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John Baptist S, Joel K, Kaddumukasa M, Michael D, Kasereka Kamabu L, Galukande M, Kaddumukasa M, Sajatovic M, Timothy Kabanda M. Fibrinogen; a predictor of injury severity and mortality among patients with traumatic brain injury in Sub-Saharan Africa: A cross-sectional observational study. Medicine (Baltimore) 2023; 102:e35685. [PMID: 37861493 PMCID: PMC10589598 DOI: 10.1097/md.0000000000035685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023] Open
Abstract
Studies show that fibrinogen concentrations <2 g/L in patients with traumatic brain injury (TBI) is associated with increased mortality. However, little is known regarding fibrinogen levels and TBI severity as well as mortality in sub-Saharan Africa despite shouldering a high burden of TBI. We therefore set out to determine whether fibrinogen levels are associated with TBI severity and outcome. To determine the sensitivity and specificity of fibrinogen levels and the association with severity and mortality among TBI patients at Mulago Hospital. We prospectively enrolled 213 patients with TBI aged between 13 and 60 years of age and presenting within 24 hours of injury. Patients with preexisting coagulopathy, concurrent use of anticoagulant or antiplatelet agents, preexisting hepatic insufficiency, diabetes mellitus and who were pregnant were excluded. Fibrinogen levels were determined using the Clauss fibrinogen assay. Logistic regression analyses were conducted to identify the association between fibrinogen level and 7-day outcomes. Majority of the patients were male (88.7%) and nearly half were aged 30 or less (48.8%). Fibrinogen levels <2 g/L were observed in 35.1% of the study participants. The average time spent in the study was 3.7 ± 2.4 days. The sensitivity and specificity using fibrinogen <2 g/L was 56.5% and 72.9% respectively. Fibrinogen levels predict TBI severity with an AUC = 0.656 (95% CI 0.58-0.73: P = .000) Fibrinogen levels <2 g/L (hypofibrinogenemia) were independently associated with severe TBI. (Adjusted odds ratio 2.87 CI, 1.34-6.14: P = .007). Levels above 4.5 g/L were also independently associated with injury severity (adjusted odds ratio 2.89, CI 1.12-7.48: P < .05) Fibrinogen levels more than 4.5 g/L were independently associated with mortality (OR 4.5, CI; 1.47-13.61, P < .05). The fibrinogen level is a useful tool in predicting severity including mortality of TBI. Fibrinogen levels may be used as an additional tool to screen TBI patients for injury severity especially among patients with Glasgow coma scale scores of <14.
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Affiliation(s)
| | - Kiryabwire Joel
- Neurosurgery Unit, Mulago National Referral Hospital, Kampala, Uganda
| | - Martin Kaddumukasa
- Department of Medicine, College of Health Sciences Makerere University, Kampala, Uganda
| | - Devereaux Michael
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center, Cleveland, OH, USA
| | | | - Moses Galukande
- Department of Surgery, College of Health Sciences Makerere University, Kampala, Uganda
| | - Mark Kaddumukasa
- Department of Medicine, College of Health Sciences Makerere University, Kampala, Uganda
| | - Martha Sajatovic
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center, Cleveland, OH, USA
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Anthony AA, Dutta R, Sarang B, David S, O'Reilly G, Raykar NP, Khajanchi M, Attergrim J, Soni KD, Sharma N, Mohan M, Gadgil A, Roy N, Gerdin Wärnberg M. Profile and triage validity of trauma patients triaged green: a prospective cohort study from a secondary care hospital in India. BMJ Open 2023; 13:e065036. [PMID: 37156594 PMCID: PMC10173999 DOI: 10.1136/bmjopen-2022-065036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
OBJECTIVES To evaluate the profile of non-urgent patients triaged 'green', as part of a triage trial in the emergency department (ED) of a secondary care hospital in India. The secondary aim was to validate the triage trial with the South African Triage Score (SATS). DESIGN Prospective cohort study. SETTING A secondary care hospital in Mumbai, India. PARTICIPANTS Patients aged 18 years and above with a history of trauma defined as having any of the external causes of morbidity and mortality listed in block V01-Y36, chapter XX of the International Classification of Disease version 10 codebook, triaged green between July 2016 and November 2019. PRIMARY AND SECONDARY OUTCOME MEASURES Outcome measures were mortality within 24 hours, 30 days and mistriage. RESULTS We included 4135 trauma patients triaged green. The mean age of patients was 32.8 (±13.1) years, and 77% were males. The median (IQR) length of stay of admitted patients was 3 (13) days. Half the patients had a mild Injury Severity Score (3-8), with the majority of injuries being blunt (98%). Of the patients triaged green by clinicians, three-quarters (74%) were undertriaged on validating with SATS. On telephonic follow-up, two patients were reported dead whereas one died while admitted in hospital. CONCLUSIONS Our study highlights the need for implementation and evaluation of training in trauma triage systems that use physiological parameters, including pulse, systolic blood pressure and Glasgow Coma Scale, for the in-hospital first responders in the EDs.
