Which AIS Based Scoring System is the Best Predictor of Outcome in Orthopaedic Blunt Trauma Patients?

Comparison of Injury Severity Score (ISS) and New Injury Severity Score (NISS) in the Evaluation of Thoracic Trauma Patients: A Retrospective Cohort Study

Objective

To explore the value of the injury severity score (ISS) and the new injury severity score (NISS) for evaluating injuries and predicting complications (pneumonia and respiratory failure) and poor prognoses (in-hospital tracheal intubation, extended length of hospital stay, ICU admission, prolonged ICU stay, and death) in patients with thoracic trauma.

Methods

The data of consecutive patients with thoracic trauma who were admitted to the department of cardiothoracic surgery of a tertiary hospital between January 2018 and December 2021 were retrospectively collected. ISS and NISS were calculated for each patient. The study outcomes were complications and poor prognoses. The differences in ISS and NISS between patients with complications and poor prognoses and patients without the abovementioned conditions were compared using the Mann‒Whitney U test. Discrimination and calibration of ISS and NISS in predicting outcomes were compared using the area under the receiver operating characteristic (ROC) curve (AUC) and Hosmer‒Lemeshow (H-L) statistic.

Results

A total of 310 patients were included. ISS and NISS of patients with complications and poor prognoses were greater than those of patients without complications and poor prognoses, respectively. The discrimination of ISS in predicting pneumonia, respiratory failure, in-hospital tracheal intubation, extended length of hospital stay, ICU admission, prolonged ICU stay, and death (AUCs: 0.609, 0.721, 0.848, 0.784, 0.763, 0.716, and 0.804, respectively) was not statistically significantly different from that of NISS in predicting the corresponding outcomes (AUCs: 0.628, 0.712, 0.795, 0.767, 0.750, 0.750, and 0.818, respectively). ISS showed better calibration than NISS for predicting pneumonia, respiratory failure, in-hospital tracheal intubation, extended length of hospital stay, and ICU admission but worse calibration for predicting prolonged ICU stay and death.

Conclusion

ISS and NISS are both suitable for injury evaluation. There was no statistically significant difference in discrimination between ISS and NISS, but they had different calibrations when predicting different outcomes.

Importance of injury severity in the choice of treatment and its impact on prognosis in gunshot fractures

PURPOSE

The management of femur and tibia fractures resulting from gunshot injuries is a challenge for orthopedic surgeons. One-stage and two-stage treatments are applied according to the anatomical location and severity of the injury. In this study, the importance of injury severity and anatomical location was evaluated in the choice of treatment method and its impact on prognosis in cases of lower extremity gunshot fractures.

METHODS

A total of 124 patients who met the study criteria were evaluated. They were grouped separately according to the anatomical location of the injury (femur, n = 73; tibia, n = 51) and the surgical method (one-stage, n = 77; two-stage, n = 47). The demographic characteristics of the patients, fracture classification, presence of neurological or vascular damage at the time of diagnosis, anatomical location of the injury, surgical procedure, and follow-up time were recorded. The time of union and the presence of malunion were evaluated radiologically. Finally, patients were assessed clinically with the New Injury Severity Score (NISS) and leg length discrepancy (LLD) calculated through measurements made on lower extremity orthoroentgenograms.

RESULTS

The rate of vascular injury and the number of Gustilo-Anderson type IIIB and IIIC cases were significantly higher in the two-stage treatment group (p = 0.001 and p = 0.000, respectively). The infection rate was also higher in the two-stage group; therefore, time to union was significantly longer (p = 0.004 and p = 0.05, respectively). LLD was higher among patients who received two-stage treatment (p = 0.015). According to the NISS scale used in clinical assessment, better scores were obtained for the one-stage group (p = 0.002). In comparisons made according to anatomical location, no significant difference was found between femur and tibia injuries.

CONCLUSION

Regardless of anatomical location and treatment method, injuries of higher severity such as Gustilo-Anderson type IIIB and IIIC are correlated with higher rates of complications such as vascular injury, postoperative infection, delayed union, and LLD. Furthermore, in cases of severe injuries, a two-stage approach is commonly favored.

Using a severity threshold to improve occupational injury surveillance: Assessment of a severe traumatic injury-based occupational health indicator across the International Classification of Diseases lexicon transition

BACKGROUND

Traumatic injury is a leading cause of death and disability among US workers. Severe injuries are less subject to systematic ascertainment bias related to factors such as reporting barriers, inpatient admission criteria, and workers' compensation coverage. A state-based occupational health indicator (OHI #22) was initiated in 2012 to track work-related severe traumatic injury hospitalizations. After 2015, OHI #22 was reformulated to account for the transition from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. This study describes rates and trends in OHI #22, alongside corresponding metrics for all work-related hospitalizations.

METHODS

Seventeen states used hospital discharge data to calculate estimates for calendar years 2012-2019. State-panel fixed-effects regression was used to model linear trends in annual work-related hospitalization rates, OHI #22 rates, and the proportion of work-related hospitalizations resulting from severe injuries. Models included calendar year and pre- to post-ICD-10-CM transition.

RESULTS

Work-related hospitalization rates showed a decreasing monotonic trend, with no significant change associated with the ICD-10-CM transition. In contrast, OHI #22 rates showed a monotonic increasing trend from 2012 to 2014, then a significant 50% drop, returning to a near-monotonic increasing trend from 2016 to 2019. On average, OHI #22 accounted for 12.9% of work-related hospitalizations before the ICD-10-CM transition, versus 9.1% post-transition.

CONCLUSIONS

Although hospital discharge data suggest decreasing work-related hospitalizations over time, work-related severe traumatic injury hospitalizations are apparently increasing. OHI #22 contributes meaningfully to state occupational health surveillance efforts by reducing the impact of factors that differentially obscure minor injuries; however, OHI #22 trend estimates must account for the ICD-10-CM transition-associated structural break in 2015.

Developing an early warning system for detecting sepsis in patients with trauma

The purpose of this study was to analyse the risk factors for sepsis in patients with trauma and develop a new scoring system for predicting sepsis in patients with trauma based on these risk factors. This will provide a simple and effective early warning method for the rapid and accurate detection and evaluation of the probability of sepsis in patients with trauma to assist in planning timely clinical interventions. We undertook a retrospective analysis of the clinical data of 216 patients with trauma who were admitted to the emergency intensive care unit of the emergency medicine department of the Hebei Medical University Third Hospital, China, between November 2017 and October 2022. We conducted a preliminary screening of the relevant factors using univariate logistic regression analysis and included those factors with a p value of <0.075 in the multivariate logistic regression analysis, from which the risk factors were screened and assigned, and obtained a total score, which was the sepsis early warning score. The incidence of sepsis in patients in the intensive care unit with trauma was 36.9%, and the mortality rate due to sepsis was 19.4%. We found statistically significant differences in several factors for patients with sepsis. The risk factors for sepsis in patients with trauma were the activated partial thromboplastin time, the New Injury Severity Score, growth differentiation factor-15 levels, shock, mechanical ventilation and the Acute Physiology and Chronic Health Evaluation II score. The area under the receiver operating characteristic curve of the sepsis early warning score for predicting sepsis in patients with trauma was 0.725. When the cutoff value of the early warning score was set at 5.0 points, the sensitivity was 69.9% and the specificity was 60.3%. The incidence of sepsis in patients with trauma can be reduced by closely monitoring patients' hemodynamics, implementing adequate fluid resuscitation promptly and by early removal of the catheter to minimize the duration of unnecessary invasive mechanical ventilation. In this study, we found that the use of the sepsis early warning score helped in a more accurate and effective evaluation of the prognosis of patients with trauma.

Positive Predictive Factors for Urogenital Injuries in Severely Injured Patients with Pelvic and Spinal Fractures: Introducing the UPPS Scoring System

Background and Objectives: Although urogenital injuries are common in severely injured patients, their diagnosis is often delayed. Predicting genitourinary injuries (GUI), especially in the immediate stages post injury, remains a challenge. This study aims to evaluate and determine positive predictive factors for the presence of GUI in polytrauma patients. Subsequently, these factors shall be used to develop an easy-to-use scoring system, deployable directly in the emergency setting. Materials and Methods: This study evaluates all severely injured patients with an Injury Severity Score (ISS) ≥ 16 admitted to the emergency departments of two German university hospitals between 2016 and 2020. These patients were retrospectively scanned for injuries of the thoracic and/or lumbar spine and/or the pelvic girdle. Demographic data was analyzed alongside trauma mechanism, type of injuries, mortality, length of hospital stays, surgeries, laboratory results, and urological treatment. Subgroup analysis was performed to compare patients with and without GUIs using t-tests. Conducting a binary logistic regression model, the significant factors were combined to create a scoring system, which was further analyzed for accuracy. Results: In total, 413 patients with an average ISS of 33.8 ± 15.0 were identified, and 47 patients (11.4%) sustained urogenital injuries with an average Abbreviated Injury Scale (AIS) score of 2.3 ± 1.1 (range: 1−5). The severity of the pelvic girdle injury correlated with the presence of urogenital injuries (p = 0.002), while there was no correlation with spinal injuries. Moreover, most GUIs resulted from motorcycle accidents (p < 0.001) and 87.2% of these patients were male. Patients with GUI were significantly more likely to show macrohematuria (p < 0.001) on admission and were more severely injured overall (ISS > 34). There was no significant difference in the length of intensive care unit (ICU) stay, the days until discharge, or death rates. Conclusions: Factors or circumstances which reliably predict the presence of GUI were found to include the male sex, a motorcycle accident, high severity of pelvic girdle fractures, macrohematuria on admission to the emergency department, and an ISS > 34. With these findings, we introduce the ‘Urotrauma in Polytrauma patients with Pelvic and/or Spinal injuries’ (UPPS) score for easier prediction of GUI in the emergency setting.

