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

Predicting Mortality in Trauma Research: Evaluating the Performance of Trauma Scoring Tools in a South African Population

Background Trauma is a leading cause of death and disability in low-resource settings, yet trauma severity scores are seldom validated in these contexts. There is a pressing need to better characterize and compare trauma scoring tools, especially within research frameworks. This study aimed to evaluate the performance of various trauma scoring tools in predicting in-hospital mortality among trauma patients in South Africa. Methods This study conducted a secondary analysis of existing data from the multicenter Epidemiology and Outcomes of Prolonged Trauma Care (EpiC) study, which included 13,548 adult trauma patients aged 18 years and older, collected between August 2021 and March 2024. The predictive ability of the scoring tools was assessed by calculating the area under the receiver operating characteristic curve (AUROC) and the area under the precision-recall curve (AUPRC). Results The mortality rate was 2.5% (n = 298). The Kampala Trauma Score (KTS) demonstrated the highest predictive ability for seven-day in-hospital mortality, with an AUROC of 0.95 and an AUPRC of 0.53. Similarly, the Trauma and Injury Severity Score (TRISS) and the New Injury Severity Score (NISS) also exhibited strong predictive capabilities, with AUROC values of 0.96 and AUPRC values of 0.62 for TRISS and an AUROC of 0.96 and AUPRC of 0.53 for NISS. In contrast, the Revised Trauma Score and Mechanism, Glasgow Coma Scale, Age, and Arterial Pressure (MGAP) showed lower predictive performance, with AUROC values of 0.87 (AUPRC = 0.51) and 0.86 (AUPRC = 0.47), respectively. Conclusions The KTS exhibited optimal performance characteristics for retrospectively predicting mortality in our cohort, outperforming other scoring tools. Notably, it is also the simplest scoring tool, featuring the fewest variables compared to other trauma severity assessments. These findings highlight the necessity for external validation of trauma scoring tools in resource-limited populations to ensure their applicability and effectiveness in trauma research across diverse healthcare settings.

Prediction of Mortality and Outcome of Various Trauma Scores in Polytrauma Patients

Background In developing nations, the primary cause of death is trauma, and the prevalence of trauma is increasing as more vehicles are driven. Numerous trauma scoring systems have been created in order to predict the mortality rate and patients with trauma's prognosis. The purpose of the current study was to assess the prognostic ability of various trauma scoring systems for patients' mortality and morbidity in cases involving chest and abdominal injuries, as they are common in the surgery department. Methodology At Ranchi, Jharkhand's Rajendra Institute of Medical Sciences, a prospective observational study was conducted from June 2021 to September 2022. All patients who met the requirements for inclusion were older than 18 and reported chest and abdominal trauma totaling 204. Before any essential therapies, primary care and resuscitation, including airway maintenance, breathing, circulation, and hemorrhage control, were established. A comprehensive clinical evaluation was done based on each patient's needs. Radiological evaluation included chest X-ray and ultrasonography (USG) for chest trauma, whereas USG (FAST) and CT scans were for abdominal trauma. Trauma scores, such as the Revised Trauma Score (RTS), the Trauma Revised Injury Severity Score (TRISS), the New Injury Severity Score (NISS), and the Injury Severity Score (ISS), were computed and examined using IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp. Results Of the 204 patients, 14.7% were female and 85.3% were male. The age range of 21-30 years old accounted for the largest percentage of cases (28%). 50 percent of injuries were caused by automobile accidents, while 25% were the result of assaults. At 83.8% versus 16.2%, blunt injuries were substantially more common than penetrating ones. In comparison to the chest, the abdomen was more frequently involved. The study's findings demonstrated that, while every trauma scoring was statistically significant in predicting mortality, the New Injury Severity Score (NISS), as well as the Trauma Revised Injury Severity Score (TRISS), became the most effective in predicting mortality (p < 0.0001). Conclusion According to the results, the most precise trauma grading method for chest and abdominal injuries is the Trauma Revised Injury Severity Score (TRISS), even though all other trauma scoring systems are useful in predicting patient outcomes. Surgeons using these metrics to predict outcomes and make well-informed treatment decisions can benefit greatly.

Comparison of GAP, R-GAP, and new trauma score (NTS) systems in predicting mortality of traffic accidents that injure hospitals at Mashhad University of medical sciences

Background

There are several trauma scoring systems with varying levels of accuracy and reliability that have been developed to predict and classify mortality in trauma patients in the hospital admission. Considering the importance of the country's emergency organization and the World Health Organization in the category of traffic accidents, we used this information in the study. The objective of this study is to evaluate and compare the predictive power of three scoring systems (R-GAP, GAP, and NTS) on traffic accident injuries.

