Diagnostic accuracy of the Kampala Trauma Score using estimated Abbreviated Injury Scale scores and physician opinion

The predictive value of the Kampala Trauma Score (KTS) in the outcome of multi-traumatic patients compared to the estimated Injury Severity Score (eISS)

PURPOSE

The classification of trauma patients in emergency settings is a constant challenge for physicians. However, the Injury Severity Score (ISS) is widely used in developed countries, it may be difficult to perform it in low- and middle-income countries (LMIC). As a result, the ISS was calculated using an estimated methodology that has been described and validated in a high-income country previously. In addition, a simple scoring tool called the Kampala Trauma Score (KTS) was developed recently. The aim of this study was to compare the diagnostic accuracy of KTS and estimated ISS (eISS) in order to achieve a valid and efficient scoring system in our resource-limited setting.

METHODS

We conducted a cross-sectional study between December 2020 and March 2021 among the multi-trauma patients who presented at the emergency department of Imam Reza hospital, Tabriz, Iran. After obtaining informed consent, all data including age, sex, mechanism of injury, GCS, KTS, eISS, final outcome (including death, morbidity, or discharge), and length of hospital stay were collected and entered into SPSS version 27.0 and analyzed.

RESULTS

381 multi-trauma patients participated in the study. The area under the curve for prediction of mortality (AUC) for KTS was 0.923 (95%CI: 0.888-0.958) and for eISS was 0.910 (95% CI: 0.877-0.944). For the mortality, comparing the AUCs by the Delong test, the difference between areas was not statistically significant (p value = 0.356). The diagnostic odds ratio (DOR) for the prediction of mortality KTS and eISS were 28.27 and 32.00, respectively.

CONCLUSION

In our study population, the KTS has similar accuracy in predicting the mortality of multi-trauma patients compared to the eISS.

The new injury severity score underestimates true injury severity in a resource-constrained setting

Background

The new injury severity score (NISS) is widely used within trauma outcomes research. NISS is a composite anatomic severity score derived from the Abbreviated Injury Scale (AIS) protocol. It has been postulated that NISS underestimates trauma severity in resource-constrained settings, which may contribute to erroneous research conclusions. We formally compare NISS to an expert panel's assessment of injury severity in South Africa.

Methods

This was a retrospective chart review of adult trauma patients seen in a tertiary trauma center. Randomly selected medical records were reviewed by an AIS-certified rater who assigned an AIS severity score for each anatomic injury. A panel of five South African trauma experts independently reviewed the same charts and assigned consensus severity scores using a similar scale for comparability. NISS was calculated as the sum of the squares of the three highest assigned severity scores per patient. The difference in average NISS between rater and expert panel was assessed using a multivariable linear mixed effects regression adjusted for patient demographics, injury mechanism and type.

Results

Of 49 patients with 190 anatomic injuries, the majority were male (n = 38), the average age was 36 (range 18-80), with either a penetrating (n = 23) or blunt (n = 26) injury, resulting in 4 deaths. Mean NISS was 16 (SD 15) for the AIS rater compared to 28 (SD 20) for the expert panel. Adjusted for potential confounders, AIS rater NISS was on average 11 points (95 % CI: 7, 15) lower than the expert panel NISS (p < 0.001). Injury type was an effect modifier, with the difference between the AIS rater and expert panel being greater in penetrating versus blunt injury (16 vs. 7; p = 0.04). Crush injury was not well-captured by AIS protocol.

Conclusion

NISS may under-estimate the 'true' injury severity in a middle-income country trauma hospital, particularly for patients with penetrating injury.

Access to quality care after injury in Northern Malawi: results of a household survey

BACKGROUND

Most injury care research in low-income contexts such as Malawi is facility centric. Community-derived data is needed to better understand actual injury incidence, health system utilisation and barriers to seeking care following injury.

METHODS

We administered a household survey to 2200 households in Karonga, Malawi. The primary outcome was injury incidence, with non-fatal injuries classified as major or minor (> 30 or 1-29 disability days respectively). Those seeking medical treatment were asked about time delays to seeking, reaching and receiving care at a facility, where they sought care, and whether they attended a second facility. We performed analysis for associations between injury severity and whether the patient sought care, stayed overnight in a facility, attended a second facility, or received care within 1 or 2 h. The reason for those not seeking care was asked.

RESULTS

Most households (82.7%) completed the survey, with 29.2% reporting an injury. Overall, 611 non-fatal and four fatal injuries were reported from 531 households: an incidence of 6900 per 100,000. Major injuries accounted for 26.6%. Three quarters, 76.1% (465/611), sought medical attention. Almost all, 96.3% (448/465), seeking care attended a primary facility first. Only 29.7% (138/465), attended a second place of care. Only 32.0% (142/444), received care within one hour. A further 19.1% (85/444) received care within 2 h. Major injury was associated with being more likely to have; sought care (94.4% vs 69.8% p < 0.001), stayed overnight at a facility (22.9% vs 15.4% P = 0.047), attended a second place of care (50.3% vs 19.9%, P < 0.001). For those not seeking care the most important reason was the injury not being serious enough for 52.1% (74/142), followed by transport difficulties 13.4% (19/142) and financial costs 5.6% (8/142).

CONCLUSION

Injuries in Northern Malawi are substantial. Community-derived details are necessary to fully understand injury burden and barriers to seeking and reaching care.

Which curve is better? A comparative analysis of trauma scoring systems in a South Asian country

Objectives

A diverse set of trauma scoring systems are used globally to predict outcomes and benchmark trauma systems. There is a significant potential benefit of using these scores in low and middle-income countries (LMICs); however, its standardized use based on type of injury is still limited. Our objective is to compare trauma scoring systems between neurotrauma and polytrauma patients to identify the better predictor of mortality in low-resource settings.

