Introduction of a novel trauma score

Nrf2 functions as a pyroptosis-related mediator in traumatic brain injury and is correlated with cytokines and disease severity: a bioinformatics analysis and retrospective clinical study

Background

Traumatic brain injury (TBI) is a serious hazard to human health. Evidence has accumulated that pyroptosis plays an important role in brain trauma. The aim of this study is to screen potential key molecules between TBI and pyroptosis, and further explore their relationships with disease severity and cytokines.

Methods

To acquire differentially expressed genes (DEGs) before and after brain injury, the GSE89866 dataset was downloaded from the Gene Expression Omnibus (GEO) database. Meanwhile, pyroptosis-related genes were obtained from the GeneCards database, and the intersected genes were identified as differentially expressed pyroptosis-related genes (DEPGs). Moreover, the hub genes were screened via four algorithms (namely Maximum Clique Centrality, Edge Percolated Component, BottleNeck and EcCentricity) in Cytoscape software. Blood levels of Nrf2 were measured by ELISA using a commercially available kit. Finally, we further investigated the correlation between Nrf2 levels and medical indicators in TBI such as clinical characteristics, inflammatory cytokines, and severity.

Results

Altogether, we found 1,795 DEGs in GSE89866 and 98 pyroptosis-related genes in the GeneCards database. Subsequently, four hub genes were obtained, and NFE2L2 was adopted for further clinical study. By using Kruskal-Wallis test and Spearman correlation test, we found that the serum Nrf2 levels in severe TBI patients were negatively correlated with GCS scores. On the contrary, there was a positive correlation between serum Nrf2 levels and pupil parameters, Helsinki CT scores, IL-1 β and IL-18.

Conclusions

In summary, bioinformatic analyses showed NFE2L2 plays a significant role in the pathology of TBI. The clinical research indicated the increase in serum Nrf2 levels was closely related to the severity of trauma and cytokines. We speculate that serum Nrf2 may serve as a promising biochemical marker for the assessment of TBI in clinical practice.

Dynamic predictors of in-hospital and 3-year mortality after traumatic brain injury: A retrospective cohort study

BACKGROUND

Mortality risks after Traumatic Brain Injury (TBI) are understudied in critical illness. We sought to identify risks of mortality in critically ill patients with TBI using time-varying covariates.

METHODS

This single-center, six-year (2006-2012), retrospective cohort study measured demographics, injury characteristics, and daily data of acute TBI patients in the Intensive Care Unit (ICU). Time-varying Cox proportional hazards models assessed in-hospital and 3-year mortality.

RESULTS

Post-TBI ICU patients (n = 2664) experienced 20% in-hospital mortality (n = 529) and 27% (n = 706) 3-year mortality. Glasgow Coma Scale motor subscore (hazard ratio (HR) 0.58, p < 0.001), pupil reactivity (HR 3.17, p < 0.001), minimum glucose (HR 1.44, p < 0.001), mSOFA score (HR 1.81, p < 0.001), coma (HR 2.26, p < 0.001), and benzodiazepines (HR 1.38, p < 0.001) were associated with in-hospital mortality. At three years, public insurance (HR 1.78, p = 0.011) and discharge disposition (HR 4.48, p < 0.001) were associated with death.

CONCLUSIONS

Time-varying characteristics influenced in-hospital mortality post-TBI. Socioeconomic factors primarily affect three-year mortality.

Extracorporeal membrane oxygenation in traumatic brain injury - A retrospective, multicenter cohort study

INTRODUCTION

Patients with traumatic brain injury (TBI) regularly require intensive care with prolonged invasive ventilation. Consequently, these patients are at increased risk of pulmonary failure, potentially requiring extracorporeal membrane oxygenation (ECMO). The aim of this work was to provide an overview of ECMO treatment in TBI patients based upon data captured into the TraumaRegister DGU® (TR-DGU).

METHODS

A retrospective multi-center cohort analysis of patients registered in the TR-DGU was conducted. Adult patients with relevant TBI (AIS_Head ≥3) who had been treated in German, Austrian, or Swiss level I or II trauma centers using ECMO therapy between 2015 and 2019 were included. A multivariable logistic regression analysis was used to identify risk factors for the need for ECMO treatment.