Methods

In an analytical cross-sectional study, all the data related to the mission of traffic accidents at the pre-hospital emergency management of Mashhad University of Medical Sciences in 2022 were extracted from the automation system, and the outcome of the patients in the hospital was recorded from the integrated hospital system. Then, GAP, R-GAP, and New Trauma Scores (NTS) were calculated, and their results were compared using ROC curve and logistic regression.

Results

In this study, 47,971 injuries from traffic accidents were evaluated. Their average age was 30.16 ± 10.93 years. R-GAP showed negligible difference than GAP and NTS scores (the area under the curve equals 0.904, 0.935, and 0.884, respectively), and the average scores of R-GAP, GAP, and NTS are equal to 22.45/45 ± 1/9, 22.25 ± 1.5, and 22.49 ± 1.3, respectively. Injury severity based on R-GAP, GAP, and NTS scores was mild in most patients. The effect of these models on the patient outcome based on OR values, R-GAP, GAP, and NTS models showed high values. All analysis was performed in SPSS 26.

Conclusion

According to the study results, it seems that R-GAP, GAP, and NTS, have the highest power to predict death in traffic accident injuries. It is recommended to include these points in the electronic file of the pre-hospital emergency for the injured. Also, the severity and outcome of the patient can be predicted by these scores, which play an important role in the triage of the injured and determining the appropriate treatment center.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Comparative Evaluation of Mortality Predictors in Trauma Patients: A Prospective Single-center Observational Study Assessing Injury Severity Score Revised Trauma Score Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II Scores

Aim

This prospective cohort study aimed to compare the predictive accuracy of outcome (survival/death) among trauma patients using various prognostic scores.

Methods

Over 3 months, 240 trauma patients in a tertiary care hospital were assessed for demographic details, trauma characteristics, vital signs, Glasgow coma scale, arterial blood gas values, and lab markers. Injury severity score (ISS), revised trauma score (RTS), trauma and injury severity score (TRISS), and acute physiology and chronic health evaluation II (APACHE II) were applied at admission, 24 hours, and 48 hours post-admission.

Results

Road traffic accidents (55.83%) were the primary cause of trauma, followed by falls (33.75%) and violence (10.41%). The all-cause mortality rate was 23.33%, with 34.16% requiring ICU admission. Head injuries (65.83%) were both the most frequent injury site and cause of mortality.

Conclusion

Analysis indicated that APACHE II outperformed other scores in predicting outcomes, with ISS following closely. The study concludes that trauma severity correlates with ICU admission and mortality, emphasizing APACHE II as a superior predictor, particularly for traumatic brain injuries leading to ICU admission and mortality.

Clinical significance

This study contributes to the existing body of knowledge by addressing the gap in comparing prognostic abilities among scoring systems for trauma patients. The unexpected superiority of APACHE II suggests its potential as a valuable tool in predicting outcomes in this specific patient population.

How to cite this article

Gupta J, Kshirsagar S, Naik S, Pande A. Comparative Evaluation of Mortality Predictors in Trauma Patients: A Prospective Single-center Observational Study Assessing Injury Severity Score Revised Trauma Score Trauma and Injury Severity Score and Acute Physiology and Chronic Health Evaluation II Scores. Indian J Crit Care Med 2024;28(5):475-482.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

Objectives

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

Methods

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

Results

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

Conclusion

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

Level of evidence

Level III.

The CBS test: Development, evaluation & cross-validation of a community-based injury severity scoring system in Cameroon