Five-year mortality after hospitalisation for suicide attempt with a violent method

OBJECTIVE

This study aimed to estimate the 5-year mortality among people admitted into a transdisciplinary unit providing combined psychiatric and somatic rehabilitation treatment.

METHODS

In this retrospective study, we analyzed the clinical records of all individuals admitted into the transdisciplinary unit from 01/01/2011 to 12/31/2017 after a suicide attempt using violent means. Vital status was ascertained for these 215 people, a standardized mortality ratio (SMR) was calculated and Log-rank tests were used to identify factors associated with mortality.

RESULTS

The crude mortality rate was 5.12% (11 deaths) and the SMR was 15.45 (95% CI = [7.71-27.65]; p < 0.001) 5.40 years after admission into the transdisciplinary unit. Factors associated with mortality were: older age (29.91 years versus 25.30 years, p < 0.001), a longer stay in acute care (p = 0.002) and a shorter stay in the transdisciplinary unit (p < 0.001).

CONCLUSION

Long-term mortality among people who have attempted suicide using violent means is 15 times higher than in the corresponding general young adult population. This study supports the hypothesis that the severity of a suicide attempt is associated with subsequent excess mortality. Therefore, there is a need to consolidate outpatient facilities that provide appropriate support for this specific population after discharge. These programmes need to ensure the continuity of coordinated psychiatric and somatic care and psychosocial rehabilitation in order to prevent the risk of suicide.

Injury severity score as a predictor of mortality in adult trauma patients by injury mechanism types in the United States: A retrospective observational study

Injury severity score (ISS) is commonly used in trauma registries to describe injury severity and to predict outcomes in trauma patients regardless of injury mechanism. This study examined the correlation between ISS and mortality in adult trauma patients presenting to emergency departments in the United States with different mechanisms of injury. A retrospective observational study was conducted using the 2014 Nationwide Emergency Department Sample. Patients' characteristics were stratified by mortality. Receiver operating characteristic (ROC) curves were generated for death against ISS for each mechanism of injury. A logistic regression model was conducted for each mechanism of injury to determine whether ISS (≥16 vs <16) is a predictor of mortality. The study sample consisted of 16,147,058 weighted adult trauma patients. Median age was 46 years. Slightly over half were females (51.9%). Falls, motor vehicle accidents and being struck by or against, were the most commonly reported mechanisms of injury (44.6%, 18.1%, and 15.3%, respectively). The overall mortality in the study population was 0.4%. The area under the ROC curve was highest in injuries sustained in accidents involving machinery (0.947; 95% confidence intervals [CI], 0.896-0.998), followed by motor vehicle traffic (MVA) (0.788; 95% CI, 0.775-0.801) and cutting or piercing (0.746; 95% CI, 0.701-0.791). Deceased patients were accurately identified by ISS 65.2% in injury by machinery, 47.7% in injury involving MVA, 39.7% in injury by firearm and 31.4% in injury by assault. After adjusting for confounders, the multivariate models in which ISS was the main independent factor performed best in predicting mortality from firearm and machinery mechanism of injuries. Although the ROC curve analysis demonstrated a moderate or high discriminatory ability to identify deceased patients in 6 out of twelve mechanisms, and the multivariate analysis revealed that ISS was a significant predictor of mortality in 9 out of 12 injury mechanisms, the sensitivities of all logistic regression models were poor. The ISS ≥ 16 threshold alone therefore should not be used to identify patients with high-mortality risk. The mortality risk assessment should be done individually and be based on clinical evaluation.

Applicability of Anatomic and Physiologic Scoring Systems for the Prediction of Outcome in Polytraumatized Patients with Blunt Aortic Injuries

Background: Most patients with blunt aortic injuries, who arrive alive in a clinic, suffer from traumatic pseudoaneurysms. Due to modern treatments, the perioperative mortality has significantly decreased. Therefore, it is unclear how exact the prediction of commonly used scoring systems of the outcome is. Methods: We analyzed data on 65 polytraumatized patients with blunt aortic injuries. The following scores were calculated: injury severity score (ISS), new injury severity score (NISS), trauma and injury severity score (TRISS), revised trauma score coded (RTSc) and acute physiology and chronic health evaluation II (APACHE II). Subsequently, their predictive value was evaluated using Spearman´s and Kendall´s correlation analysis, logistic regression and receiver operating characteristics (ROC) curves. Results: A proportion of 83% of the patients suffered from a thoracic aortic rupture or rupture with concomitant aortic wall dissection (54/65). The overall mortality was 24.6% (16/65). The sensitivity and specificity were calculated as the area under the receiver operating curves (AUC): NISS 0.812, ISS 0.791, APACHE II 0.884, RTSc 0.679 and TRISS 0.761. Logistic regression showed a slightly higher specificity to anatomical scoring systems (ISS 0.959, NISS 0.980, TRISS 0.957, APACHE II 0.938). The sensitivity was highest in the APACHE II with 0.545. Sensitivity and specificity for the RTSc were not significant. Conclusion: The predictive abilities of all scoring systems were very limited. All scoring systems, except the RTSc, had a high specificity but a low sensitivity. In our study population, the RTSc was not applicable. The APACHE II was the most sensitive score for mortality. Anatomical scoring systems showed a positive correlation with the amount of transfused blood products.

New injury severity score (NISS) outperforms injury severity score (ISS) in the evaluation of severe blunt trauma patients

PURPOSE

The injury severity score (ISS) and new injury severity score (NISS) have been widely used in trauma evaluation. However, which scoring system is better in trauma outcome prediction is still disputed. The purpose of this study is to evaluate the value of the two scoring systems in predicting trauma outcomes, including mortality, intensive care unit (ICU) admission and ICU length of stay.

METHODS

The data were collected retrospectively from three hospitals in Zhejiang province, China. The comparisons of NISS and ISS in predicting outcomes were performed by using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics.

RESULTS

A total of 1825 blunt trauma patients were enrolled in our study. Finally, 1243 patients were admitted to ICU, and 215 patients died before discharge. The ISS and NISS were equivalent in predicting mortality (area under ORC curve [AUC]: 0.886 vs. 0.887, p = 0.9113). But for the patients with ISS ≥25, NISS showed better performance in predicting mortality. NISS was also significantly better than ISS in predicting ICU admission and prolonged ICU length of stay.

CONCLUSION

NISS outperforms ISS in predicting the outcomes for severe blunt trauma and can be an essential supplement of ISS. Considering the convenience of NISS in calculation, it is advantageous to promote NISS in China's primary hospitals.

Evolving concepts and strategies in the management of polytrauma patients

Major trauma is one of the leading causes of morbidity and mortality in young adults. The impact of disability on the quality of life and functionality in this younger population is worrisome. This remains a major public health concern across the globe. Immediate and early deaths account for nearly 80% of trauma deaths occurring within the first few hours of injury to the first few days, usually because of traumatic brain injury or major exsanguination and subsequently due to shock or hypoxia. Worldwide adoption of comprehensive trauma systems and evolving models of trauma care including prehospital interventions have led improvements in trauma and critical care over the last few decades. Resuscitation and damage control orthopaedics are two key pillars in the management of polytrauma patient. Trauma-related coagulopathy can be an emerging complication during resuscitation of such patients which should be recognized early so appropriate corrective measures can be undertaken. We describe the evolving models of care in the management of polytrauma and trauma associated coagulopathy.

Prevalence, injury-, and non-injury-related factors associated with anxiety and depression in polytrauma patients - A retrospective 20 year follow-up study

Introduction

Survival rate after polytrauma increased over the past decades resulting in an increase of long-term complaints. These include physical and psychological impairments. The aim of this study was to describe the prevalence and risk factors for developing depression and anxiety more than twenty years after polytrauma.

Methods

We contacted patients who were treated due to a polytrauma between 1973 and 1990 at one level 1 trauma center after more than 20 years. These patients received a self-administered questionnaire, to assess symptoms of depression and anxiety. Analysis based on multivariable logistic regression models include injury severity and non-injury related factors to determine risk factors associated with the development of depression and anxiety.