RESULTS

12,247 patients fulfilled the inclusion criteria. The overall rate of ECMO treatment was 1.1% (134 patients). Patients on ECMO had an overall hospital mortality rate of 38% (51/134 patients) while 13% (1523/12,113 patients) of TBI patients without ECMO therapy died. Male gender (p = 0.014), AIS_Chest 3+ (p<0.001), higher Injury Severity Score (p<0.001) and packed red blood cell (pRBC) transfusion (p<0.001) were associated with ECMO treatment.

CONCLUSION

ECMO therapy is a potentially lifesaving modality for the treatment of moderate-to-severe TBI when combined with severe chest trauma and pulmonary failure. The in-hospital mortality is increased in this high-risk population, but the majority of patients is surviving.

The Influence of Serious Extracranial Injury on In-Hospital Mortality in Children with Severe Traumatic Brain Injury

(1) Background: Severe traumatic brain injury (sTBI) is the leading cause of death in children. Serious extracranial injury (SEI) commonly coexists with sTBI after the high impact of trauma. Limited studies evaluate the influence of SEI on the prognosis of pediatric sTBI. We aimed to analyze SEI’s clinical characteristics and initial presentations and evaluate if SEI is predictive of higher in-hospital mortality in these sTBI children. (2) Methods: In this 11-year-observational cohort study, a total of 148 severe sTBI children were enrolled. We collected patients’ initial data in the emergency department, including gender, age, mechanism of injury, coexisting SEI, motor components of the Glasgow Coma Scale (mGCS) score, body temperature, blood pressure, blood glucose level, initial prothrombin time, and intracranial Rotterdam computed tomography (CT) score of the first brain CT scan, as potential mortality predictors. (3) Results: Compared to sTBI children without SEI, children with SEI were older and more presented with initial hypotension and hypothermia; the initial lab showed more prolonged prothrombin time and a higher in-hospital mortality rate. Multivariate analysis showed that motor components of mGCS, fixed pupil reaction, prolonged prothrombin time, and higher Rotterdam CT score were independent predictors of in-hospital mortality in sTBI children. SEI was not an independent predictor of mortality. (4) Conclusions: sTBI children with SEI had significantly higher in-hospital mortality than those without. SEI was not an independent predictor of mortality in our study. Brain injury intensity and its presentations, including lower mGCS, fixed pupil reaction, higher Rotterdam CT score, and severe injury-induced systemic response, presented as initial prolonged prothrombin time, were independent predictors of in-hospital mortality in these sTBI children.

Cranial nerve injuries in patients with moderate to severe head trauma - Analysis of 91,196 patients from the TraumaRegister DGU® between 2008 and 2017

OBJECTIVE

Traumatic brain injury (TBI) constitutes a major cause of trauma-related disability and mortality. The epidemiology and implications of associated cranial nerve injuries　(CNI)　in moderate to severe TBI are largely unknown. We aimed to determine the incidence of CNI in a large European cohort of TBI patients as well as clinical differences between TBI cases with and without concomitant CNI (CNI vs. control group) by means of a multinational trauma registry.

METHODS

The TraumaRegister DGU® was evaluated for trauma patients with head injuries ≥ 2 Abbreviated Injury Scale, who had to be treated on intensive care units after emergency admission to European hospitals between 2008 and 2017. CNI and control cases were compared with respect to demographic, clinical, and outcome variables.

RESULTS

1.0% (946 of 91,196) of TBI patients presented with additional CNI. On average, CNI patients were younger than control cases (44.3 ± 20.6 vs. 51.8 ± 23.0 years) but did not differ regarding sex distribution (CNI 69.4% males vs. control 69.1%). Traffic accidents were encountered more frequently in CNI cases (52.3% vs. 46.7%; p < 0.001; chi-squared test) and falls more commonly in the control group (45.2% vs. 37.1%; p < 0.001). CNI patients suffered more frequently from concomitant face injuries (28.2% vs. 17.5%; p < 0.001) and skull base fractures (51.0% vs. 23.5%; p < 0.001). Despite similar mean Injury Severity Score (CNI 21.8 ± 11.3; control 21.1 ± 11.7) and Glasgow Coma Scale score (CNI 10.9 ± 4.2, control 11.1 ± 4.4), there was a considerably higher proportion of anisocoria in CNI patients (20.1% vs. 11.2%; p < 0.001). Following primary treatment, 50.8% of CNI and 35.5% of control cases showed moderate to severe disability (Glasgow Outcome Scale score 3-4; p < 0.001).