Methods

Data were extracted from a digital, multicenter trauma registry implemented in South Asia for a secondary analysis. Adult patients (≥18 years) presenting with a traumatic injury from December 2021 to December 2022 were included in this study. Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Revised Trauma Score (RTS), Mechanism/GCS/Age/Pressure score and GCS/Age/Pressure score were calculated for each patient to predict in-hospital mortality. We used receiver operating characteristic curves to derive sensitivity, specificity and area under the curve (AUC) for each score, including Glasgow Coma Scale (GCS).

Results

The mean age of 2007 patients included in this study was 41.2±17.8 years, with 49.1% patients presenting with neurotrauma. The overall in-hospital mortality rate was 17.2%. GCS and RTS proved to be the best predictors of in-hospital mortality for neurotrauma (AUC: 0.885 and 0.874, respectively), while TRISS and ISS were better predictors for polytrauma patients (AUC: 0.729 and 0.722, respectively).

Conclusion

Trauma scoring systems show differing predictability for in-hospital mortality depending on the type of trauma. Therefore, it is vital to take into account the region of body injury for provision of quality trauma care. Furthermore, context-specific and injury-specific use of these scores in LMICs can enable strengthening of their trauma systems.

Level of evidence

Level III.

Glasgow coma scale compared to other trauma scores in discriminating in-hospital mortality of traumatic brain injury patients admitted to urban Indian hospitals: A multicentre prospective cohort study

BACKGROUND

Glasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting.

METHOD

We analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality.

RESULTS

A total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS.

CONCLUSION

This study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.

Back to the basics: Clinical assessment yields robust mortality prediction and increased feasibility in low resource settings

INTRODUCTION

Mortality prediction aids clinical decision-making and is necessary for trauma quality improvement initiatives. Conventional injury severity scores are often not feasible in low-resource settings. We hypothesize that clinician assessment will be more feasible and have comparable discrimination of mortality compared to conventional scores in low and middle-income countries (LMICs).

METHODS

Between 2017 and 2019, injury data were collected from all injured patients as part of a prospective, four-hospital trauma registry in Cameroon. Clinicians used physical exam at presentation to assign a highest estimated abbreviated injury scale (HEAIS) for each patient. Discrimination of hospital mortality was evaluated using receiver operating characteristic curves. Discrimination of HEAIS was compared with conventional scores. Data missingness for each score was reported.

RESULTS

Of 9,635 presenting with injuries, there were 206 in-hospital deaths (2.2%). Compared to 97.5% of patients with HEAIS scores, only 33.2% had sufficient data to calculate a Revised Trauma Score (RTS) and 24.8% had data to calculate a Kampala Trauma Score (KTS). Data from 2,328 patients with all scores was used to compare models. Although statistically inferior to the prediction generated by RTS (AUC 0.92-0.98) and KTS (AUC 0.93-0.99), HEAIS provided excellent overall discrimination of mortality (AUC 0.84-0.92). Among 9,269 patients with HEAIS scores was strongly predictive of mortality (AUC 0.93-0.96).

CONCLUSION

Clinical assessment of injury severity using HEAIS strongly predicts hospital mortality and far exceeds conventional scores in feasibility. In contexts where traditional scoring systems are not feasible, utilization of HEAIS could facilitate improved data quality and expand access to quality improvement programming.

Factors associated with HIV testing among patients seeking emergent injury care in Kigali, Rwanda

Introduction

Emergency centres (ECs) can be important access points for HIV testing. In Rwanda, one in eight people with HIV are unaware of their infection status, which impedes epidemic control. This could be addressed via increased testing. This cross-sectional study evaluated factors associated with EC-based HIV testing among injured patients at the Centre Hospitalier Universitaire de Kigali (CHUK), in Kigali, Rwanda.

Methods

Adult injury patients were prospectively enrolled between January-June 2020. Trained study personnel collected data on demographics, injury aspects, treatments, HIV testing, and disposition. The primary outcome was the completion of EC-based HIV testing. Differences between those receiving and those not receiving testing were assessed. Regression models yielding adjusted odds ratios with associated 95% confidence intervals (CI) were calculated to quantify magnitudes of effect.

Results

Among 579 patients, the majority were under 45 years of age (78.1%) and male (74.4%). The most common mechanism of injury was road traffic accidents (50.3%). EC discharge occurred in 54.4% of cases. HIV testing was performed in 221 (38.2%) cases, of which 5.9% had a positive result. HIV testing was more likely among males (aOR=1.69, 95% CI: 1.02-2.78; p=0.04), cases transported by prehospital services (aOR=2.07, 95% CI: 1.28-3.35; p=0.003) and those receiving surgical consultation (aOR=3.13, 95% CI: 1.99-4.94; p<0.001). Cases with lower acuity were less likely to be tested (OR=0.70, 95% CI: 0.55-0.90; p=0.004), as were those discharged (OR=0.28, 95% CI: 0.18-0.43; p<0.001).

Conclusion

In the population studied, most patients did not undergo HIV testing. EC-based physician directed testing was more likely among male patients and patients with greater care needs. These results may inform approaches to increase EC-based testing services in Rwanda and other similar settings with high HIV burdens.

