The prognostic importance of trauma scoring systems for morbidity in children with penetrating abdominal wounds: 17 years of experience

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.

Epidemiology of penetrating injury in an urban versus rural level 1 trauma center in the Netherlands

Background:

Penetrating injury can encompass a large spectrum of injuries dependent on the penetrating object, the location of entry, and the trajectory of the object through the human body. Therefore, the management of penetrating injuries can be challenging and often requires rapid assessment and intervention. No universal definition of penetrating injury exists in the literature and little is known about the demographics and outcome of penetrating injury in the Netherlands.

Objective:

A research was carried out to ascertain the size and outcome of penetrating injuries in two level-one trauma centers in the Netherlands.

Methods:

Using the trauma registry of the Radboud University Medical Center in Nijmegen and VU University Medical Center in Amsterdam, all patients with penetrating injury were identified who were admitted to these level 1 trauma centers in the period between January 1, 2009, and January 1, 2014. Penetrating injury was defined as an injury that caused disruption of the body surface and extended into the underlying tissue or into a body cavity. Data concerning age, gender, mechanism of injury, Glasgow Coma Scale, number of injuries, type of injury, and Injury Severity Score were collected and analyzed. Patient results were stratified by Injury Severity Score.

Results:

In total, 354 patients were identified, making up around 2% of all admitted trauma patients 3.1% (VU Medical Center) and 1.6% (Radboud Medical Center). Patients were overwhelmingly male (83.1%) and median age was 36 years (range = 1–88 years). Most injuries were caused by stabbings (51.1%) followed by shootings (26.3%). Admission to the intensive care unit occurred in 41.1% of all patients. Median stay in the intensive care unit was 5.1 days (range = 1–96 days) and median total hospital stay was 8 days (range = 1–95 days). Mortality among these patients was 7.1%, ranging from 0% among patients with Injury Severity Score 1–8 to 100% in patients with Injury Severity Score > 34. High mortality figures were associated with injuries caused by firearms (19.4%), injuries to the head (27.9%), and alleged assaults (10.9%). Differences in demographics between the two centers were not significant.

Conclusion:

Penetrating injury is a relative rare occurrence in the Netherlands compared with other countries. It is associated with high mortality and substantial hospital costs. The incidence of penetrating injuries is higher in metropolitan areas than in rural areas. A universal definition of penetrating trauma should be agreed upon in order to ensure that future studies remain free of bias, and also to ensure that data remain homogeneous.

Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings

INTRODUCTION

Trauma is a leading cause of mortality and disability in children worldwide. The World Health Organization reports that 95% of all childhood injury deaths occur in Low-Middle-Income Countries (LMIC). Injury scores have been developed to facilitate risk stratification, clinical decision making, and research. Trauma registries in LMIC depend on adapted trauma scores that do not rely on investigations that require unavailable material or human resources. We sought to review and assess the existing trauma scores used in pediatric patients. Our objective is to determine their wideness of use, validity, setting of use, outcome measures, and criticisms. We believe that there is a need for an adapted trauma score developed specifically for pediatric patients in low-resource settings.

MATERIALS AND METHODS

A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. We constructed a search strategy in collaboration with a senior hospital librarian. Multiple databases were searched, including Embase, Medline, and the Cochrane Central Register of Controlled Trials. Articles were selected based on predefined inclusion criteria by two reviewers and underwent qualitative analysis.

RESULTS

The scores identified are suboptimal for use in pediatric patients in low-resource settings due to various factors, including reliance on precise anatomic diagnosis, physiologic parameters maladapted to pediatric patients, or laboratory data with inconsistent accessibility in LMIC.

CONCLUSION

An important gap exists in our ability to simply and reliably estimate injury severity in pediatric patients and predict their associated probability of outcomes in settings, where resources are limited. An ideal score should be easy to calculate using point-of-care data that are readily available in LMIC, and can be easily adapted to the specific physiologic variations of different age groups.

