and torso injury changes with age. We estimated age-based variability in seat belt protection against fatal injuries, injuries with maximum abbreviated injury scale greater than two (MAIS 3+), and torso injuries.

METHODS

We leveraged the Crash Outcome Data Evaluation System to analyze binary indicators of fatal, MAIS 3+, and torso injuries. Using a matched cohort design and conditional Poisson regression, we estimated age-based relative risks (RR) of the outcomes associated with seat belt use.

RESULTS

Our results suggested that seat belts were highly protective against fatal injuries for all ages. For ages 16-30, seat belt use was associated with 66% lower risk of MAIS3+ injury (RR 0.34, 95% CI 0.30, 0.38) for occupants of the same vehicle, whereas for ages 75 and older, seat belt use was associated with 38% lower risk of MAIS3+ injury (RR 0.62; 95% CI 0.45, 0.86) for occupants in the same vehicle. The association between restraint use and torso injury also attenuated with age.

CONCLUSIONS

In multi-occupant crashes, seat belts were highly protective against fatal and MAIS3+ injury, however seat belt protection against MAIS3+ and torso injury attenuated with age.

Endotracheal intubation in trauma patients with isolated shock: universally recommended but rarely performed

PURPOSE

The indication for pre-hospital endotracheal intubation (ETI) must be well considered as it is associated with several risks and complications. The current guidelines recommend, among other things, ETI in case of shock (systolic blood pressure < 90 mmHg). This study aims to investigate whether isolated hypotension without loss of consciousness is a useful criterion for ETI.

METHODS

The data of 37,369 patients taken from the TraumaRegister DGU® were evaluated in a retrospective study with regard to pre-hospital ETI and the underlying indications. Inclusion criteria were the presence of any relevant injuries (Abbreviated Injury Scale [AIS] ≥ 3) and complete pre-hospital management information.

RESULTS

In our cohort, 29.6% of the patients were intubated. The rate of pre-hospital ETI increased with the number of indications. If only one criterion according to current guidelines was present, ETI was often omitted. In 582 patients with shock as the only indication for pre-hospital ETI, only 114 patients (19.6%) were intubated. Comparing these subgroups, the intervention was associated with longer time on scene (25.3 min vs. 41.6 min; p < 0.001), higher rate of coagulopathy (31.8% vs. 17.2%), an increased mortality (8.2% vs. 11.5%) and higher standard mortality ratio (1.17 vs. 1.35). If another intubation criterion was present in addition to shock, intubation was performed more frequently.

CONCLUSION

Decision making for pre-hospital intubation in trauma patients is challenging in front of a variety of factors. Despite the presence of a guideline recommendation, ETI is not always executed. Patients presenting with shock as remaining indication and subsequent intubation showed a decreased outcome. Thus, isolated shock does not appear to be an appropriate indication for pre-hospital ETI, but clearly remains an important surrogate of trauma severity and the need for trauma team activation.