Results

Patients included in this study (n = 337) had a mean ISS of 20.3 (4 to 50) points. In total, 173 (51.3%) showed psychiatric sequelae (depression n = 163, 48.2%; anxiety n = 14, 4.1%). Injury severity was not associated with the development of depression or anxiety. However, the patients, who required psychiatric therapy prior to the injury had higher risk of developing psychiatric symptoms (OR 1.3, 95%CI 1.1 to 1.8, p = 0.018) as did patients who suffered from additional psychiatric insults after the injury (OR 1.4, 95%CI 1.2 to 2.0, p = 0.049).

Conclusion

More than half of polytrauma patients developed psychiatric sequelae. Risk factors include mainly non-injury related factors such as psychiatric comorbidities and additional psychiatric insults after the injury.

Predictors of psychological distress following major trauma

AIM

The aim of this study was to identify variables that may predict later psychological distress in patients following admission to a Major Trauma Centre (MTC) and to determine whether a psychological screening tool, the Posttraumatic Adjustment Screen (PAS), administered on admission was able to contribute to this.

METHODS

Patients referred to the MTC clinical psychology service completed the PAS during their inpatient stay over an eight-month period. Following discharge from hospital, patients were telephoned (1 month, 3 months and 6 months post injury) by a member of the clinical psychology team and asked two validated questionnaires; the Impact of Events Scale revised (IES-R) (measure of posttraumatic stress symptoms) and the CORE-10 (measure of global psychological distress). In addition, patients' data from the local Trauma Audit & Research Network (TARN) database was reviewed to identify information related to injury and other demographic data. Patients were divided into groups for comparison based upon their PAS scores using previously described severity cut offs for posttraumatic stress symptoms and depression. Receiver Operator Characteristic and Multiple Linear Regression analysis was used to examine for significant baseline predictors of psychological distress during follow up according to the IES and CORE-10 scores.

RESULTS

One hundred and fourteen patients completed the PAS over the study period. Follow-up psychological data was available for 63 (56%) of patients. Except for the patient's home address, no baseline parameter examined in this study regarding patient demographics, injury or treatment was associated with reported psychological symptoms in the first six months post injury as measured by the IES-R or CORE-10 scores. Multiple linear regression analysis revealed that both PAS-P and PAS-D were significant predictor variables for patients reporting significant symptoms of posttraumatic stress and global psychological distress (according to IES-R and CORE-10 scores) in the first six months post injury.

CONCLUSIONS

Psychological screening on admission may be helpful in identifying patients admitted to MTCs who are at risk at developing posttraumatic stress symptoms and psychological distress following major trauma.

From Northern Ireland to Afghanistan: half a century of blast injuries

Introduction

Throughout the last half century, blast injuries have been a common occurrence to UK military personnel during combat operations. This study investigates casualty data from three different military operations to determine whether survivability from blast injuries has improved over time and whether the tactics used could have influenced the injuries sustained.

Methods

Casualty data from operations in Northern Ireland, Iraq and Afghanistan were reviewed and found to contain a total of 2629 casualties injured by improvised explosive devices. The injury severities were examined and the suitability of comparison between conflicts was considered.

Results

The case fatality rate and mean severity score sustained remained consistent among the operations included in this study. Using the New Injury Severity Score, the probabilities of survival were calculated for each separate operation. The body regions injured were identified for both fatalities and survivors. Using this information, comparisons of injury severities sustained at an Abbreviated Injury Scale of 3 and above (identified as a threshold for fatal injury) were conducted between the different operations.

Conclusions

The data showed that as operations changed over time, survivability improved and the proportions of body regions injured also changed; however, this study also highlights how studying casualty data from different conflicts without taking account for the contextual differences may lead to misleading conclusions.

Injury severity in polytrauma patients is underestimated using the injury severity score: a single-center correlation study in air rescue

PURPOSE

Prehospital estimation of injury severity is essential for prehospital therapy, deciding on the destination hospital and the associated emergency room care. The aim of this study was to compare prehospital estimates of the abbreviated injury scale (AIS) and the Injury Severity Score (ISS) by emergency physicians with the values of AIS and ISS of injury severity determined at the conclusion of diagnostics.

METHODS

In this prospective study, the ISS was determined prehospital by emergency physicians. The validated AIS and ISS were analyzed based on final diagnoses. A Bland-Altman plot was used in analyzing the agreement between two different assays as well as sensitivity and specificity were determined. Confidence intervals were calculated for a Wilson score. Significance level was set at p ≤ 0.05.

RESULTS

The prehospital ISS was estimated at 26.0 ± 13.0 and was 34.7 ± 16.3 (p < 0.001) after in-hospital validation. In addition, most of the AIS subgroups were significantly higher in the final calculation than preclinically estimated (p < 0.05). When analyzing subgroups of trauma patients (ISS < 16 vs. ISS ≥ 16), we were able to demonstrate a sensitivity of > 90% to identify a multiple-trauma patient. Diagnosing a higher injury severity group (ISS ≥ 25), sensitivity dropped to 61.1%. The Bland-Altman plot demonstrates that injury severity is underestimated in higher injury levels.

CONCLUSION

Multiple-trauma patients can be identified using the ISS. Anatomic scores might be used for transport decisions; however, an accurate estimation of the injury severity should also be based on other criteria such as patient status, mechanism of injury, and other triage criteria.

Evaluation of the Revised Trauma Score in Predicting Outcomes of Trauma Patients

Introduction

The revised trauma score (RTS) was developed more than 20 years ago. Few studies investigated its usefulness in predicting trauma outcomes. This is especially true for the weighted version of RTS (RTS-w). The aim of this study was to test the predicting power of RTS-w for the trauma outcomes including mortality, admission to intensive care unit (ICU), hospital length of stay and ICU length of stay through a comparison with Injury Severity Score (ISS).

Methods

Descriptive data, variables related to the trauma scores and outcomes were collected. The statistical performance of RTS-w and ISS in predicting the trauma outcomes using receiver operating characteristics (ROC) curves and the area under the curve (AUC) with 95% confidence interval and p value were calculated. The Hosmer-Lemeshow chi-squared statistic was performed to measure its calibration.

Results

A total of 3323 patients were enrolled in the study. RTS-w was significantly better than ISS in predicting mortality of trauma patients (AUC: 0.934 vs.0.880, p<0.0001). However, for the other three outcomes, i.e. admission to ICU, hospital length of stay and intensive care unit length of stay, the performance of RTS-w was inferior to ISS.

Conclusions

The RTS-w is a better predictor of mortality than ISS. But its ability to predict other trauma outcomes is not as good as ISS. More studies are needed to identify the predictive ability of RTS-w for the outcomes other than mortality. Besides, updating the coefficients of the formula may make RTS-w more accurate.

Validation of the criteria for early critical care resource use in assessing the effectiveness of field triage

BACKGROUND

This study aimed to validate the criteria for early critical care resource (CCR) use as an outcome predictor for seriously injured patients triaged in the field by comparing the effectiveness of the criteria for early CCR use with that of criteria defined by an Injury Severity Score (ISS) >15.

METHODS

We analysed data from seriously injured trauma patients who were triaged using a field triage protocol by emergency medical service providers (EMS-ST patients). Early CCR use was defined as the use of any of the following treatment modalities or outcomes: advanced airway management, blood transfusion, or interventional radiology (<4h), emergency operation or cardiopulmonary resuscitation, or thoracotomy (<24h), or admission for spinal cord injury. The primary endpoint was inhospital mortality. We generated area under the receiver operating characteristic (AUROC) curves to compare the value of the early CCR use criteria with that of the ISS >15 criteria in the discrimination between survivors and non-survivors.

RESULTS

Of the 14,352 adult EMS-ST patients, 9299 were enrolled in this study. Approximately 19.6% required early CCR use, and 18.0% had an ISS >15. The rate of in-hospital mortality was 9.4%. The AUROC values for the performances of the early CCR use and ISS>15 criteria in the prediction of in-hospital mortality were 0.89 (95% confidence interval [CI] 0.85-0.91) and 0.84 (95% CI 0.79-0.86), respectively (p<0.01).

CONCLUSION

The early CCR use criteria demonstrated better performance than the ISS >15 criteria in the prediction of mortality in EMS-ST patients.

Early decreased neutrophil responsiveness is related to late onset sepsis in multitrauma patients: An international cohort study

Background

Severe trauma can lead to the development of infectious complications after several days, such as sepsis. Early identification of patients at risk will aid anticipating these complications. The aim of this study was to test the relation between the acute (<24 hours) inflammatory response after injury measured by neutrophil responsiveness and the late (>5 days) development of septic complications and validate this in different trauma populations.