CONCLUSION

CNI rarely occur in the context of TBI. When present, they indicate a higher likelihood of functional impairment following primary care and complicating skull base fractures should be suspected.

The impact of delayed time to first CT head on functional outcomes after blunt head trauma with moderately depressed GCS

Purpose

Recent work suggests patients with moderately depressed Glasgow Coma Scale (GCS) score in the Emergency Department (ED) who do not undergo immediate head CT (CTH) have delayed neurosurgical intervention and longer ED stay. The present study objective was to determine the impact of time to first CTH on functional neurologic outcomes in this patient population.

Methods

Blunt trauma patients presenting to our Level I trauma center (11/2015–10/2019) with first ED GCS 9–12 were retrospectively identified and included. Transfers and those with extracranial AIS ≥ 3 were excluded. The study population was stratified into Immediate (≤ 1 h) and Delayed (1–6 h) CTH groups based on time from ED arrival to first CTH. Outcomes included functional outcomes at hospital discharge based on the Modified Rankin Scale (mRS).

Results

After exclusions, 564 patients were included: 414 (73%) with Immediate CTH and 150 (27%) Delayed CTH. Both groups arrived with median GCS 11 and alcohol/drug intoxication did not differ (p > 0.05). AIS Head/Neck was comparable (3[3–4] vs. 3[3–3], p = 0.349). Time to ED disposition decision and ED exit were significantly shorter after Immediate CTH (2.8[1.5–5.3] vs. 5.2[3.6–7.5]h, p < 0.001 and 5.5[3.3–8.9] vs. 8.1[5.2–11.7]h, p < 0.001). Functional outcomes were slightly worse after Immediate CTH (mRS 2[1–4] vs. 2[1–3], p = 0.002). Subgroup analysis of patients requiring neurosurgical intervention demonstrated a greater proportion of moderately disabled patients with a lower proportion of severely disabled or dead patients after Immediate CTH as compared to Delayed CTH (51 vs. 20%, p = 0.063 and 35 vs. 60%, p = 0.122).

Conclusions

Immediate CTH shortened time to disposition decision out of the ED and ED exit. Patients requiring neurosurgical intervention after Immediate CTH had improved functional outcomes when compared to those undergoing Delayed CTH. These differences did not reach statistical significance in this single-center study and, therefore, a large, multicenter study is the next step in demonstrating the potential functional outcomes benefit of Immediate CTH after blunt head trauma.

Epidemiology and predictors of traumatic spine injury in severely injured patients: implications for emergency procedures

PURPOSE

This study aimed to identify the prevalence and predictors of spinal injuries that are suitable for immobilization.

METHODS

Retrospective cohort study drawing from the multi-center database of the TraumaRegister DGU^®, spinal injury patients ≥ 16 years of age who scored ≥ 3 on the Abbreviated Injury Scale (AIS) between 2009 and 2016 were enrolled.

RESULTS

The mean age of the 145,833 patients enrolled was 52.7 ± 21.1 years. The hospital mortality rate was 13.9%, and the mean injury severity score (ISS) was 21.8 ± 11.8. Seventy percent of patients had no spine injury, 25.9% scored 2-3 on the AIS, and 4.1% scored 4-6 on the AIS. Among patients with isolated traumatic brain injury (TBI), 26.8% had spinal injuries with an AIS score of 4-6. Among patients with multi-system trauma and TBI, 44.7% had spinal injuries that scored 4-6 on the AIS. Regression analysis predicted a serious spine injury (SI; AIS 3-6) with a prevalence of 10.6% and cervical spine injury (CSI; AIS 3-6) with a prevalence of 5.1%. Blunt trauma was a predictor for SI and CSI (OR 4.066 and OR 3.640, respectively; both p < 0.001) and fall > 3 m for SI (OR 2.243; p < 0.001) but not CSI (OR 0.636; p < 0.001). Pre-hospital shock was predictive for SI and CSI (OR 1.87 and OR 2.342, respectively; both p < 0.001), and diminished or absent motor response was also predictive for SI (OR 3.171) and CSI (OR 7.462; both p < 0.001). Patients over 65 years of age were more frequently affected by CSI.