Injury-related deaths overwhelmingly occur in low and middle-income countries (LMICs). Community-based injury surveillance is essential to accurately capture trauma epidemiology in LMICs, where one-third of injured individuals never present to formal care. However, community-based studies are constrained by the lack of a validated surrogate injury severity metric. The primary objective of this bipartite study was to cross-validate a novel community-based injury severity (CBS) scoring system with previously-validated injury severity metrics using multi-center trauma registry data. A set of targeted questions to ascertain injury severity in non-medical settings-the CBS test-was iteratively developed with Cameroonian physicians and laypeople. The CBS test was first evaluated in the community-setting in a large household-based injury surveillance survey in southwest Cameroon. The CBS test was subsequently incorporated into the Cameroon Trauma Registry, a prospective multi-site national hospital-based trauma registry, and cross-validated in the hospital setting using objective injury metrics in patients presenting to four trauma hospitals. Among 8065 surveyed household members with 503 injury events, individuals with CBS indicators (CBS+) were more likely to report ongoing disability after injury compared to CBS- individuals (OR 1.9, p = 0.004), suggesting the CBS test is a promising injury severity proxy. In 9575 injured patients presenting for formal evaluation, the CBS test strongly predicted death in patients after controlling for age, sex, socioeconomic status, and injury type (OR 30.26, p<0.0001). Compared to established injury severity scoring systems, the CBS test comparably predicts mortality (AUC: 0.8029), but is more feasible to calculate in both the community and clinical contexts. The CBS test is a simple, valid surrogate metric of injury severity that can be deployed widely in community-based surveys to improve estimates of injury severity in under-resourced settings.

Validation of the Pediatric Resuscitation and Trauma Outcome (PRESTO) model in injury patients in Tanzania

INTRODUCTION

Sub-Saharan Africa has the highest rate of unintentional paediatric injury deaths. The Pediatric Resuscitation and Trauma Outcome (PRESTO) model predicts mortality using patient variables available in low-resource settings: age, systolic blood pressure (SBP), heart rate (HR), oxygen saturation, need for supplemental oxygen (SO) and neurologic status (Alert Verbal Painful Unresponsive (AVPU)). We sought to validate and assess the prognostic performance of PRESTO for paediatric injury patients at a tertiary referral hospital in Northern Tanzania.

METHODS

This is a cross-sectional study from a prospective trauma registry from November 2020 to April 2022. We performed exploratory analysis of sociodemographic variables and developed a logistic regression model to predict mortality using R (V.4.1). The logistic regression model was evaluated using area under the receiver operating curve (AUC).

RESULTS

499 patients were enrolled with a median age of 7 years (IQR 3.41-11.18). 65% were boys, and in-hospital mortality was 7.1%. Most were classified as alert on AVPU Scale (n=326, 86%) and had normal SBP (n=351, 98%). Median HR was 107 (IQR 88.5-124). The logistic regression model based on the original PRESTO model revealed that AVPU, HR and SO were statistically significant to predict in-hospital mortality. The model fit to our population revealed AUC=0.81, sensitivity=0.71 and specificity=0.79.

CONCLUSION

This is the first validation of a model to predict mortality for paediatric injury patients in Tanzania. Despite the low number of participants, our results show good predictive potential. Further research with a larger injury population should be done to improve the model for our population, such as through calibration.

Abdominal Trauma Imaging in a Nigerian Tertiary Hospital-Our Experience with 87 Adult Patients

Introduction

Abdominal trauma is a major cause of morbidity and mortality in low- and medium-income countries (LMICs). Abdominal trauma imaging is important in determining the location and severity of organ injury, the need for surgery, and the identification of complications. The choice of imaging in abdominal trauma in LMICs is influenced by peculiar problems, which include the availability of imaging modality, expertise, and cost. There are few reports on options of trauma imaging in LMICs, and this study aimed to identify and characterise the type of imaging done for patients presenting with abdominal trauma at the University of Ilorin Teaching Hospital.

Materials and Methods

This was a retrospective observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from 2013 to 2019. Records were identified, and data were extracted and analysed.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females. The abdominal ultrasound was the commonest modality done in 36 (41%) patients, whereas abdominal computed tomography was done in five (6%) patients. Eleven patients (13%) had no imaging done, and 10 of these patients proceeded to having surgery. In patients with intraoperative finding of perforated viscus, the sensitivity of radiography was 85% and specificity was 100%, whereas that of the ultrasound was 86.7% and 50% for sensitivity and specificity, respectively. The ultrasound scan was the commonest imaging done for patients who presented with features of haemorrhage (P = 0.04), odds ratio (OR) = 1.29 (95% confidence interval [CI] = 1.08-1.6), and patients with severe injury, P = 0.03, OR = 2.07 (95% CI = 1.06-4.06). Gender (P = 0.64), shock at presentation (P = 0.19), and mechanism of injury (P = 0.11) did not influence the choice of imaging.

Conclusions

Abdominal trauma imaging in this setting was majorly via ultrasound and abdominal radiographs. Factors suggested to influence the pattern of abdominal trauma imaging in LMICs include the availability of specific imaging modality, cost, lack of standardisation and definite abdominal trauma protocols.