Methods and findings

Two prospective, observational, cohort series in the Netherlands and South Africa, consisting of severely injured trauma patients. Neutrophil responsiveness by fMLF-induced active FcγRII was measured in whole blood flowcytometry, as read out for the systemic immune response within hours after trauma. Sepsis was scored daily. Ten of the 36 included Dutch patients developed septic shock. In patients with septic shock, neutrophils showed a lower expression of fMLF-induced active FcγRII immediately after trauma when compared to patients without septic shock (P = 0.001). In South Africa 11 of 73 included patients developed septic shock. Again neutrophils showed lower expression of fMLF induced active FcγRII (P = 0.001). In the combined cohort, all patients who developed septic shock demonstrated a decreased neutrophil responsiveness.

Conclusions

Low responsiveness of neutrophils for the innate stimulus fMLF immediately after trauma preceded the development of septic shock during admission by almost a week and did not depend on a geographical/racial background, hospital protocols and health care facilities. Decreased neutrophil responsiveness appears to be a prerequisite for septic shock after trauma. This might enable anticipation of this severe complication in trauma patients.

Comparison of the Ability to Predict Mortality between the Injury Severity Score and the New Injury Severity Score: A Meta-Analysis

Background: Description of the anatomical severity of injuries in trauma patients is important. While the Injury Severity Score has been regarded as the “gold standard” since its creation, several studies have indicated that the New Injury Severity Score is better. Therefore, we aimed to systematically evaluate and compare the accuracy of the Injury Severity Score and the New Injury Severity Score in predicting mortality. Methods: Two researchers independently searched the PubMed, Embase, and Web of Science databases and included studies from which the exact number of true-positive, false-positive, false-negative, and true-negative results could be extracted. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies checklist criteria. The meta-analysis was performed using Meta-DiSc. Meta-regression, subgroup analyses, and sensitivity analyses were conducted to determine the source(s) of heterogeneity and factor(s) affecting the accuracy of the New Injury Severity Score and the Injury Severity Score in predicting mortality. Results: The heterogeneity of the 11 relevant studies (total n = 11,866) was high (I² > 80%). The meta-analysis using a random-effects model resulted in sensitivity of 0.64, specificity of 0.93, positive likelihood ratio of 5.11, negative likelihood ratio of 0.27, diagnostic odds ratio of 27.75, and area under the summary receiver operator characteristic curve of 0.9009 for the Injury Severity Score; and sensitivity of 0.71, specificity of 0.87, positive likelihood ratio of 5.22, negative likelihood ratio of 0.20, diagnostic odds ratio of 24.74, and area under the summary receiver operating characteristic curve of 0.9095 for the New Injury Severity Score. Conclusion: The New Injury Severity Score and the Injury Severity Score have similar abilities in predicting mortality. Further research is required to determine the appropriate use of the Injury Severity Score or the New Injury Severity Score based on specific patient condition and trauma type.

Industrial Injury Hospitalizations Billed to Payers Other Than Workers' Compensation: Characteristics and Trends by State

OBJECTIVE

To describe characteristics of industrial injury hospitalizations, and to test the hypothesis that industrial injuries were increasingly billed to non-workers' compensation (WC) payers over time.

DATA SOURCES

Hospitalization data for 1998-2009 from State Inpatient Databases, Healthcare Cost and Utilization Project, and Agency for Healthcare Research and Quality.

STUDY DESIGN

Retrospective secondary analyses described the distribution of payer, age, gender, race/ethnicity, and injury severity for injuries identified using industrial place of occurrence codes. Logistic regression models estimated trends in expected payer.

PRINCIPAL FINDINGS

There was a significant increase over time in the odds of an industrial injury not being billed to WC in California and Colorado, but a significant decrease in New York. These states had markedly different WC policy histories. Industrial injuries among older workers were more often billed to a non-WC payer, primarily Medicare.

CONCLUSIONS

Findings suggest potentially dramatic cost shifting from WC to Medicare. This study adds to limited, but mounting evidence that, in at least some states, the burden on non-WC payers to cover health care for industrial injuries is growing, even while WC-related employer costs are decreasing-an area that warrants further research.

Gun-shot injuries in UK military casualties - Features associated with wound severity

INTRODUCTION

Surgical treatment of high-energy gun-shot wounds (GSWs) to the extremities is challenging. Recent surgical doctrine states that wound tracts from high-energy GSWs should be laid open, however the experience from previous conflicts suggests that some of these injuries can be managed more conservatively. The aim of this study is to firstly characterise the GSW injuries sustained by UK forces, and secondly test the hypothesis that the likely severity of GSWs can be predicted by features of the wound.

METHODS

The UK Military trauma registry was searched for cases injured by GSW in the five years between 01 January 2009 and 31 December 2013: only UK personnel were included. Clinical notes and radiographs were then reviewed. Features associated with energy transfer in extremity wounds in survivors were further examined with number of wound debridements used as a surrogate marker of wound severity.

RESULTS

There were 450 cases who met the inclusion criteria. 96 (21%) were fatally injured, with 354 (79%) surviving their injuries. Casualties in the fatality group had a median New Injury Severity Score (NISS) of 75 (IQR 75-75), while the median NISS of the survivors was 12 (IQR 4-48) with 10 survivors having a NISS of 75. In survivors the limbs were most commonly injured (56%). 'Through and through' wounds, where the bullet passes intact through the body, were strongly associated with less requirement for debridement (p<0.0001). When a bullet fragmented there was a significant association with a requirement for a greater number of wound debridements (p=0.0002), as there was if a bullet fractured a bone (p=0.0006).

CONCLUSIONS

More complex wounds, as indicated by the requirement for repeated debridements, are associated with injuries where the bullet does not pass straight through the body, or where a bone is fractured. Gunshot wounds should be assessed according to the likely energy transferred, extremity wounds without features of high energy transfer do not require extensive exploration.

Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study

Background

Anatomy-based injury severity scores are commonly used with physiological scores for reporting severity of injury in a standardized manner. However, there is lack of consensus on choice of scoring system, with the commonly used injury severity score (ISS) performing poorly for certain sub-groups, eg head-injured patients. We hypothesized that adding a dichotomous variable for polytrauma (yes/no for Abbreviated Injury Scale (AIS) scores of 3 or more in at least two body regions) to the New Injury Severity Score (NISS) would improve the prediction of in-hospital mortality in injured patients, including head-injured patients—a subgroup that has a disproportionately high mortality. Our secondary hypothesis was that the ISS over-estimates the risk of death in polytrauma patients, while the NISS under-estimates it.

Methods

Univariate and multivariable analysis was performed on retrospective cohort data of blunt injured patients aged 18 and over with an ISS over 9 from the Singapore National Trauma Registry from 2011–2013. Model diagnostics were tested using discrimination (c-statistic) and calibration (Hosmer-Lemeshow goodness-of-fit statistic). All models included age, gender, and comorbidities.

Results

Our results showed that the polytrauma and NISS model outperformed the other models (polytrauma and ISS, NISS alone or ISS alone) in predicting 30-day and in-hospital mortality. The NISS underestimated the risk of death for patients with polytrauma, while the ISS overestimated the risk of death for these patients.

When used together with the NISS and polytrauma, categorical variables for deranged physiology (systolic blood pressure of 90 mmHg or less, GCS of 8 or less) outperformed the traditional ‘ISS and RTS (Revised Trauma Score)’ model, with a c-statistic of greater than 0.90. This could be useful in cases when the RTS cannot be scored due to missing respiratory rate.

Discussion

The NISS and polytrauma model is superior to current scores for prediction of 30-day and in-hospital mortality. We propose that this score replace the ISS or NISS in institutions using AIS-based scores.

Conclusions

Adding polytrauma to the NISS or ISS improves prediction of 30-day mortality. The superiority of the NISS or ISS depends on the proportion of polytrauma and head-injured patients in the study population.

A New Method to Classify Injury Severity by Diagnosis: Validation Using Workers' Compensation and Trauma Registry Data

PURPOSE

Acute work-related trauma is a leading cause of death and disability among U.S. workers. Existing methods to estimate injury severity have important limitations. This study assessed a severe injury indicator constructed from a list of severe traumatic injury diagnosis codes previously developed for surveillance purposes. Study objectives were to: (1) describe the degree to which the severe injury indicator predicts work disability and medical cost outcomes; (2) assess whether this indicator adequately substitutes for estimating Abbreviated Injury Scale (AIS)-based injury severity from workers' compensation (WC) billing data; and (3) assess concordance between indicators constructed from Washington State Trauma Registry (WTR) and WC data.

METHODS

WC claims for workers injured in Washington State from 1998 to 2008 were linked to WTR records. Competing risks survival analysis was used to model work disability outcomes. Adjusted total medical costs were modeled using linear regression. Information content of the severe injury indicator and AIS-based injury severity measures were compared using Akaike Information Criterion and R(2).

RESULTS

Of 208,522 eligible WC claims, 5 % were classified as severe. Among WC claims linked to the WTR, there was substantial agreement between WC-based and WTR-based indicators (kappa = 0.75). Information content of the severe injury indicator was similar to some AIS-based measures. The severe injury indicator was a significant predictor of WTR inclusion, early hospitalization, compensated time loss, total permanent disability, and total medical costs.