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Affiliation(s)
| | - Rohini Dutta
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Bhakti Sarang
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
- Department of Surgery, Terna Medical College & Hospital, New Mumbai, India
| | - Siddarth David
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
| | - Gerard O'Reilly
- Department of Emergency Medicine, Monash University, Clayton, Victoria, Australia
| | - Nakul P Raykar
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
- Department of Emergency Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Monty Khajanchi
- Department of Surgery, Seth Gowardhandas Sunderdas Medical College and King Edward Memorial Hospital, Mumbai, India
| | - Jonatan Attergrim
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
| | - Kapil Dev Soni
- Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Naveen Sharma
- Department of Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Monali Mohan
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Anita Gadgil
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Nobhojit Roy
- World Health Organization Collaborating Center for Research in Surgical Care Delivery in Low-and-Middle Income Countries, Mumbai, India
| | - Martin Gerdin Wärnberg
- Department of Global Public Health, Karolinska Institutet, Solna, Sweden
- Function Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden
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Ssenyondwa JB, Kiryabwire J, Kaddumukasa M, Michael D, Kamabu LK, Galukande M, Kaddumukasa M, Sajatovic M, Makumbi TK. Fibrinogen; a predictor of injury severity and mortality among patients with traumatic brain injury in Sub-Saharan Africa: a prospective study. RESEARCH SQUARE 2023:rs.3.rs-2596161. [PMID: 36909492 PMCID: PMC10002822 DOI: 10.21203/rs.3.rs-2596161/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/05/2023]
Abstract
Introduction Fibrinogen levels drop quicker than any other factors in severe trauma such as Traumatic Brain Injury (TBI). Contemporaneous studies show that fibrinogen concentrations < 2 g/L are strongly related to mortality. However, little is known regarding fibrinogen levels and TBI severity as well as mortality in sub-Saharan Africa. We therefore set out to determine whether fibrinogen levels are associated with TBI severity and seven days outcomes. Objectives To determine the sensitivity and specificity of fibrinogen levels and the association with severity and mortality among TBI patients at Mulago Hospital. Methods We prospectively enrolled 213 patients with TBI aged between 13 and 60 years of age and presenting within 24hrs of injury. Patients with pre-existing coagulopathy, concurrent use of anticoagulant or antiplatelet agents, pre-existing hepatic insufficiency, diabetes mellitus and who were pregnant were excluded. Fibrinogen levels were determined using the Clauss fibrinogen assay. Results Majority of the patients were male (88.7%) and nearly half were aged 30 or less (48.8%). Fibrinogen levels less than 2g/L were observed in 74 (35.1%) of the patients while levels above 4.5 g/L were observed in 30(14.2%) of the patients. The average time spent in the study was 3.7 ± 2.4 days. The sensitivity and specificity using fibrinogen < 2g/L was 56.5% and 72.9% respectively. Fibrinogen levels predict TBI severity with an AUC = 0.656 (95% CI 0.58-0.73: p = 0.000) Fibrinogen levels < 2g/L (hypofibrinogenemia) were independently associated with severe TBI. (AOR 2.87 CI,1.34-6.14: p = 0.007). Levels above 4.5g/L were also independently associated with injury severity (AOR 2.89, CI 1.12-7.48: p < 0.05) Fibrinogen levels more than 4.5g/L were independently associated with mortality (OR 4.5, CI;1.47-13.61, p < 0.05). Conclusions The fibrinogen level is a useful tool in predicting severity including mortality of TBI in our settings. We recommend the routine use of fibrinogen levels in TBI patient evaluations as levels below 2g/L and levels above 4.5g/L are associated with severe injuries and mortality.