Urban paediatric trauma due to stab wounds: an Israeli hospital experience

OBJECTIVE

To assess the incidence and types of stab wounds to hospitalized children and adolescents.

SUBJECTS

The sample consisted of patients, age 6-18 years, who were admitted to our hospital with sustained injury between 1991 and 2007.

RESULTS

In total, 83 patients were admitted as a result of penetrating (n = 51) and superficial (n = 32) injuries. Eighty-two were hospitalized, and one was declared dead upon arrival. Only 11 patients were hospitalized during the 1991-2000 period, and 71 during the 2001-2007 period. Ten patients were admitted to the intensive care unit (ICU); 23 patients were operated (hospital mortality = 0). Evacuation time (time from injury to hospital) was 10 min (mean time; maximum 35 min).

CONCLUSION

This study found higher rates of hospitalization compared with those over a decade ago. These rates reflect not only changes in hospitalization trends and/or population growth in the hospital area but also an increase of urban violence. Israeli hospitalization system deals with paediatric trauma effectively, being well trained because of permanent terrorist activity.

The prognostic importance of trauma scoring systems in pediatric patients

PURPOSE

Traumas are among important causes of morbidity and mortality in the pediatric group. Our aim was to evaluate the predicting effects of general trauma scores on mortality and morbidity rates.

METHODS

The files of 74 patients, who were admitted to our hospital with trauma between the years 2006 and 2008, were retrospectively investigated. Patients' ages, sex, types of trauma, the time between the trauma and entrance to the hospital, vital and laboratory findings, length of hospital stay, length of intensive care unit (ICU) stay, surgical interventions, the organs affected by the trauma, morbidity, and mortality rates were recorded., glasgow coma scale (GCS), abbreviated injury scale (AIS), trauma score-injury severity score (TRISS), revised trauma score (RTS), injury severity score (ISS), pediatric trauma score (PTS), specific trauma scores for lung, liver, and spleen were calculated using the data in the files.

RESULTS

The mean age of patients was 7.0+/-4.34 (1-16) years and 50% of them were men. The types of the trauma were blunt in 66 (89.2%) patients, penetrating in 5 (6.8%) patients and injury due to gun shot in 3 (4.1%) patients. The mean time between the trauma and entrance to the emergency service was 80.40+/-36.67 (10-120) min. Emergency operation and elective surgery was performed in 13 (17%) and 20 (27%) patients, respectively. The mean length of hospitalization was 4.50+/-7.93 (1-35) days.Seven (9.5%) patients needed ICU. The morbidity and mortality rates were 60.8% (n=45) and 2.7% (n=2), respectively. AIS, ISS, TRISS and PTS were independent predictors of morbidity (p<0.05). AIS and ISS were independent predictors of the length of hospital stay (p<0.05). RTS, TRISS, ISS and PTS were independent predictors of the need for ICU (p<0.05). Among laboratory findings, blood glucose, AST and ALT were found to be independent predictors of liver trauma.

CONCLUSION

ISS was found to be more valuable than other trauma scoring systems for prognostic evaluation of pediatric trauma patients. On the other hand, blood glucose, AST, and ALT are easily available, cheap, and valuable alternative laboratory findings in prognostic evaluation.

The evolution of trauma services at Beaumont Hospital

OBJECTIVE

To review and examine the epidemiology, severity and management of trauma admissions at the national neurosurgical teaching hospital.

METHODS

An extensive audit of volume, type and severity of injury and the management requirements of the trauma population admitted to the hospital.

RESULTS

The vast majority of severely injured patients were referred from outside the catchment area of the hospital with only 26% being admitted directly through the Emergency Department. As a consequence, 73% of patients arrived out of normal working hours, which posed problems in providing skilled trauma specialists.

CONCLUSIONS

The management of patients with serious injury is complex. The large proportion of patients with critical injuries, some of whom were paediatric, highlighted the need for 24 h cover by senior trauma personnel and the provision of radiology and operating facilities to meet their needs. The inclusion of indicators of alterations in innate or adaptive immune responses may improve the predictive power of severity of injury scores.