CONCLUSIONS

Severe traumatic injuries can be directly identified when diagnosis codes are available. This method provides a simple and transparent alternative to AIS-based injury severity estimation.

Assessment of pelvic injuries treated with ilio-sacral screws: injury severity and accuracy of screw positioning

PURPOSE

The aim of this study was to analyse possible indicative parameters for percutaneous ilio-sacral stabilisation and to identify parameters associated with screw misplacement.

METHODS

Cohort study, level I trauma centre.

INCLUSION CRITERIA

(1) unstable pelvic injury, (2) percutaneous ilio-sacral screws placement.

EXCLUSION CRITERIA

(1) sacral dysmorphy, (2) failed closed reduction, (3) navigated techniques. Indicative parameters were age, gender, body mass index, number of screws, screw angulation, fracture type and injury severity. End points were ilio-sacral screw position and associated complications. Screw placement accuracy was graded as follows: grade 0, no perforation; grade 1, perforation <2 mm; grade 2, perforation from 2 to 4 mm; grade 3, ≥4 mm perforation.

RESULTS

Between March 2008 and March 2013, 102 (53 women) patients were included (mean age, 48.5 ± 21.4 years). The Injury Severity Score (ISS) and New Injury Severity Score (NISS) were 18.9 ± 9.9 and 22.3 ± 22.3, respectively. The positions of 137 ilio-sacral screws were analysed. Of all screws, 87.6 % (120) were placed satisfactory (<2 mm perforation). The incidence of screw misplacement was significantly higher in the case of two unilateral S1 screws compared with a single screw (failure rate: two unilateral screws 23.1 % vs single screw 7.0 %; p < 0.05). Screw perforation anterior to the lateral mass (in-out-in) represented the most frequent malposition. Revision was necessary in three cases due to malpositioning. Furthermore, no major complication occurred.

CONCLUSIONS

We conclude, that twofold ilio-sacral screw positioning from one side increases the risk for screw misplacement. In this case, alternative techniques like navigation should be considered. Anterior screw perforation represents a common problem with a high incidence and warrants particular attention.

Disparities in occupational injury hospitalization rates in five states (2003-2009)

BACKGROUND

Achievement of health equity and elimination of disparities are overarching goals of Healthy People 2020, yet there is a paucity of population-based data regarding race/ethnicity-based disparities in occupational injuries.

METHODS

Hospital discharge data for five states (Arizona, California, Florida, New Jersey, and New York) were obtained from the Healthcare Cost & Utilization Project (HCUP) for 2003-2009. Age-adjusted rates and trends for work-related injury hospitalizations were calculated using negative binomial regression (reference category: non-Latino white).

RESULTS

Latinos were significantly more likely to have a work-related traumatic injury hospitalization. The disparity for Latinos was greatest for machinery-related hospitalizations. Latinos were also more likely to have a fall-related hospitalization. African-Americans were more likely to have an occupational assault-related hospitalization, but less likely to have a fall-related hospitalization.

CONCLUSIONS

We found evidence of substantial multistate disparities in occupational injury-related hospitalizations. Enhanced surveillance and further research are needed to identify and address underlying causes.

Using injury severity to improve occupational injury trend estimates

BACKGROUND

Hospitalization-based estimates of trends in injury incidence are also affected by trends in health care practices and payer coverage that may differentially impact minor injuries. This study assessed whether implementing a severity threshold would improve occupational injury surveillance.

METHODS

Hospital discharge data from four states and a national survey were used to identify traumatic injuries (1998-2009). Negative binomial regression was used to model injury trends with/without severity restriction, and to test trend divergence by severity.

RESULTS

Trend estimates were generally biased downward in the absence of severity restriction, more so for occupational than non-occupational injuries. Restriction to severe injuries provided a markedly different overall picture of trends.

CONCLUSIONS

Severity restriction may improve occupational injury trend estimates by reducing temporal biases such as increasingly restrictive hospital admission practices, constricting workers' compensation coverage, and decreasing identification/reporting of minor work-related injuries. Injury severity measures should be developed for occupational injury surveillance systems.

Prediction of sepsis in trauma patients

Trauma is one of the leading causes of death worldwide. Approximately 39.5% of deaths occur in the hospital, and the mortality rate of delayed death caused by septic complications is still high. Early prediction of the development of sepsis can help promote early intervention and treatment for patients and contribute to improving patient outcomes. Thus so far, biomarkers, patient demographics and injury characteristics are the main methods used for predicting sepsis in trauma patients. However, studies that verify their predictive value are limited, and the results are still controversial. More work should be conducted to explore more efficient and accurate ways to predict post-traumatic sepsis.

Predicting work-related disability and medical cost outcomes: a comparison of injury severity scoring methods

INTRODUCTION

Acute work-related trauma is a leading cause of death and disability among U.S. workers. Occupational health services researchers have described the pressing need to identify valid injury severity measures for purposes such as case-mix adjustment and the construction of appropriate comparison groups in programme evaluation, intervention, quality improvement, and outcome studies. The objective of this study was to compare the performance of several injury severity scores and scoring methods in the context of predicting work-related disability and medical cost outcomes.

METHODS

Washington State Trauma Registry (WTR) records for injuries treated from 1998 to 2008 were linked with workers' compensation claims. Several Abbreviated Injury Scale (AIS)-based injury severity measures (ISS, New ISS, maximum AIS) were estimated directly from ICD-9-CM codes using two software packages: (1) ICDMAP-90, and (2) Stata's user-written ICDPIC programme (ICDPIC). ICDMAP-90 and ICDPIC scores were compared with existing WTR scores using the Akaike Information Criterion, amount of variance explained, and estimated effects on outcomes. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modelled using linear regression.

RESULTS

The linked sample contained 6052 work-related injury events. There was substantial agreement between WTR scores and those estimated by ICDMAP-90 (kappa=0.73), and between WTR scores and those estimated by ICDPIC (kappa=0.68). Work disability and medical costs increased monotonically with injury severity, and injury severity was a significant predictor of work disability and medical cost outcomes in all models. WTR and ICDMAP-90 scores performed better with regard to predicting outcomes than did ICDPIC scores, but effect estimates were similar. Of the three severity measures, maxAIS was usually weakest, except when predicting total permanent disability.

CONCLUSIONS

Injury severity was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity can be estimated using either ICDMAP-90 or ICDPIC when ICD-9-CM codes are available. We observed little practical difference between severity measures or scoring methods. This study demonstrated that using existing software to estimate injury severity may be useful to enhance occupational injury surveillance and research.

Predicting work-related disability and medical cost outcomes: estimating injury severity scores from workers' compensation data

PURPOSE

Acute work-related trauma is a leading cause of death and disability among US workers. The research objectives were to assess: (1) the feasibility of estimating Abbreviated Injury Scale-based injury severity scores (ISS) from ICD-9-CM codes available in workers' compensation (WC) medical billing data, (2) whether ISS predicts work-related disability and medical cost outcomes, (3) whether ISS adds value over other injury severity proxies, and (4) whether the utility of ISS differs for an all-injury sample compared with three specific injury samples (amputations, extremity fractures, traumatic brain injury).

METHODS

ISS was estimated from ICD-9-CM codes using Stata's user-written -icdpic- program for 208,522 compensable nonfatal WC claims for workers injured in Washington State from 1998 to 2008. The Akaike Information Criterion and R(2) were used to compare severity measures. Competing risks survival analysis was used to evaluate work disability outcomes. Adjusted total medical costs were modeled using linear regression.

RESULTS

Work disability and medical costs increased monotonically with injury severity. For a subset of 4,301 claims linked to the Washington State Trauma Registry (WTR), there was moderate agreement between WC-based ISS and WTR-based ISS. Including ISS together with an early hospitalization indicator resulted in the most informative models; however, early hospitalization is a more downstream measure.

CONCLUSIONS

ISS was significantly associated with work disability and medical cost outcomes for work-related injuries. Injury severity should be considered as a potential confounder for occupational injury intervention, program evaluation, or outcome studies, and can be estimated using existing software when ICD-9-CM codes are available.