Evaluating Post-Injury Functional Status among Patients Presenting for Emergency Care in Kigali, Rwanda

Despite high injury-related morbidity, approaches for evaluating post-injury functional status after emergency care are poorly characterized in resource-limited settings. This study evaluated the feasibility of standardized disability assessments among patients presenting with significant trauma to the Centre Hospitalier Universitaire de Kigali ED in Rwanda from January–June 2020. The functional status at 28-days post-injury was assessed using the World Health Organization Disability Assessment Schedule 2.0 (WHODAS-2), the Katz Activities of Daily Living (ADL) Scale, and self-reported functional state. The primary outcome was a descriptive profile of the disability status at 28-days post-injury. The WHODAS 2.0, Katz ADL Scale and patients’ self-perceived functional status was compared using Kendall’s rank correlation coefficient. Twenty-four patients were included. The most common injury mechanism was road traffic accident (70.8%); 58.3% of patients had traumatic brain injury. The self-perception questionnaire and the Katz ADL scale were strongly correlated with the WHODAS 2.0 scale; however, self-perception was not well correlated with the ADL scale. Post-injury morbidity was high and morbidity assessment was feasible, with a strong correlation between patients’ self-perceived functional status and the WHODAS-2 scale. Structured post-injury assessments may serve to inform the development of rehabilitation services in Rwanda, although larger studies are needed to inform such initiatives.

The Kampala Trauma Score: A 20-year track record

ABSTRACT

Quantifying the severity of traumatic injury has been foundational for the standardization of outcomes, quality improvement research, and health policy throughout the evolution of trauma care systems. Many injury severity scores are difficult to calculate and implement, especially in low- and middle-income countries (LMICs) where human resources are limited. The Kampala Trauma Score (KTS)-a simplification of the Trauma Injury Severity Score-was developed in 2000 to accommodate these settings. Since its development, numerous instances of KTS use have been documented, but extent of adoption is unknown. More importantly, does the KTS remain useful for determining injury severity in LMICs? This review aims to better understand the legacy of the KTS and assess its strengths and weaknesses. Three databases were searched to identify scientific papers concerning the KTS. Google Scholar was searched to identify grey literature. The search returned 357 papers, of which 199 met inclusion criteria. Eighty-five studies spanning 16 countries used the KTS in clinical settings. Thirty-seven studies validated the KTS, assessing its ability to predict outcomes such as mortality or need for admission. Over 80% of these studies reported the KTS equalled or exceeded more complicated scores at predicting mortality. The KTS has stood the test of time, proving itself over the last twenty years as an effective measure of injury severity across numerous contexts. We recommend the KTS as a means of strengthening trauma systems in LMICs and suggest it could benefit high-income trauma systems that do not measure injury severity.

Injury burdens and care delivery in relation to the COVID-19 pandemic in Kigali, Rwanda: A prospective interrupted cross-sectional study

Introduction

Injuries cause significant burdens in sub-Saharan Africa. In Rwanda, national regulations to reduce COVID-19 altered population mobility and resource allocations. This study evaluated epidemiological trends and care among injured patients preceding and during the COVID-19 pandemic at the Centre Hospitalier Universitaire de Kigali (CHUK) in Kigali, Rwanda.

Methods

This prospective interrupted cross-sectional study enrolled injured adult patients (≥15 years) presenting to the CHUK emergency department (ED) from January 27th-March 21st (pre-COVID-19 period) and June 1st-28th (intra-COVID-19 period). Trained study personnel continuously collected standardized data on enrolled participants through the first six-hours of ED care. The Kampala Trauma Score (KTS) was calculated as a metric of injury severity. Case characteristics prior to and during the pandemic were compared, statistical differences were assessed using χ² or Fisher's exact tests.

Results

Data were collected from 409 pre-COVID-19 and 194 intra-COVID-19 cases. Median age was 32, with a male predominance (74.3%). Road traffic injuries (RTI) were the most common injury mechanism pre-COVID-19 (47.8%) and intra-COVID-19 (53.6%) (p = 0.27). There was a significant increase in the number of transfer cases during the intra-COVID-19 period (52.1%) versus pre-COVID-19 (41.3%) (p = 0.01). KTS was significantly lower among intra-COVID-19 patients (p = 0.04), indicating higher severity of presentation. In the intra-COVID-19 period, there was a significant increase in the number of surgery consultations (40.7%) versus pre-COVID-19 (26.7%) (p < 0.001). The number of hospital admissions increased from 35.5% pre-COVID-19 to 46.4% intra-COVID-19 (p = 0.01). There was no significant mortality difference pre-COVID-19 as compared to the intra-COVID-19 period among injured patients (p = 0.76).

Conclusion

Emergency injury care showed increased injury burden, inpatient admission and resource requirements during the pandemic period. This suggests the spectrum of disease may be more severe and that greater resources for injury management may continue to be needed during the ongoing COVID-19 pandemic in Rwanda and other similar settings.

Fatal and nonfatal firearm injuries in the eastern Democratic Republic of Congo: a hospital-based retrospective descriptive cohort study assessing correlates of adult mortality

Introduction

The Eastern Democratic Republic of Congo (DRC) has been the battleground for multiple armed conflicts, resulting in many fatal and nonfatal firearm injuries (F&NFFIs). Chronic insecurity has stressed the health system’s resources and created barriers to seeking, reaching, and receiving timely care further increasing the F&NFFI burden. Our institution is the largest trauma center in the region and receives the bulk of F&NFFI cases. We aimed to identify correlates of mortality in Congolese F&NFFI patients.

Methods

We included all F&NFFI patients admitted to our institution between 2017 and 2020. We extracted data from patient charts and admission logs. We identified mortality correlates using the two-sample t-test, Chi-square test, and multivariable regression analysis. A P-value of less than 0.05 was considered statistically significant.

Results

This study included 814 adult patients, mostly male (86%) with an average age of 34.5 years and living 154.4 km away from the hospital on average. The most affected anatomical sites were the lower limbs (48.2%) and upper limbs (23.2%). The median length of stay was 34.0 days, and the in-hospital mortality rate was 3.6%. In addition, mortality was negatively correlated with diastolic blood pressure (P = 0.01), SaO₂ (P < 0.001), and hemoglobin concentration (P = 0.002).

Conclusion

F&NFFIs cause an enormous burden in the region, and mortality is correlated with some clinical and biological variables. Thus, the study findings will inform F&NFFI referral, triage, and management in low-resource and mass casualty settings.