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Affiliation(s)
| | | | | | - Devereaux Michael
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center
| | | | | | | | - Martha Sajatovic
- Neurological and Behavioral Outcome Center, University Hospitals, Case Medical Center
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Liu TT, Cheng CT, Hsu CP, Chaou CH, Ng CJ, Jeng MJ, Chang YC. Validation of a five-level triage system in pediatric trauma and the effectiveness of triage nurse modification: A multi-center cohort analysis. Front Med (Lausanne) 2022; 9:947501. [PMID: 36388924 PMCID: PMC9664936 DOI: 10.3389/fmed.2022.947501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 09/27/2022] [Indexed: 01/24/2023] Open
Abstract
INTRODUCTION Triage is one of the most important tasks for nurses in a modern emergency department (ED) and it plays a critical role in pediatric trauma. An appropriate triage system can improve patient outcomes and decrease resource wasting. However, triage systems for pediatric trauma have not been validated worldwide. To ensure clinical reliability, nurses are allowed to override the acuity level at the end of the routine triage process. This study aimed to validate the Taiwan Triage and Acuity Scale (TTAS) for pediatric trauma and evaluate the effectiveness of triage nurse modification. METHODS This was a multicenter retrospective cohort study analyzing triage data of all pediatric trauma patients who visited six EDs across Taiwan from 2015 to 2019. Each patient was triaged by a well-trained nurse and assigned an acuity level. Triage nurses can modify their acuity based on their professional judgment. The primary outcome was the predictive performance of TTAS for pediatric trauma, including hospitalization, ED length of stay, emergency surgery, and costs. The secondary outcome was the accuracy of nurse modification and the contributing factors. Multivariate regression was used for data analysis. The Akaike information criterion and C-statistics were utilized to measure the prediction performance of TTAS. RESULTS In total, 45,364 pediatric patients were included in this study. Overall mortality, hospitalization, and emergency surgery rates were 0.17, 5.4, and 0.76%, respectively. In almost all cases (97.48%), the triage nurses agreed upon the original scale. All major outcomes showed a significant positive correlation with the upgrade of acuity levels in TTAS in pediatric trauma patients. After nurse modification, the Akaike information criterion decreased and C-statistics increased, indicating better prediction performance. The factors contributing to this modification were being under 6 years of age, heart rate, respiratory rate, and primary location of injuries. CONCLUSION The TTAS is a reliable triage tool for pediatric trauma patients. Modification by well-experienced triage nurses can enhance its prediction performance. Younger age, heart rate, respiratory rate, and primary location of injuries contributed to modifications of the triage nurse. Further external validation is required to determine its role in pediatric trauma worldwide.