Systematic review of predictive performance of injury severity scoring tools

Many injury severity scoring tools have been developed over the past few decades. These tools include the Injury Severity Score (ISS), New ISS (NISS), Trauma and Injury Severity Score (TRISS) and International Classification of Diseases (ICD)-based Injury Severity Score (ICISS). Although many studies have endeavored to determine the ability of these tools to predict the mortality of injured patients, their results have been inconsistent. We conducted a systematic review to summarize the predictive performances of these tools and explore the heterogeneity among studies. We defined a relevant article as any research article that reported the area under the Receiver Operating Characteristic curve as a measure of predictive performance. We conducted an online search using MEDLINE and Embase. We evaluated the quality of each relevant article using a quality assessment questionnaire consisting of 10 questions. The total number of positive answers was reported as the quality score of the study. Meta-analysis was not performed due to the heterogeneity among studies. We identified 64 relevant articles with 157 AUROCs of the tools. The median number of positive answers to the questionnaire was 5, ranging from 2 to 8. Less than half of the relevant studies reported the version of the Abbreviated Injury Scale (AIS) and/or ICD (37.5%). The heterogeneity among the studies could be observed in a broad distribution of crude mortality rates of study data, ranging from 1% to 38%. The NISS was mostly reported to perform better than the ISS when predicting the mortality of blunt trauma patients. The relative performance of the ICSS against the AIS-based tools was inconclusive because of the scarcity of studies. The performance of the ICISS appeared to be unstable because the performance could be altered by the type of formula and survival risk ratios used. In conclusion, high-quality studies were limited. The NISS might perform better in the mortality prediction of blunt injuries than the ISS. Additional studies are required to standardize the derivation of the ICISS and determine the relative performance of the ICISS against the AIS-based tools.

CK/CK-MB ratio as an indirect predictor for survival in polytraumatized patients

BACKGROUND

Accurate assessment of injury severity is critical for decision making related to the prevention, triage, and treatment of several injured patients. Early estimation of mortality risk of critically injured patients is mandatory for adequate therapeutic strategies. Current risk stratification relies on clinical diagnosis and scoring systems. In our study, we hypothesized whether a simple laboratory test, the CK/CK-MB ratio, could help improving risk prediction in severely traumatized patients.

METHODS

In a 9-year period, 328 nonselected trauma patients were included in our retrospective study at a Level I Trauma Center up to September 2002. Data for this study were obtained from our computerized trauma database, established in September 1992.

RESULTS

In our study population, we could show a negative correlation between Injury Severity Score (ISS) and leukocytes. A positive correlation was detected for liver enzymes and CK-MB. The correlation between ISS and Na(+) was significant. No correlation between ISS, K(+), and Hb/Ht could be observed. Exitus was associated with ISS, alteration in thrombocytes, CK, CK-MB, CRP, Crea, and Na(+).

CONCLUSION

In our study population, CK-MB levels showed a significant correlation with overall surveillance in polytraumatized patients. In our opinion, this might suggest that CK-MB levels could be taken as an indirect predictor for survival. Our findings need to be proven in further prospective clinical trials.

The role of the New Trauma and Injury Severity Score (NTRISS) for survival prediction

The objective of this study was to verify if replacing the Injury Severity Score (ISS) by the New Injury Severity Score (NISS) in the original Trauma and Injury Severity Score (TRISS) form would improve the survival rate estimation. This retrospective study was performed in a level I trauma center during one year. ROC curve was used to identify the best indicator (TRISS or NTRISS) for survival probability prediction. Participants were 533 victims, with a mean age of 38±16 years. There was predominance of motor vehicle accidents (61.9%). External injuries were more frequent (63.0%), followed by head/neck injuries (55.5%). Survival rate was 76.9%. There is predominance of ISS scores ranging from 9-15 (40.0%), and NISS scores ranging from 16-24 (25.5%). Survival probability equal to or greater than 75.0% was obtained for 83.4% of the victims according to TRISS, and for 78.4% according to NTRISS. The new version (NTRISS) is better than TRISS for survival prediction in trauma patients.

The counterintuitive effect of multiple injuries in severity scoring: a simple variable improves the predictive ability of NISS

Background

Injury scoring is important to formulate prognoses for trauma patients. Although scores based on empirical estimation allow for better prediction, those based on expert consensus, e.g. the New Injury Severity Score (NISS) are widely used. We describe how the addition of a variable quantifying the number of injuries improves the ability of NISS to predict mortality.

Methods

We analyzed 2488 injury cases included into the trauma registry of the Italian region Emilia-Romagna in 2006-2008 and assessed the ability of NISS alone, NISS plus number of injuries, and the maximum Abbreviated Injury Scale (AIS) to predict in-hospital mortality. Hierarchical logistic regression was used. We measured discrimination through the C statistics, and calibration through Hosmer-Lemeshow statistics, Akaike's information criterion (AIC) and calibration curves.

Results

The best discrimination and calibration resulted from the model with NISS plus number of injuries, followed by NISS alone and then by the maximum AIS (C statistics 0.775, 0.755, and 0.729, respectively; AIC 1602, 1635, and 1712, respectively). The predictive ability of all the models improved after inclusion of age, gender, mechanism of injury, and the motor component of Glasgow Coma Scale (C statistics 0.889, 0.898, and 0.901; AIC 1234, 1174, and 1167). The model with NISS plus number of injuries still showed the best performances, this time with borderline statistical significance.

Conclusions

In NISS, the same weight is assigned to the three worst injuries, although the contribution of the second and third to the probability of death is smaller than that of the worst one. An improvement of the predictive ability of NISS can be obtained adjusting for the number of injuries.

The role of trauma scoring in developing trauma clinical governance in the Defence Medical Services

This paper discusses mathematical models of expressing severity of injury and probability of survival following trauma and their use in establishing clinical governance of a trauma system. There are five sections: (i) Historical overview of scoring systems--anatomical, physiological and combined systems and the advantages and disadvantages of each. (ii) Definitions used in official statistics--definitions of 'killed in action' and other categories and the importance of casualty reporting rates and comparison across conflicts and nationalities. (iii) Current scoring systems and clinical governance--clinical governance of the trauma system in the Defence Medical Services (DMS) by using trauma scoring models to analyse injury and clinical patterns. (iv) Unexpected outcomes--unexpected outcomes focus clinical governance tools. Unexpected survivors signify good practice to be promulgated. Unexpected deaths pick up areas of weakness to be addressed. Seventy-five clinically validated unexpected survivors were identified over 2 years during contemporary combat operations. (v) Future developments--can the trauma scoring methods be improved? Trauma scoring systems use linear approaches and have significant weaknesses. Trauma and its treatment is a complex system. Nonlinear methods need to be investigated to determine whether these will produce a better approach to the analysis of the survival from major trauma.

Penetrating and orthopaedic trauma from blast versus gunshots caused by terrorism: Israel's National Experience

OBJECTIVE

Evaluation of the demographics, features, and outcomes of musculoskeletal injury patterns caused by terrorism in the civil setting and comparing injuries from explosions with gunshot injuries.

DESIGN

Retrospective cohort analysis of a prospective database.

SETTING

National trauma registry consisting of all the six Level I and four Level II trauma centers.

PATIENTS

A total of 1245 casualties with terror-related musculoskeletal trauma. Five hundred fifty-one had high-velocity gunshot wound and 694 blast wounded (BW) caused by explosion.

MAIN OUTCOME MEASUREMENTS

Demographic and injury data analyzed for age, gender, New Injury Severity Score, and associated injuries. Outcome of were analyzed according to length of hospital stay, intensive care unit stay, surgical procedures, and mortality.

RESULTS

Severe injuries (New Injury Severity Score 16 or greater) were more common in the BW group (P < 0.01). In the BW group, a significantly higher proportion of casualties had associated injuries (73% versus 43%), intensive care unit care, longer length of stay, and mortality. Orthopaedic injuries were similar among the two groups with more open extremity fractures in the gunshot wound group and less significant injuries in the BW group. With casualties matched to the same New Injury Severity Score groups, the ones with the musculoskeletal injuries had longer hospitalization than those without.

CONCLUSIONS

Musculoskeletal injury caused by blast is associated with multiple penetrating injuries, differing from more "conventional" penetrating trauma such as caused by gunshot injuries. Although the treatment of specific injuries caused by both mechanisms is essentially similar, the systemic effect of the blast must be taken into consideration in anticipation of an increased overall injury severity.

Risk of mortality: the relationship with associated injuries and fracture treatment methods in patients with unilateral or bilateral femoral shaft fractures

BACKGROUND

The aim of the study was to determine the relative contributions to mortality of a unilateral or a bilateral femoral fracture in patients with or without injuries to other body regions.

STUDY DESIGN

An observational cohort study of the prospectively recorded England and Wales Trauma Registry data (Trauma Audit Research Network) from 1989 to 2003.

METHODS

Patients were divided into the following groups: UFi (isolated unilateral femur injury), BFi (isolated bilateral femur injury), and UFa and BFa, if an associated injury was present. Injury and treatment data were collected for each patient. Logistic regression data analysis was performed to determine variables that were associated with increased mortality.

RESULTS

Patients in group BFa had an increased mortality rate (31.6% vs. 9.8%) than patients in isolated bilateral femur injury group. Group BFa patients had an increased number of associated injuries (80%) than group UFa patients. Bilateral fracture, even in isolation, significantly increased the odds of mortality by 3.07. Intramedullary nailing was the method of fracture fixation associated with the lowest patient mortality overall. When assessing patient mortality in the BFa group with an New Injury Severity Score of >40, seven other fracture fixation regimens were associated with a lower mortality.