Predicting surgical resource consumption and in-hospital mortality in resource-scarce conflict settings: a retrospective study

Background

In armed conflicts, civilian health care struggles to cope. Being able to predict what resources are needed is therefore vital. The International Committee of the Red Cross (ICRC) implemented in the 1990s the Red Cross Wound Score (RCWS) for assessment of penetrating injuries. It is unknown to what extent RCWS or the established trauma scores Kampala trauma Score (KTS) and revised trauma score (RTS) can be used to predict surgical resource consumption and in-hospital mortality in resource-scarce conflict settings.

Methods

A retrospective study of routinely collected data on weapon-injured adults admitted to ICRC’s hospitals in Peshawar, 2009–2012 and Goma, 2012–2014. High resource consumption was defined as ≥3 surgical procedures or ≥ 3 blood-transfusions or amputation. The relationship between RCWS, KTS, RTS and resource consumption, in-hospital mortality was evaluated with logistic regression and adjusted area under receiver operating characteristic curves (AUC). The impact of missing data was assessed with imputation. Model fit was compared with Akaike Information Criterion (AIC).

Results

A total of 1564 patients were included, of these 834 patients had complete data. For high surgical resource consumption AUC was significantly higher for RCWS (0.76, 95% CI 0.74–0.78) than for KTS (0.53, 95% CI 0.50–0.56) and RTS (0.51, 95% CI 0.48–0.54) for all patients. Additionally, RCWS had lower AIC, indicating a better model fit. For in-hospital mortality AUC was significantly higher for RCWS (0.83, 95% CI 0.79–0.88) than for KTS (0.71, 95% CI 0.65–0.76) and RTS (0.70, 95% CI 0.63–0.76) for all patients, but not for patients with complete data.

Conclusion

RCWS appears to predict surgical resource consumption better than KTS and RTS. RCWS may be a promising tool for planning and monitoring surgical care in resource-scarce conflict settings.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-021-00488-2.

Association between volume resuscitation & mortality among injured patients at a tertiary care hospital in Kigali, Rwanda

BACKGROUND

Injuries cause significant morbidity and mortality in sub-Saharan African countries such as Rwanda. These burdens may be compounded by limited access to intravenous (IV) resuscitation fluids such as crystalloids and blood products. This study evaluates the association between emergency department (ED) intravenous volume resuscitation and mortality outcomes in adult trauma patients treated at the University Teaching Hospital-Kigali (UTH- K).

METHODS

Data were abstracted using a structured protocol for a random sample of ED patients treated during periods from 2012 to 2016. Patients under 15 years of age were excluded. Data collected included demographics, clinical aspects, types of IV fluid resuscitation provided and outcomes. The primary outcome was facility-based mortality. Descriptive statistics were used to explore characteristics of the population. Kampala Trauma Scores (KTS) were used to control for injury severity. Magnitudes of effects were quantified using multivariable regression models adjusted for gender, KTS, time period, clinical interventions, presence of head injury and transfer to a tertiary care centre to yield adjusted odds ratios (aOR) with 95% confidence intervals (CI).

RESULTS

From the random sample of 3609 cases, 991 trauma patients were analysed. The median age was 32 [IQR 26, 46] years and 74.3% were male. ED volume resuscitation was given to 50.1% of patients with 43.5% receiving crystalloid and 6.4% receiving crystalloid and packed red blood cell (PRBC) transfusions. The median KTS score was 13 [IQR 12, 13]. In multivariable regression, mortality likelihood was increased in those who received crystalloid (aOR = 4.31, 95%CI 1.24, 15.05, p = 0.022) and PRBC plus crystalloid (aOR = 9.97, 95%CI 2.15,46.17, p = 0.003) as compared to trauma patients not treated with IV resuscitation fluids.

CONCLUSIONS

Injured ED patients treated with volume resuscitation had higher mortality, which may be due to unmeasured confounding or therapies provided. Further studies on fluid resuscitation in trauma populations in resource-limited settings are needed.

Performance of Prognostication Scores for Mortality in Injured Patients in Rwanda

INTRODUCTION

While trauma prognostication and triage scores have been designed for use in lower-resourced healthcare settings specifically, the comparative clinical performance between trauma-specific and general triage scores for risk-stratifying injured patients in such settings is not well understood. This study evaluated the Kampala Trauma Score (KTS), Revised Trauma Score (RTS), and Triage Early Warning Score (TEWS) for accuracy in predicting mortality among injured patients seeking emergency department (ED) care at the Centre Hospitalier Universitaire de Kigali (CHUK) in Rwanda.

METHODS

A retrospective, randomly sampled cohort of ED patients presenting with injury was accrued from August 2015-July 2016. Primary outcome was 14-day mortality and secondary outcome was overall facility-based mortality. We evaluated summary statistics of the cohort. Bootstrap regression models were used to compare areas under receiver operating curves (AUC) with associated 95% confidence intervals (CI).

RESULTS

Among 617 cases, the median age was 32 years and 73.5% were male. The most frequent mechanism of injury was road traffic incident (56.2%). Predominant anatomical regions of injury were craniofacial (39.3%) and lower extremities (38.7%), and the most common injury types were fracture (46.0%) and contusion (12.0%). Fourteen-day mortality was 2.6% and overall facility-based mortality was 3.4%. For 14-day mortality, TEWS had the highest accuracy (AUC = 0.88, 95% CI, 0.76-1.00), followed by RTS (AUC = 0.73, 95% CI, 0.55-0.92), and then KTS (AUC = 0.65, 95% CI, 0.47-0.84). Similarly, for facility-based mortality, TEWS (AUC = 0.89, 95% CI, 0.79-0.98) had greater accuracy than RTS (AUC = 0.76, 95% CI, 0.61-0.91) and KTS (AUC = 0.68, 95% CI, 0.53-0.83). On pairwise comparisons, RTS had greater prognostic accuracy than KTS for 14-day mortality (P = 0.011) and TEWS had greater accuracy than KTS for overall (P = 0.007) mortality. However, TEWS and RTS accuracy were not significantly different for 14-day mortality (P = 0.864) or facility-based mortality (P = 0.101).