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Affiliation(s)
- Tien-Tien Liu
- Department of Nursing, Chang Gung Memorial Hospital, Taoyuan, Taiwan,Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan
| | - Chi-Tung Cheng
- Division of Trauma and Emergency Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Po Hsu
- Division of Trauma and Emergency Surgery, Department of General Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Hsien Chaou
- College of Medicine, Chang Gung University, Taoyuan, Taiwan,Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Chip-Jin Ng
- Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan,National Working Group of Taiwan Triage and Acuity Scale (TTAS), Taipei, Taiwan
| | - Mei-Jy Jeng
- Institute of Emergency and Critical Care Medicine, National Yang-Ming Chiao-Tung University, Taipei, Taiwan,Department of Pediatrics, Taipei Veterans General Hospital, Taipei, Taiwan,*Correspondence: Mei-Jy Jeng
| | - Yu-Che Chang
- College of Medicine, Chang Gung University, Taoyuan, Taiwan,Chang Gung Medical Education Research Centre (CG-MERC), Taoyuan, Taiwan,Department of Emergency Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan,National Working Group of Taiwan Triage and Acuity Scale (TTAS), Taipei, Taiwan,Yu-Che Chang
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Khari S, Zandi M, Yousefifard M. Glasgow Coma Scale Versus Physiologic Scoring Systems in Predicting the Outcome of ICU admitted Trauma Patients; a Diagnostic Accuracy Study. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2022; 10:e25. [PMID: 35573721 PMCID: PMC9078058 DOI: 10.22037/aaem.v10i1.1483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction There is no consensus on the performance of decision rules in predicting the prognosis of trauma patients. Therefore, the present study aimed to compare the value of Glasgow coma scale (GCS) and physiologic scoring systems in predicting mortality and poor outcome of trauma patients. Methods This diagnostic accuracy study was conducted on multiple trauma patients admitted to the intensive care units of two hospitals in Tehran, Iran, from 21 November 2020 to 22 May 2021. The patients' demographic characteristics, length of stay in the intensive care unit (ICU), the vital signs, and the GCS on admission were recorded. Finally, the mortality, disability, and complete recovery of patients at the time of discharge were evaluated and receiver operating characteristics (ROC) curve analysis was used to compare the performance of physiologic scoring systems with GCS. Results 200 trauma patients with the mean age of 43.53±19.84 years were evaluated (74% male). The area under the ROC curve for New Trauma Score (NTS), Revised Trauma Score (RTS), Worthing Physiological Scoring System (WPSS), Rapid Acute Physiology Score (RAPS), Rapid Emergency Medicine Score (REMS), Modified Early Warning Score (MEWS), National Early Warning Score (NEWS), Glasgow Coma Scale, Age, and Systolic Blood Pressure score (GAPS) ,Glasgow coma scale (GCS) in prediction of mortality were 0.95, 0.95, 0.83, 0.89, 0.91, 0.84, 0.77, 0.97, and 0.98 respectively. The performance of GCS was statistically superior to RTS (P=0.005), WPSS (P=0.0001), RAPS (P=0.0002), REMS (P=0.002), MEWS (P<0.0001), and NEWS (P<0.0001). However, the performance of GCS, NTS (P=0.146), and GAPS (P=0.513) were not significantly different. Also, in prediction of poor outcomes, the AUC of GCS (0.98) was significantly higher than RTS (0.95), RAPS (0.85), REMS (0.85), MEWS (0.84), NEWS (0.77), and WPSS (0.75). Conclusion The GCS score seems to be a better instrument to predict mortality and poor outcome in trauma patients compared to other tools due to its high accuracy, wide application, and easy calculation.
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Affiliation(s)
- Sorour Khari
- Student Research Committee, School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mitra Zandi
- School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Mahmoud Yousefifard
- Physiology Research Center, Iran University of Medical Sciences, Tehran, Iran
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Abstract
The increasing digitalization of social life opens up new possibilities for modern health care. This article describes innovative application possibilities that could help to sustainably improve the treatment of severe injuries in the future with the help of methods such as big data, artificial intelligence, intelligence augmentation, and machine learning. For the successful application of these methods, suitable data sources must be available. The TraumaRegister DGU® (TR-DGU) currently represents the largest database in Germany in the field of care for severely injured patients that could potentially be used for digital innovations. In this context, it is a good example of the problem areas such as data transfer, interoperability, standardization of data sets, parameter definitions, and ensuring data protection, which still represent major challenges for the digitization of trauma care. In addition to the further development of new analysis methods, solutions must also continue to be sought to the question of how best to intelligently link the relevant data from the various data sources.
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