CONCLUSIONS

The increase in mortality with BFs is more closely associated with the presence of associated injuries and poor physiologic parameters than with the presence of the BF alone. The presence of BFs should alert the clinician to the very high likelihood (80%) of significant associated injuries in other body systems and their life-threatening potential. Damage control fixation options should be considered in the subgroup with a very high New Injury Severity Score.

[The Abbreviated Injury Scale (AIS). Options and problems in application]

The new AIS (Abbreviated Injury Scale) was released with an update by the AAAM (Association for the Advancement of Automotive Medicine) in 2008. It is a universal scoring system in the field of trauma applicable in clinic and research. In engineering it is used as a classification system for vehicle safety. The AIS can therefore be considered as an international, interdisciplinary and universal code of injury severity. This review focuses on a historical overview, potential applications and new coding options in the current version and also outlines the associated problems.

Severity of trauma victims admitted in intensive care units: comparative study among different indexes

This study compared the performance of the Injury Severity Score (ISS) with the New Injury Severity Score (NISS) and also the Simplified Acute Physiology Score II (SAPS II) with the Logistic Organ Dysfunction System (LODS) in trauma victims, in order to predict mortality and length of stay in Intensive Care Units (ICU), besides identifying which indexes have been the most effective to estimate these results. A retrospective analysis was done in the records of 185 victims admitted in ICU between June and December 2006. None of the four indexes properly discriminated the patients according to length of stay at the ICU. The ISS and the NISS did not show a good discriminating capacity in case of death, but the SAPS II and the LODS presented good performance to estimate mortality at the ICU. Results pointed towards the use of SAPS II and LODS when trauma victims are admitted in an ICU.

Role of lung contusions on posttraumatic inflammatory response and organ dysfunction in traumatized patients

BACKGROUND

Multiple trauma is often accompanied by lung contusion leading to secondary pulmonary inflammation and organ dysfunction. The particular role of lung contusions on the systemic inflammatory response remains unclear. Therefore, the aim of the present study was to compare the degree of lung contusion with markers of inflammation and multiple organ failure (MOF) in trauma patients.

METHODS

According to the Injury Severity Score (ISS), 45 patients were assigned to a low (< 25 points) and a high ISS group (> 25 points), respectively. Both groups were subdivided into minor and major lung injury groups as defined by computed tomography (CT) scan. Plasma levels of interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor (TNF) receptors, C-reactive protein (CRP), and polymorphonuclear (PMN) elastase were assessed, as well as the Murray lung score (MLS) and the MOF score.

RESULTS

Patients with low ISS present moderate activation of inflammation which is not influenced by the degree of lung contusion. In contrast, patients with a high ISS develop significant posttraumatic inflammation and MOF. Patients with high ISS and severe lung contusions present significantly higher MLS and MOF scores. Interestingly, patients of the high ISS group without severe lung contusions develop a similar degree of MLS and MOF only after 5 days following the traumatic insult. However, the initial plasma levels of IL-6 and IL-8 differ significantly in this group.

CONCLUSION

Our data show that severe lung contusions contributes to an immediate onset of posttraumatic inflammation in severely traumatized patients, resulting in MOF, while in severely injured patients without lung contusion, this development requires up to 5 days.

Modulation of the innate immune response after trauma visualised by a change in functional PMN phenotype

BACKGROUND

Acute Respiratory Distress Syndrome (ARDS) is a frequent and severe complication after trauma, caused by an excessive inflammatory response mediated by polymorphonuclear granulocytes (PMNs). It was previously demonstrated that patients with activated PMNs in the lungs have PMNs in the peripheral circulation with a reduced active FcgammaRII up-regulating capacity. We tested the hypothesis that a correlation exists between the severity of inflammation and the extent of decreased responsiveness of active FcgammaRII on circulating PMNs, as a sign of altered immunological capacity.

METHODS

Fifty-two patients were included and injury severity was assessed by clinical injury severity scores and base deficit. Symptoms and signs of inflammation were recorded on a daily basis and fMLP-induced active FcgammaRII on PMNs was assessed by FACS analysis within 24h after injury. Results were compared with 10, age matched healthy controls.

RESULTS

The baseline PMN membrane expression of Mac-1/CD11b and active FcgammaRII/CD32 did not correlate with injury severity. Levels of the acute phase protein Interleukin 6 (IL-6) correlated significantly with injury severity, indicating that a range in severity of the inflammatory response was present in the studied population. A statistically significant correlation between the PMN responsiveness towards the bacterial derived peptide fMLP of active FcgammaRII and injury severity was demonstrated. In addition, decreasing responsiveness of active FcgammaRII on PMNs was found in patients who developed systemic inflammatory response syndrome (SIRS) or acute lung injury (ALI)/ARDS.

CONCLUSIONS

The extent of the sustained injury and the subsequent cellular innate immune response is reflected by changes in a functional PMN phenotype of fMLP-induced active FcgammaRII in the peripheral blood.

Development and validation of the Excess Mortality Ratio-adjusted Injury Severity Score Using the International Classification of Diseases 10th Edition

OBJECTIVES

This study aimed to develop and validate a new method for measuring injury severity, the excess mortality ratio-adjusted Injury Severity Score (EMR-ISS), using the International Classification of Diseases 10th Edition (ICD-10).

METHODS

An injury severity grade similar to the Abbreviated Injury Scale (AIS) was converted from the ICD-10 codes on the basis of quintiles of the EMR for each ICD-10 code. Like the New Injury Severity Score (NISS), the EMR-ISS was calculated from three maximum severity grades using data from the Korean National Injury Database. The EMR-ISS was then validated using the Hosmer-Lemeshow goodness-of-fit chi-square (HL chi-square, with lower values preferable), the area under the receiver operating characteristic curve (AUC-ROC), and the Pearson correlation coefficient to compare it with the International Classification of Diseases 9th Edition-based Injury Severity Score (ICISS). Nationwide hospital discharge abstract data (DAD) from stratified-sample general hospitals (n = 150) in 2004 were used for an external validation.

RESULTS

The total number of study subjects was 29,282,531, with five subgroups of particular interest identified for further study: traumatic brain injury (TBI, n = 3,768,670), traumatic chest injury (TCI,n = 1,169,828), poisoning (n = 251,565), burns (n = 869,020), and DAD (n = 26,374). The HL chi-square was lower for EMR-ISS than for ICISS in all groups: 42,410.8 versus 55,721.9 in total injury, 7,139.6 versus 20,653.9 in TBI, 6,603.3 versus 4,531.8 in TCI, 2,741.2 versus 9,112.0 in poisoning, 764.4 versus 4,532.1 in burns, and 28.1 versus 49.4 in DAD. The AUC-ROC for death was greater for EMR-ISS than for ICISS: 0.920 versus 0.728 in total injury, 0.907 versus 0.898 in TBI, 0.675 versus 0.799 in TCI, 0.857 versus 0.900 in poisoning, 0.735 versus 0.682 in burns, and 0.850 versus 0.876 in DAD. The Pearson correlation coefficient between the two scores was )0.68 in total injury, )0.76 in TBI, )0.86 in TCI, )0.69 in poisoning,)0.58 in burns, and )0.75 in DAD.

CONCLUSIONS

The EMR-ISS showed better calibration and discrimination power for prediction of death than the ICISS in most injury groups. The EMR-ISS appears to be a feasible tool for passive injury surveillance of large data sets, such as insurance data sets or community injury registries containing diagnosis codes. Additional further studies for external validation on prospectively collected data sets should be considered.

How to design a good case series

A case series is a descriptive study that follows a group of patients who have a similar diagnosis or who are undergoing the same procedure over a certain period of time. As there is no experimental protocol or control for allocation of patients to treatment, surgeons and patients decide on whether or not treatment is given, making the clinical sample representative of a common clinical population. Results of case series can generate hypotheses that are useful in designing further studies, including randomized controlled trials. However, no causal inferences should be made from case series regarding the efficacy of the investigated treatment. This article will provide principles for the design, analysis, and reporting of case series, illustrated by examples from the orthopaedic surgical literature.

30 years of polytrauma care: An analysis of the change in strategies and results of 4849 cases treated at a single institution

The quality and progress of treatment of 4849 multiple trauma patients treated at one institution was reviewed retrospectively. Three periods, 1975-1984 (decade I; n=1469) and 1985-1994 (decade II; n=1937) and 1995-2004 (decade III; n=1443) were compared. 65% of multiple trauma patients had cerebral injuries, 58% thoracic trauma and 81% extremity fractures (37% open injuries). Injury combinations decreased during all decades with head/extremity injuries being the most common combination. Throughout the three decades pre-hospital care became more aggressive with an increase of intravenous fluid resuscitation (I: 80%, II: 97%, III: 98%). Chest tube insertion decreased after an initial increase (I: 41%, II: 83%, III: 27%) as well as intubation (I: 82%, II: 94%, III: 59%). Rescue times were progressively shortened. For initial clinical diagnosis of massive abdominal haemorrhage ultrasound (I: 17%, II: 92%, III: 97%) replaced peritoneal lavage (I: 44%, II: 28%, III: 0%). CT-scans were used more frequently for the initial diagnosis of head injuries and other injuries to the trunk throughout the observation time. With regard to complications, acute renal failure decreased by half (I: 8.4%; II: 3.7%; III: 3.9%), ARDS initially decreased but increased again in the last decade (I: 18.1%, II: 13.4%, III: 15.3%), whereas the rate of multiple organ dysfunction syndrome (MODS) increased continuously (I: 14.2%, II: 18.9%, III: 19.8%) probably due to a decline of the mortality rate from 37% in the first to 22% in the second and 18% in the third decade and parallel increase of the time of death. These treatment results summarise the enormous clinical effort as well as medical progress in polytrauma management over the past 30 years. Further reduction of mortality is desirable, but probably only possible when immediate causal therapy of later posttraumatic organ failure can be established.