CONCLUSION

In this cohort of emergently injured patients in Rwanda, the TEWS demonstrated the greatest accuracy for predicting mortality outcomes, with no significant discriminatory benefit found in the use of the trauma-specific RTS or KTS instruments, suggesting that the TEWS is the most clinically useful approach in the setting studied and likely in other similar ED environments.

A Comparison of the Predictive Value of the Glasgow Coma Scale and the Kampala Trauma Score for Mortality and Length of Hospital Stay in Head Injury Patients at a Tertiary Hospital in Uganda: A Diagnostic Prospective Study

Introduction

The prevalence rates of head injury have been shown to be as high as 25% among trauma patients with severe head injury contributing to about 31% of all trauma deaths. Triage utilizes numerical cutoff points along the scores continuum to predict the greatest number of people who would have a poor outcome, “severe” patients, when scoring below the threshold and a good outcome “non severe” patients, when scoring above the cutoff or numerical threshold. This study aimed to compare the predictive value of the Glasgow Coma Scale and the Kampala Trauma Score for mortality and length of hospital stay at a tertiary hospital in Uganda.

Methods

A diagnostic prospective study was conducted from January 12, 2018 to March 16, 2018. We recruited patients with head injury admitted to the accidents and emergency department who met the inclusion criteria for the study. Data on patient's demographic characteristics, mechanisms of injury, category of road use, and classification of injury according to the GCS and KTS at initial contact and at 24 hours were collected. The receiver operating characteristics (ROC) analysis and logistic regression analysis were used for comparison.

Results

The GCS predicted mortality and length of hospital stay with the GCS at admission with AUC of 0.9048 and 0.7972, respectively (KTS at admission time, AUC 0.8178 and 0.7243). The GCS predicted mortality and length of hospital stay with the GCS at 24 hours with AUC of 0.9567 and 0.8203, respectively (KTS at 24 hours, AUC 0.8531 and 0.7276). At admission, the GCS at a cutoff of 11 had a sensitivity of 83.23% and specificity of 82.61% while the KTS had 88.02% and 73.91%, respectively, at a cutoff of 13 for predicting mortality. At admission, the GCS at a cutoff of 13 had sensitivity of 70.48% and specificity of 66.67% while the KTS had 68.07% and 62.50%, respectively, at a cutoff of 14 for predicting length of hospital stay.

Conclusion

Comparatively, the GCS performed better than the KTS in predicting mortality and length of hospital stay. The GCS was also more accurate at labelling the head injury patients who died as severely injured as opposed to the KTS that categorized most of them as moderately injured. In general, the two scores were sensitive at detection of mortality and length of hospital stay among the study population.

Diversity of Spectrum and Management of Animal-Inflicted Injuries in the Pediatric Age Group: A Prospective Study from a Pediatric Surgery Department Catering Primarily to the Rural Population

Introduction:

Animal-inflicted injuries continue to be a major health problem worldwide. In developing countries, the outcome of such injuries, especially in children may be poor.

Aim:

The study aimed to evaluate the diversity of spectrum and management of animal-inflicted injuries in the pediatric age group.

Materials and Methods:

This was a prospective study on animal-inflicted injuries in children between 1 to 15 years of age over a period of 12 months. Data on various parameters such as age and sex, animal species involved, provoked/unprovoked, mechanism of injury, time of injury, prehospital care, injury-arrival interval, pattern and type of injury, trauma score, body region injured, treatment given and complications were collected and analyzed.

Results:

Fifty-two children with animal-inflicted injuries were included, constituting <1% of all trauma cases seen during the study period (male:female = 2:1). The mean age of the cohort was 9.65 years. Domestic animals were responsible in 41 children (78.84%) and wild animals in 11 children (21.16%). Dog bite was the most common (57.69%). Penetrating injury was observed in 40 (76.9%) and blunt injury was observed in 12 (23.1%). The musculoskeletal system was the most common organ-system injured affecting 36 children (69.23%). Thirty-five children (67.3%) after minor treatment were discharged. Seventeen children (32.7%) required admission. Thirty-four children (65.38%) underwent surgical procedures. Wound debridement was the most common procedure performed. Wound infection was observed in 20 children (38.46%) and was significantly higher (P < 0.01) in delayed presenters. The length of hospital stay for the admitted children ranged from 3 to 28 days.

Conclusion:

Animal-inflicted injuries are rare in children and have a wide spectrum of presentation. Severe injuries require extensive resuscitation and expert surgical care. Mild injuries can be managed conservatively with the use of proper dressings, antibiotics, and analgesics.

Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review

Background

About 5.8 million people die each year as a result of injuries, and nearly 90% of these deaths occur in low and middle-income countries (LMIC). Trauma scoring is a cornerstone of trauma quality improvement (QI) efforts, and is key to organizing and evaluating trauma services. The objective of this review was to assess the appropriateness, feasibility, and QI applicability of traditional trauma scoring systems in LMIC settings.

Materials and methods

This systematic review searched PubMed, Scopus, CINAHL, and trauma-focused journals for articles describing the use of a standardized trauma scoring system to characterize holistic health status. Studies conducted in high-income countries (HIC) or describing scores for isolated anatomic locations were excluded. Data reporting a score’s capacity to discriminate mortality, feasibility of implementation, or use for QI were extracted and synthesized.