Thoracic trauma in national hospital Abuja, Nigeria: The epidemiology, injury severity and initial management options

Background

Trauma is the leading cause of death in individuals between the ages of 1 and 44 years and it is the third commonest cause of death regardless of age. Thoracic trauma is a relatively common cause of preventable death among trauma patients. The spectrum of injuries after blunt chest trauma presents a challenging problem to the emergency physician. This study is intended to discuss the epidemiology, severity and initial management strategies in chest trauma patients, in a low income country.

Methods

A cross sectional retrospective study among chest trauma patients seen in the emergency room of National Hospital Trauma Centre, Abuja, Nigeria, from January 2015 to December 2017. Relevant patients' information was retrieved from the trauma registry kept in the trauma centre. Data processing and analysis was done using statistical package for social sciences (SPSS) version 24. Test of significance was done where applicable using chi square and student t test, using p value less than 0.05 as significant. Results are presented in tables and figures.

Results

A total of 637 patients, male to female ratio of 3.6 and mean age of 34.18 ± 11.34 were enrolled into the study. The most common mechanisms of injury were MVC (54.6%) and assault (23.5%). Blunt injuries were 3.5 times more frequent than the penetrating injuries. The RTS of 12 (76.3%) and the ISS of 1-15 category (52.3%) were the most common scores. Up to 98% of patients were managed non-operatively. Recovery rate was high (89%) with relatively low mortality rate of 4.2%.

Conclusion

Majority of thoracic trauma can be managed effectively by employing simple, non-operative procedures such as needle decompression and chest tube insertion. Efforts should be made to include these procedures in the skill set of every medical officer working in the emergency room, particularly in low and middle income countries where there is paucity of emergency physicians.

Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey

Background

Trauma is the leading cause of death in India resulting in a significant public health burden. Indian Society of Critical Care Medicine (ISCCM) has established a trauma network committee to understand current practices and identify the gaps and challenges in trauma management in Indian settings.

Material and methods

An online survey-based, cross-sectional, descriptive study was conducted with high-priority research questions based on hospital profile, resource availability, and trauma management protocols.

Results

Data from 483 centers were analyzed. A significant difference was observed in infrastructure, resource utilization, and management protocols in different types of hospitals and between small and big size hospitals across different tier cities in India (p < 0.05). The advanced trauma life support (ATLS)-trained emergency room (ER) physician had a significant impact on infrastructure organization and trauma management protocols (p < 0.05). On multivariate analysis, the highest impact of ATLS-trained ER physicians was on the use of extended focused assessment with sonography in trauma (eFAST) (2.909 times), followed by hospital trauma code (2.778 times), dedicated trauma team (1.952 times), and following trauma scores (1.651 times).

Conclusion

We found that majority of the centers are well equipped with optimal infrastructure, ATLS-trained physician, and management protocols. Still many aspects of trauma management need to be prioritized. There should be proactive involvement at an organizational level to manage trauma patients with a multidisciplinary approach. This survey gives us a deep insight into the current scenario of trauma care and can guide to strengthen across the country.

How to cite this article

Sodhi K, Khasne RW, Chanchalani G, Jagathkar G, Kola VR, Mishra M et al. Practice Patterns and Management Protocols in Trauma across Indian Settings: A Nationwide Cross-sectional Survey. Indian J Crit Care Med 2023;27(1):38-51.

Pattern of Presentation and Outcome of Adult Patients with Abdominal Trauma - A 7-Year Retrospective Study in a Nigerian Tertiary Hospital

Introduction

Abdominal trauma is a major cause of morbidity and mortality in low- and middle-income countries. There is a paucity of trauma data in this region and this study aimed to show the pattern of presentation and outcome of patients with abdominal trauma at a North-Central Nigerian Teaching Hospital.

Methods

This was a retrospective, observational study of patients with abdominal trauma who presented at the University of Ilorin Teaching Hospital from January 2013 to December 2019. Patients with clinical and/or radiological evidence of abdominal trauma were identified, and data extracted and analyzed.

Results

A total of 87 patients were included in the study. There were 73 males and 14 females (5.2:1) with a mean age of 34.2 years. Blunt abdominal injury occurred in 53 (61%) patients with 10 patients (11%) having concomitant extra-abdominal injuries. A total of 105 abdominal organ injuries occurred in 87 patients with the small bowel being the most frequently injured organ in penetrating trauma, while in blunt abdominal injury, the spleen was most commonly injured. A total of 70 patients (80.5%) had emergency abdominal surgery with a morbidity rate of 38.6% and negative laparotomy rate of 2.9%. There were 15 deaths in the period accounting for 17% of patients with sepsis as the most common cause of death (66%). Shock at presentation, late presentation >12 h, need for perioperative intensive care unit admission, and repeat surgery were associated with a higher risk of mortality (P < 0.05).