Comparison of the new injury severity score and the injury severity score in multiple trauma patients

OBJECTIVE

To assess whether these characteristics of less misclassification and greater area under receiver operator characteristic (ROC) curve of the new injury severity score (NISS) are better than the injury severity score (ISS) as applying it to our multiple trauma patients registered into the emergency intensive care unit (EICU).

METHODS

This was a retrospective review of registry data from 2 286 multiple trauma patients consecutively registered into the EICU from January 1,1997 to December 31, 2006 in the Second Affiliated Hospital, Medical School of Zhejiang University in China. Comparisons between ISS and NISS were made using misclassification rates, ROC curve analysis, and the H-L statistics by univariate and multivariate logistic progression model.

RESULTS

Among the 2 286 patients, 176 (7.7%) were excluded because of deaths on arrival or patients less than 16 years of age. The study population therefore comprised 2 110 patients. Mean EICU length of stay (LOS) was 7.8 days ?2.4 days. Compared with the blunt injury group, the penetrating injury group had a higher percentage of male, lower mean EICU LOS and age. The most frequently injured body regions were extremities and head/neck, followed by thorax, face and abdomen in the blunt injury group; whereas, thorax and abdomen were more frequently seen in the penetrating injury group. The minimum misclassification rate for NISS was slightly less than ISS in all groups (4.01% versus 4.49%). However, NISS had more tendency to misclassify in the penetrating injury group. This, we noted, was attributed mainly to a higher false-positive rate (21.04% versus 15.55% for ISS, t equal to 3.310, P less than 0.001), resulting in an overall misclassification rate of 23.57% for NISS versus 18.79% for ISS (t equal to 3.290, P less than 0.001). In the whole sample, NISS presented equivalent discrimination (area under ROC curve: NISS equal to 0.938 versus ISS equal to 0.943). The H-L statistics showed poorer calibration (48.64 versus 32.11, t equal to 3.305, P less than 0.001) in the penetrating injury group.

CONCLUSIONS

NISS should not replace ISS because they share similar accuracy and calibration in predicting multiple blunt trauma patients. NISS may be more sensitive but less specific than ISS in predicting mortality in certain penetrating injury patients.

Effects of changing strategies of fracture fixation on immunologic changes and systemic complications after multiple trauma: damage control orthopedic surgery

In the treatment of polytrauma patients, multiple studies have shown how the timing and the type of the initial surgery of long bone fractures influence the incidence of systemic complications. Database analyses documented that unduly long surgical procedures undertaken early after trauma increase the risk of acute respiratory distress syndrome (ARDS), especially when femoral shaft fractures are stabilized. Animal research and prospective clinical studies also support the fact that the type of stabilization of a femoral shaft fracture may influence the systemic response to trauma. Reamed intramedullary reaming and nailing for a femoral shaft fracture is associated with an increased risk of pulmonary fat embolization from the medullary canal. This can result in pulmonary compromise if certain cofactors are also present. Modified reamers have been developed to reduce this side effect. The mediating effects are immunologic changes, varying according to the magnitude of the surgical procedure. Pro-inflammatory markers (e.g., Interleukins) may be used to assess the inflammatory response to injury as well as the magnitude of surgery and the systemic impact induced by surgery. Serum levels of such markers can be used clinically to tailor the amount of surgery that is performed to the clinical condition of the patient. The potentially negative impact of excessive surgery in high-risk patients can be avoided by using a new grading system for the assessment of the clinical status of the injured patient. Most recently, a large prospective randomized multicenter study has documented that this grading system is effective for identifying these borderline patients, and that in the borderline patient a staged surgical approach, such as temporary femoral stabilization with an external fixator, reduces the incidence of systemic complications. This work has changed the surgical management of multiply injured patients toward an approach that is tailored to the clinical condition of the patient, as indicated by well-defined clinical parameters as well as objective measurements of serum cytokine levels.

Ten years of new injury severity score (NISS): is it a possible change?

The article is a bibliographic review which intends to present the actual range of researches comparing the Injury Severity Score (ISS) and the New Injury Severity Score (NISS). Databases were searched using the keyword NISS, with 42 articles, 23 of which didn't compare the two indexes. Most part of the 19 selected articles showed that NISS has been more accurate in predicting the outcomes (dependent variables) than ISS, moreover in severe and specific trauma. Studies with populations between 1,000 and 10,000 resulted in NISS-favorable results, whereas studies with populations larger than 10,000 or smaller than 1,000 showed either NISS-favorable results or no difference between the two groups. However, there were no studies showing ISS-favorable results. These results and the easier calculation of NISS lead to a future replacement of ISS by NISS.

[Prehospital treatment of severely injured patients in the field: an update]

Life or extremity threatening injuries have to be diagnosed and treated rapidly by emergency physicians during prehospital care for severely injured patients. The cooperation with other rescue services, the fire brigade and the police must be coordinated and early transportation has to be organized. Rapid sequence intubation by trained personnel for correct indications, such as head injury or severe chest trauma is recommended as well as prehospital chest tube placement in cases of severe or penetrating thoracic injury. Crystalloids and colloidal solutions remain the first choice for intravenous volume replacement. The amount of fluid depends on the individual response, such as palpable peripheral and central pulse for blunt or penetrating trauma. Ultrasound or near infrared spectroscopy could not be routinely implemented for extended prehospital diagnostic procedures. Transportation to the closest appropriate hospital has to be accomplished as early as possible. Helicopters show positive outcomes if the destination is a level I trauma center, even if secondary alarm calls or more extensive measures prolong the prehospital interval.

The injury severity score or the new injury severity score for predicting mortality, intensive care unit admission and length of hospital stay: experience from a university hospital in a developing country

INTRODUCTION

Limited research has been performed to compare the predictive abilities of the injury severity score (ISS) and the new ISS (NISS) in the developing world.

PATIENTS AND METHODS

From January 2001 until January 2003 all trauma patients admitted to the American University of Beirut Medical Centre were enrolled. The statistical performance of the ISS/NISS in predicting mortality, admission to the intensive care unit (ICU) and length of hospital stay (LOS dichotomised as <10 or > or =10 days) was evaluated using receiver operating characteristic and the Hosmer-Lemeshow calibration statistic.

RESULTS

A total of 891 consecutive patients were enrolled. The ISS and NISS were equivalent in predicting survival, and both performed better in patients younger than 65 years of age. However, the ISS predicted ICU admission and LOS better than the NISS. However, these predictive abilities were lower for the geriatric trauma patients aged 65 years and above compared to the other age groups.

DISCUSSION

There are conflicting results in the literature about the abilities of ISS and NISS to predict mortality. However, this is the first study to report that ISS has a superior ability in predicting both LOS and ICU admission.

CONCLUSION

The scoring of trauma severity may need to be individualised to different countries and trauma systems.

Guidelines for the Conduction of Follow-up Studies Measuring Injury-Related Disability

BACKGROUND

Scientific knowledge on functional outcome after injury is limited. During the past decade, a variety of measures have been used at various moments in different study populations. Guidelines are needed to increase comparability between studies.

METHODS

A working group of the European Consumer Safety Association conducted a literature review of empirical studies into injury-related disability (1995-2005). We included injury from all levels of severity and selected studies using generic health status measures with both short-term and long-term follow up. The results were used as input for a consensus procedure toward the development of guidelines for defining the study populations, selecting the health status measures, selecting the timings of the assessments, and data collection procedures.

RESULTS

The group reached consensus on a common core of health status measures and assessment moments. The group advises to use a combination of EuroQol-5D and Health Utilities Mark III in all studies on injury-related disability. This combination covers all relevant health domains, is applicable in all kinds of injury populations and in widely different age ranges, provides a link with utility scores, and has several practical advantages (e.g., brevity, availability in different languages). For specific types of injury, the common core may be supplemented by injury-specific measures. The group advises a common core of assessments at 1, 2, 4, and 12 months after injury.

CONCLUSIONS

Our guidelines should be tested and may lead to improved and more consistent epidemiologic data on the incidence, severity, and duration of injury-related disability.