CONCLUSIONS

In addition to the clinical symptoms of pain, we identify '4S' [spill (fall) > 3 m, seniority (age > 65 years), seriously injured, skull/traumatic brain injury] as an indication for increased attention for CSIs or indication for spinal motion restriction.

The AdHOC (age, head injury, oxygenation, circulation) score: a simple assessment tool for early assessment of severely injured patients with major fractures

Purpose

We sought to develop a simple, effective and accurate assessment tool using well-known prognostic parameters to predict mortality and morbidity in severely injured patients with major fractures at the stage of the trauma bay.

Methods

European Data from the TraumaRegister DGU^® were queried for patients aged 16 or older and with an ISS of 9 and higher with major fractures. The development (2012–2015) and validation (2016) groups were separated. The four prognostic aspects Age, Head injury, Oxygenation and Circulation along with parameters were identified as having a relevant impact on the outcome of severely injured patients with major fractures. The performance of the score was analyzed with the area under the receiver operating characteristics curve and compared to other trauma scores.

Results

An increasing AdHOC (Age, Head injury, Oxygenation, Circulation) score value in the 17,827 included patients correlated with increasing mortality (0 points = 0.3%, 1 point = 5.3%, 2 points = 15.6%, 3 points = 42.5% and 4 points = 62.6%). With an AUROC of 0.858 for the development (n = 14,047) and 0.877 for the validation (n = 3780) group dataset, the score is superior in performance compared to the Injury Severity Score (0.806/0.815).

Conclusion

The AdHOC score appears to be easy and accessible in every emergency room without the requirement of special diagnostic tools or knowledge of the exact injury pattern and can be useful for the planning of further surgical treatment.

Cross-validation of two prognostic trauma scores in severely injured patients

Introduction

Trauma scoring systems are important tools for outcome prediction and severity adjustment that informs trauma quality assessment and research. Discrimination and precision of such systems is tested in validation studies. The German TraumaRegister DGU^® (TR-DGU) and the Trauma Audit and Research Network (TARN) from the UK agreed on a cross-validation study to validate their prediction scores (RISC II and PS14, respectively).

Methods

Severe trauma patients with an Injury Severity Score (ISS) ≥ 9 documented in 2015 and 2016 were selected in both registries (primary admissions only). The predictive scores from each registry were applied to the selected data sets. Observed and predicted mortality were compared to assess precision; area under the receiver operating characteristic curve was used for discrimination. Hosmer–Lemeshow statistic was calculated for calibration. A subgroup analysis including patients treated in intensive care unit (ICU) was also carried out.

Results

From TR-DGU, 40,638 patients were included (mortality 11.7%). The RISC II predicted mortality was 11.2%, while PS14 predicted 16.9% mortality. From TARN, 64,622 patients were included (mortality 9.7%). PS14 predicted 10.6% mortality, while RISC II predicted 17.7%. Despite the identical cutoff of ISS ≥ 9, patient groups from both registries showed considerable difference in need for intensive care (88% versus 18%). Subgroup analysis of patients treated on ICU showed nearly identical values for observed and predicted mortality using RISC II.

Discussion

Each score performed well within its respective registry, but when applied to the other registry a decrease in performance was observed. Part of this loss of performance could be explained by different development data sets: the RISC II is mainly based on patients treated in an ICU, while the PS14 includes cases mainly cared for outside ICU with more moderate injury severity. This is according to the respective inclusion criteria of the two registries.

Conclusion

External validations of prediction models between registries are needed, but may show that prediction models are not fully transferable to other health-care settings.