Results

Of the 896 articles screened, 336 were included. Over half of studies (56%) reported Glasgow Coma Scale, followed by Injury Severity Score (ISS; 51%), Abbreviated Injury Scale (AIS; 24%), Revised Trauma Score (RTS; 19%), Trauma and Injury Severity Score (TRISS; 14%), and Kampala Trauma Score (7%). While ISS was overwhelmingly predictive of mortality, 12 articles reported limited feasibility of ISS and/or AIS. RTS consistently underestimated injury severity. Over a third of articles (37%) reporting TRISS assessmentsobserved mortality that was greater than that predicted by TRISS. Several articles cited limited human resources as the key challenge to feasibility.

Conclusions

The findings of this review reveal that implementing systems designed for HICs may not be relevant to the burden and resources available in LMICs. Adaptations or alternative scoring systems may be more effective.

PROSPERO registration number

CRD42017064600.

Evaluation of a modified South African Triage Score as a predictor of patient disposition at a tertiary hospital in Rwanda

Background

Triage is essential for efficient and effective delivery of care in emergency centers (ECs) where numerous patients present simultaneously with varying acuity of conditions. Implementing EC triage systems provides a method of recognizing which patients may require admission and are at higher risks for poor health outcomes. Rwanda is experiencing increased demand for emergency care; however, triage has not been well-studied. The University Teaching Hospital of Kigali (UTH-K) is an urban tertiary care health center utilizing a locally modified South African Triage Score (mSATS) that classifies patients into five color categories. Our study evaluated the utility of the mSATS tool at UTH-K.

Methods

UTH-K implemented mSATS in April 2013. All patients aged 15 years or older from August 2015 to July 2016 were eligible for inclusion in the database. Variables of interest included demographic information, mSATS category, patient case type (trauma or medical), disposition from the ED and mortality.

Results

1438 cases were randomly sampled; the majority were male (61.9%) and median age was 35 years. Injuries accounted for 56.7% of the cases while medical conditions affected 43.3%. Admission likelihood significantly increased with higher triage color category for medical patients (OR: Yellow = 3.61, p < .001 to Red (with alarm) = 7.80, p < .01). Likelihood for trauma patients, however, was not significantly increased (OR: Yellow = .84, p = .75 to Red (with alarm) = 1.50, p = .65). Mortality rates increased with increasing triage category with the red with alarm category having the highest mortality (7.7%, OR 18.91).

Conclusion

The mSATS tool accurately predicted patient disposition and mortality for the overall ED population. The mSATS tool provided useful clinical guidance on the need for hospital admission for medical patients but did not accurately predict patient disposition for injured patients. Further trauma-specific triage studies are needed to improve emergency care in Rwanda.

The search for a simple injury score to reliably discriminate the risk of in-hospital mortality in South Africa

BACKGROUND

The Injury Severity Score and Trauma and Injury Severity Score are used commonly to quantify the severity of injury, but they require comprehensive data collection that is impractical in many low- and middle-income countries . We sought to develop an injury score that is more feasible to implement in low- and middle-income countries with discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score.

METHODS

Clinical data from KwaZulu-Natal, South Africa were used to compare the discrimination of the Injury Severity Score and the Trauma and Injury Severity Score with that of the 5, simple injury scores that rely primarily on physiologic data: Revised Trauma Score for Triage, "Mechanism, Glasgow Coma Scale, Age, Pressure" Score, Kampala Trauma Score, modified Kampala Trauma Score, and "Reversed Shock Index Multiplied by Glasgow Coma Scale" Score.

RESULTS

Data for 3,991 patients were analyzed. The Trauma and Injury Severity Score, the Injury Severity Score, and Kampala Trauma Score had similar discrimination (area under the receiver operating curve 0.85, 0.84, and 0.84, respectively). The simple injury scores demonstrated worse discrimination among patients presenting more than 6 hours postinjury, although Kampala Trauma Score maintained the best discrimination of the simple injury scores.

CONCLUSION

In this patient population, Kampala Trauma Score demonstrated discrimination similar to the Injury Severity Score and the Trauma and Injury Severity Score and may be useful to quantify the severity of injury when calculation of the Injury Severity Score or the Trauma and Injury Severity Score is not feasible. Delay in presentation can degrade the discrimination of simple injury scores that rely primarily on physiologic data.

Comparison of emergency department trauma triage performance of clinicians and clinical prediction models: a cohort study in India

OBJECTIVE

The aim of this study was to evaluate and compare the abilities of clinicians and clinical prediction models to accurately triage emergency department (ED) trauma patients. We compared the decisions made by clinicians with the Revised Trauma Score (RTS), the Glasgow Coma Scale, Age and Systolic Blood Pressure (GAP) score, the Kampala Trauma Score (KTS) and the Gerdin et al model.

DESIGN

Prospective cohort study.

SETTING

Three hospitals in urban India.

PARTICIPANTS

In total, 7697 adult patients who presented to participating hospitals with a history of trauma were approached for enrolment. The final study sample included 5155 patients. The majority (4023, 78.0%) were male.

MAIN OUTCOME MEASURE

The patient outcome was mortality within 30 days of arrival at the participating hospital. A grid search was used to identify model cut-off values. Clinicians and categorised models were evaluated and compared using the area under the receiver operating characteristics curve (AUROCC) and net reclassification improvement in non-survivors (NRI+) and survivors (NRI-) separately.

RESULTS

The differences in AUROCC between each categorised model and the clinicians were 0.016 (95% CI -0.014 to 0.045) for RTS, 0.019 (95% CI -0.007 to 0.058) for GAP, 0.054 (95% CI 0.033 to 0.077) for KTS and -0.007 (95% CI -0.035 to 0.03) for Gerdin et al. The NRI+ for each model were -0.235 (-0.37 to -0.116), 0.17 (-0.042 to 0.405), 0.55 (0.47 to 0.65) and 0.22 (0.11 to 0.717), respectively. The NRI- were 0.385 (0.348 to 0.4), -0.059 (-0.476 to -0.005), -0.162 (-0.18 to -0.146) and 0.039 (-0.229 to 0.06), respectively.