Initial pupil status is a strong predictor for in-hospital mortality after aneurysmal subarachnoid hemorrhage

Prognosis of patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) is only insufficiently displayed by current standard prognostic scores. This study aims to evaluate the role of pupil status for mortality prediction and provide improved prognostic models. Anonymized data of 477 aSAH patients admitted to our medical center from November 2010 to August 2018 were retrospectively analyzed. Identification of variables independently predicting in-hospital mortality was performed by multivariable logistic regression analysis. Final regression models included Hunt & Hess scale (H&H), pupil status and age or in a simplified variation only H&H and pupil status, leading to the design of novel H&H-Pupil-Age score (HHPA) and simplified H&H-Pupil score (sHHP), respectively. In an external validation cohort of 402 patients, areas under the receiver operating characteristic curves (AUROC) of HHPA (0.841) and sHHP (0.821) were significantly higher than areas of H&H (0.794; p < 0.001) or World Federation of Neurosurgical Societies (WFNS) scale (0.775; p < 0.01). Accordingly, including information about pupil status improves the predictive performance of prognostic scores for in-hospital mortality in patients with aSAH. HHPA and sHHP allow simple, early and detailed prognosis assessment while predictive performance remained strong in an external validation cohort suggesting adequate generalizability and low interrater variability.

[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]

BACKGROUND

Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured.

MATERIAL AND METHODS

Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis.

RESULTS

The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset.

CONCLUSION

The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.

Does an assessment aid improve Glasgow Coma Scale scoring by helicopter rescuers in Hong Kong: A randomised controlled trial

BACKGROUND

Glasgow Coma Scale (GCS) is one of the most commonly used patient assessment tools. This study aimed to determine whether an assessment aid can improve the GCS scoring accuracy by helicopter rescuers in Hong Kong.

METHODS

In this randomised controlled trial, Air Crewman Officers (ACMOs) of Government Flying Service in Hong Kong were randomised into two groups, with and without assessment aid. The group with the assessment aid was provided a printed copy of the GCS scoring table while watching the patient simulated videos. Ten videos with GCS scores ranging from 3 to 15 were used to test the performance of total GCS (tGCS) and motor component of GCS (mGCS) scoring.

RESULTS

78% (n=25/32) of ACMOs participated in the study. By comparing the groups with and without an assessment aid, there was no significant difference in the accuracy of tGCS score (60% versus 60%; p=0.85) or mGCS score (80% versus 80%; p=0.75). Overall, mGCS has a higher accuracy than tGCS (p<0.001). The accuracy of mGCS was better than tGCS in mild and moderate brain injury scenarios.

CONCLUSION

The use of an assessment aid did not improve GCS scoring by helicopter rescuers. The assessing of mGCS was more accurate than tGCS, further supporting the use of mGCS for prehospital conscious level assessment.

Influence of severity of traumatic brain injury at hospital admission on clinical outcomes

ABSTRACT Traumatic brain injury (TBI) is a public health problem with high mortality and socioeconomic repercussions. We aimed to investigate the influence of TBI severity on the length of mechanical ventilation (MV) stay and length of hospital stay and on the prevalence of tracheostomy, pneumonia, neurosurgery and death. This retrospective, observational study evaluated medical records of 67 patients with TBI admitted to Irmandade da Santa Casa de Misericórdia de São Paulo. Severity was determined according to the Glasgow Coma Scale (GCS): mild (13-15 points; 36 patients; 53.7%), moderate (9-12 points; 14 patients; 20.9%) or severe (3-8 points; 17 patients; 25.4%). Severe TBI patients had higher prevalence of tracheostomy, pneumonia and neurosurgery. No significant differences were observed between TBI severity, mortality and length of MV stay. However, TBI severity influenced the length of hospital stay. TBI severity at admission, evaluated according to the GCS, influenced the prevalence of tracheostomy, pneumonia, neurosurgery and was associated to prolonged hospital stay.

Data Improvement Through Simplification: Implications for Low-Resource Settings

BACKGROUND

The focus of many data collection efforts centers on creation of more granular data. The assumption is that more complex data are better able to predict outcomes. We hypothesized that data are often needlessly complex. We sought to demonstrate this concept by examination of the American Society of Anesthesiologists (ASA) scoring system.

METHODS

First, we created every possible consecutive two, three and four category combinations of the current five category ASA score. This resulted in 14 combinations of simplified ASA. We compared the predictive ability of these simplified scores for postoperative outcomes for 2.3 million patients in the NSQIP database. Individual model performance was assessed by comparing receiver operator characteristic (ROC) curves for each model with the standard ASA.