CONCLUSION

The findings of this study suggest that there are no substantial differences in discrimination and net reclassification improvement between clinicians and all four clinical prediction models when using 30-day mortality as the outcome of ED trauma triage in adult patients.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT02838459).

Epidemiology of paediatric injuries in Rwanda using a prospective trauma registry

BACKGROUND

Child survival initiatives historically prioritized efforts to reduce child morbidity and mortality from infectious diseases and maternal conditions. Little attention has been devoted to paediatric injuries in resource-limited settings. This study aimed to evaluate the demographics and outcomes of paediatric injury in a sub-Saharan African country in an effort to improve prevention and treatment.

METHODS

A prospective trauma registry was established at the two university teaching campuses of the University of Rwanda to record systematically patient demographics, prehospital care, initial physiology and patient outcomes from May 2011 to July 2015. Univariable analysis was performed for demographic characteristics, injury mechanisms, geographical location and outcomes. Multivariable analysis was performed for mortality estimates.

RESULTS

Of 11 036 patients in the registry, 3010 (27·3 per cent) were under 18 years of age. Paediatric patients were predominantly boys (69·9 per cent) and the median age was 8 years. The mortality rate was 4·8 per cent. Falls were the most common injury (45·3 per cent), followed by road traffic accidents (30·9 per cent), burns (10·7 per cent) and blunt force/assault (7·5 per cent). Patients treated in the capital city, Kigali, had a higher incidence of head injury (7·6 per cent versus 2·0 per cent in a rural town, P < 0·001; odds ratio (OR) 4·08, 95 per cent c.i. 2·61 to 6·38) and a higher overall injury-related mortality rate (adjusted OR 3·00, 1·50 to 6·01; P = 0·019). Pedestrians had higher overall injury-related mortality compared with other road users (adjusted OR 3·26, 1·37 to 7·73; P = 0·007).

CONCLUSION

Paediatric injury is a significant contributor to morbidity and mortality. Delineating trauma demographics is important when planning resource utilization and capacity-building efforts to address paediatric injury in low-resource settings and identify vulnerable populations.

Evaluating trauma scoring systems for patients presenting with gunshot injuries to a district-level urban public hospital in Cape Town, South Africa

Introduction

Trauma scoring systems are widely used in emergency settings to guide clinical decisions and to predict mortality. It remains unclear which system is most suitable to use for patients with gunshot injuries at district-level hospitals. This study compares the Triage Early Warning Score (TEWS), Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), Kampala Trauma Score (KTS) and Revised Trauma Score (RTS) as predictors of mortality among patients with gunshot injuries at a district-level urban public hospital in Cape Town, South Africa.

Methods

Gunshot-related patients admitted to the resuscitation area of Khayelitsha Hospital between 1 January 2016 and 31 December 2017 were retrospectively analysed. Receiver Operating Characteristic (ROC) analysis were used to determine the accuracy of each score to predict all-cause in-hospital mortality. The odds ratio (with 95% confidence intervals) was used as a measure of association.

Results

In total, 331 patients were included in analysing the different scores (abstracted from database n = 431, excluded: missing files n = 16, non gunshot injury n = 10, <14 years n = 1, information incomplete to calculate scores n = 73). The mortality rate was 6% (n = 20). The TRISS and KTS had the highest area under the ROC curve (AUC), 0.90 (95% CI 0.83-0.96) and 0.86 (95% CI 0.79–0.94), respectively. The KTS had the highest sensitivity (90%, 95% CI 68-99%), while the TEWS and RTS had the highest specificity (91%, 95% CI 87–94% each).

Conclusions

None of the different scoring systems performed better in predicting mortality in this high-trauma burden area. The results are limited by the low number of recorded deaths and further studies are needed.

•

Gunshot injuries most often occurs in young males.

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Trauma scores can be used to prognosticate patients in order to allocate appropriate resources.

•

Accuracy-related data of trauma scores in entry-level hospitals is limited.

The Malawi trauma score: A model for predicting trauma-associated mortality in a resource-poor setting

BACKGROUND

Globally, traumatic injury is a leading cause of morbidity and mortality in low-income countries. Current tools for predicting trauma-associated mortality are often not applicable in low-resource environments due to a lack of diagnostic adjuncts. This study sought to derive and validate a model for predicting mortality that requires only a history and physical exam.

METHODS

We conducted a retrospective analysis of all patients recorded in the Kamuzu Central Hospital trauma surveillance registry in Lilongwe, Malawi from 2011 through 2014. Using statistical randomization, 80% of patients were used for derivation and 20% were used for validation. Logistic regression modeling was used to derive factors associated with mortality and the Malawi Trauma Score (MTS) was constructed. The model fitness was tested.

RESULTS

62,354 patients are included. Patients are young (mean age 23.0, SD 15.9 years) with a male preponderance (72%). Overall mortality is 1.8%. The MTS is tabulated based on initial mental status (alert, responds to voice, responds only to pain or worse), anatomical location of the most severe injury, the presence or absence of a radial pulse on examination, age, and sex. The score range is 2-32. A mental status exam of only responding to pain or worse, head injury, the absence of a radial pulse, extremes of age, and male sex all conferred a higher probability of mortality. The ROC area under the curve for the derivation cohort and validation cohort were 0.83 (95% CI 0.78, 0.87) and 0.83 (95% CI 0.75, 0.92), respectively. A MTS of 25 confers a 50% probability of death.

CONCLUSIONS

The MTS provides a reliable tool for trauma triage in sub-Saharan Africa and helps risk stratify patient populations. Unlike other models previously developed, its strength is its utility in virtually any environment, while reliably predicting injury- associated mortality.