RESULTS

Two of our 4-category models and one of our 3-category models had ability to predict all outcomes equivalent to standard ASA. These results held for all outcomes and on all subgroups tested. The performance of the three best performing simplified ASA scores were also equivalent to the standard ASA score in the univariate analysis and when included in a multivariate model.

CONCLUSIONS

It is assumed that the most granular data and use of the largest number of variables for risk-adjusted predictions will increase accuracy. This complexity is often at the expense of utility. Using the single best predictor in surgical outcomes research, we have shown this is not the case. In this example, we demonstrate that one can simplify ASA into a 3-category variable without losing any ability to predict outcomes.

Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIS_head) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIS_head score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.

Nomogram for Predicting Time to Death After Withdrawal of Life-Sustaining Treatment in Patients With Devastating Neurological Injury

Reliable prediction of time of death after withdrawal of life-sustaining treatment in patients with devastating neurological injury is crucial to successful donation after cardiac death. Herein, we conducted a study of 419 neurocritical patients who underwent life support withdrawal at four neurosurgical centers in China. Based on a retrospective cohort, we used multivariate Cox regression analysis to identify prognostic factors for patient death, which were then integrated into a nomogram. The model was calibrated and validated using data from an external retrospective cohort and a prospective cohort. We identified 10 variables that were incorporated into a nomogram. The C-indexes for predicting the 60-min death probability in the training, external validation and prospective validation cohorts were 0.96 (0.93-0.98), 0.94 (0.91-0.97), and 0.99 (0.97-1.00), respectively. The calibration plots after WLST showed an optimal agreement between the prediction of time to death by the nomogram and the actual observation for all cohorts. Then we identified 22, 26 and 37 as cut-points for risk stratification into four groups. Kaplan-Meier curves indicated distinct prognoses between patients in the different risk groups (p < 0.001). In conclusion, we have developed and validated a nomogram to accurately identify potential cardiac death donors in neurocritical patients in a Chinese population.

Update of the trauma risk adjustment model of the TraumaRegister DGU™: the Revised Injury Severity Classification, version II

INTRODUCTION

The TraumaRegister DGU™ (TR-DGU) has used the Revised Injury Severity Classification (RISC) score for outcome adjustment since 2003. In recent years, however, the observed mortality rate has fallen to about 2% below the prognosis, and it was felt that further prognostic factors, like pupil size and reaction, should be included as well. Finally, an increasing number of cases did not receive a RISC prognosis due to the missing values. Therefore, there was a need for an updated model for risk of death prediction in severely injured patients to be developed and validated using the most recent data.

METHODS

The TR-DGU has been collecting data from severely injured patients since 1993. All injuries are coded according to the Abbreviated Injury Scale (AIS, version 2008). Severely injured patients from Europe (ISS ≥ 4) documented between 2010 and 2011 were selected for developing the new score (n = 30,866), and 21,918 patients from 2012 were used for validation. Age and injury codes were required, and transferred patients were excluded. Logistic regression analysis was applied with hospital mortality as the dependent variable. Results were evaluated in terms of discrimination (area under the receiver operating characteristic curve, AUC), precision (observed versus predicted mortality), and calibration (Hosmer-Lemeshow goodness-of-fit statistic).

RESULTS

The mean age of the development population was 47.3 years; 71.6% were males, and the average ISS was 19.3 points. Hospital mortality rate was 11.5% in this group. The new RISC II model consists of the following predictors: worst and second-worst injury (AIS severity level), head injury, age, sex, pupil reactivity and size, pre-injury health status, blood pressure, acidosis (base deficit), coagulation, haemoglobin, and cardiopulmonary resuscitation. Missing values are included as a separate category for every variable. In the development and the validation dataset, the new RISC II outperformed the original RISC score, for example AUC in the development dataset 0.953 versus 0.939.

CONCLUSIONS

The updated RISC II prognostic score has several advantages over the previous RISC model. Discrimination, precision and calibration are improved, and patients with partial missing values could now be included. Results were confirmed in a validation dataset.