A Comparison between the Ability of Revised Trauma Score and Kampala Trauma Score in Predicting Mortality; a Meta-Analysis

INTRODUCTION

Describing injury severity in trauma patients is vital. In some recent articles the Revised Trauma Score (RTS) and Kampala Trauma Score (KTS) have been suggested as easily performed and feasible triage tools which can be used in resource-limited settings. The present meta-analysis was performed to evaluate and compare the accuracy of the RTS and KTS in predicting mortality in low-and middle income countries (LMICs).

METHODS

Two investigators searched the Web of Science, Embase, and Medline databases and the articles which their exact number of true-positive, true-negative, false-positive, and false-negative results could be extracted were selected. Sensitivity and subgroup analysis were performed using Stata software version 14 to determine the factor(s) affecting the accuracy of the RTS and KTS in predicting mortality and source(s) of heterogeneity.

RESULTS

The heterogeneity was high (I2 > 80%) among 11 relevant studies (total n = 20,631). While the sensitivity of the KTS (0.88) was slightly higher than RTS (0.82), the specificity, diagnostic odds ratio, negative likelihood ratio, and positive likelihood ratio of the KTS (0.73, 20, 0.16, 3.30, respectively) were lower than those of the RTS (0.91, 45, 0.20, 8.90, respectively). The area under the summary-receiver operator characteristic curve for KTS and RTS was 0.88 and 0.93, respectively.

CONCLUSION

However, regarding accuracy and performance, RTS was better than KTS for distinguishing between mortality and survival; both of them are beneficial trauma scoring tools which can be used in LMICs. Further studies are required to specify the appropriate choice of the RTS or KTS regarding the type of injury and different conditions of the patient.

Injury severity levels and associated factors among road traffic collision victims referred to emergency departments of selected public hospitals in Addis Ababa, Ethiopia: the study based on the Haddon matrix

BACKGROUND

Globally, about 1.25 million people die annually from road trafficcollisions. Evidence from global safety report shows a decreasing trend of road traffic injury indeveloped countries while there is an increasing trend in many developing countriesincluding Ethiopia. This study is aimed at assessing factors affecting injury severity levels of road traffic collision victims referred to selected public hospitals in Addis Ababa based on the Haddon Matrix.

METHODS

Ahospital-based cross-sectional study designwas implemented to randomly select a total of 363 road traffic collision victims. The collected data was cleaned andentered into Epidata version 3.1 and exported to SPSS Version 21 for analysis. Bivariate and multivariate logisticregression models were used to examine the association between explanatory and outcome variables.

RESULTS

A total of 363 individual sustained road traffic injuries were included to the study. Theprevalence of severe injury among road traffic accident victims was 36.4%. The following variables were significantly associated with increased injury severity: motorbike rider or motorbike passenger without helmet, adjusted odds ratio (AOR) 4.7(95% CI: 1.04-21.09); driving under the influence of alcohol, crude odds ratio (COR) 2.64(95% CI;1.23-5.64); victim with multiple injuries, AOR 3.88(95% CI: 2.26-6.65); vehicle size, AOR 2.14(95% CI: 1.01-4.52); collision in dark lighting condition, AOR 1.93(95% CI: 1.01-3.65); collision in cross city/rural, AOR 1.95(95% CI: 1.18-3.24) and vehicle occupant travelling unrestrained on the back of a truck, AOR3.9 (95% CI: 1.18-12.080). On the other hand, victims extricated at the scene by health care professional, AOR 0.33(95% CI: 0.13-0.83); victims extricated at the scene by police AOR 0.47(95% CI: 0.24-0.94); strict traffic police control at the scene of the collision, AOR 0.49(95% CI: 0.27-0.88) were significantly associated with less severe injuries.

CONCLUSIONS

Findings reported in this paper suggest the need forimmediate and pragmatic steps to be taken to curb the unnecessary loss of livesoccurring on the roads. In particular, there is urgent need to introduce road safety interventions.

Ambulance use is not associated with patient acuity after road traffic collisions: a cross-sectional study from Addis Ababa, Ethiopia

BACKGROUND

Africa accounts for one sixth of global road traffic deaths-most in the pre-hospital setting. Ambulance transport is expensive relative to other modes of pre-hospital transport, but has advantages in time-sensitive, high-acuity scenarios. Many countries, including Ethiopia, are expanding ambulance fleets, but clinical characteristics of patients using ambulances remain ill-defined.

METHODS

This is a cross-sectional study of 662 road traffic collisions (RTC) patients arriving to a single trauma referral center in Addis Ababa, Ethiopia, over 7 months. Emergency Department triage records were used to abstract clinical and arrival characteristics, including acuity. The outcome of interest was ambulance arrival. Secondary outcomes of interest were inter-facility referral and referral communication. Descriptive and multivariable statistics were computed to identify factors independently associated with outcomes.

RESULTS

Over half of patients arrived with either high (13.1%) or moderate (42.2%) acuity. Over half (59.0%) arrived by ambulance, and nearly two thirds (65.9%) were referred. Among referred patients, inter-facility communication was poor (57.7%). Patients with high acuity were most likely to be referred (aOR 2.20, 95%CI 1.16-4.17), but were not more likely to receive ambulance transport (aOR 1.56, 95%CI 0.86-2.84) or inter-facility referral communication (aOR 0.98, 95%CI 0.49-1.94) than those with low acuity. Nearly half (40.2%) of all patients were referred by ambulance despite having low acuity.

CONCLUSIONS

Despite ambulance expansion in Addis Ababa, ambulance use among RTC patients remains heavily concentrated among those with low-acuity. Inter-facility referral appears a primary contributor to low-acuity ambulance use. In other contexts, similar routine ambulance monitoring may help identify low-value utilization. Regional guidelines may help direct ambulance use where most valuable, and warrant further evaluation.