Conclusion

Abdominal trauma in this setting is associated with a significant amount of morbidity and mortality. Typical patients present late and with poor physiologic parameters often resulting in an undesirable outcome. There should be steps targeted at preventive policies focused on reducing the incidence of road traffic crashes, terrorism, and violent crimes as well as improving health care infrastructure to cater to this specific group of patients.

Malawi Trauma Score is Predictive of Mortality at a District Hospital: A Validation Study

BACKGROUND

Trauma scoring systems can identify patients who should be transferred to referral hospitals, but their utility in LMICs is often limited. The Malawi Trauma Score (MTS) reliably predicts mortality at referral hospitals but has not been studied at district hospitals. We sought to validate the MTS at a Malawi district hospital and evaluate whether MTS is predictive of transfer to a referral hospital.

METHODS

We performed a retrospective study using trauma registry data from Salima District Hospital (SDH) from 2017 to 2021. We excluded patients brought in dead, discharged from the Casualty Department, or missing data needed to calculate MTS. We used logistic regression modeling to study the relationship between MTS and mortality at SDH and between MTS and transfer to a referral hospital. We used receiver operating characteristic analysis to validate the MTS as a predictor of mortality.

RESULTS

We included 2196 patients (84.3% discharged, 12.7% transferred, 3.0% died). These groups had similar ages, sex, and admission vitals. Mean (SD) MTS was 7.9(3.0) among discharged patients, 8.4(3.9) among transferred patients, and 14.2(8.0) among patients who died (p < 0.001). Higher MTS was associated with increased odds of mortality at SDH (OR 1.21, 95% CI 1.14-1.29, p < 0.001) but was not related to transfer. ROC area for mortality was 0.73 (95% CI 0.65-0.80).

CONCLUSIONS

MTS is predictive of district hospital mortality but not inter-facility transfer. We suggest that MTS be used to identify patients with severe trauma who are most likely to benefit from transfer to a referral hospital.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Kampala Trauma Score: A 20-year track record

ABSTRACT

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

Predicting mortality in trauma patients - A retrospective comparison of the performance of six scoring systems applied to polytrauma patients from the emergency centre of a South African central hospital

Introduction

Over 90% of trauma-related deaths worldwide, ensue in low- and middle-income countries. Multiple useful trauma scoring systems have been devised. Although validated in high-income countries, they cannot always be replicated in resource-limited countries. This study compares six trauma scores to identify the best-suited system to use for polytrauma patients in a hospital in Pretoria, South Africa.

Methods

This is an observational retrospective analysis of polytrauma admissions from 1 July 2016 to 31 December 2016. Data collected from patients' records from the EC of Steve Biko Academic Hospital, was analysed using Stata Release 14. Outcomes were recorded as 30-day survival, ICU– and overall hospital LOS. Scores pertaining to patient mortality, were compared in terms of sensitivity, specificity, and cut-off points based on ROC curve. Finally, for LOS Pearson correlation analysis was used.

Results

At the best calculated mortality prediction cut-points for the scores, the sensitivities and specificities were respectively 87% and 68% for TRISS, 81% and 61% for ISS, RTS yielded 81% and 60%, while for REMS it was 61% and 69%. The SI and RSI (cut-points used in agreement with the literature) produced sensitivities 58% and only 48%, and specificities of 73% and 83%, respectively.

45(41,7%) patients required ICU admission. Though the ICU LOS best correlated with ISS(r = 0.2710), the ICU LOS correlation coefficient was weak for all trauma scores. None of the scores had a significant p value for hospital LOS.

Discussion

Among the scores compared, TRISS had the highest sensitivity and NPV for mortality prediction in this South African polytrauma population. ISS correlated best with ICU LOS. However, compared to developed countries, ROC analyses & predictability of these scores fare relatively worse, and no correlation was found with hospital LOS. Therefore, we conclude that further studies are needed to ascertain a more suitable system for resource-limited settings.

Shock index as a prognosticator for emergent surgical intervention and mortality in trauma patients in Johannesburg: A retrospective cohort study

Introduction

Trauma is the leading cause of morbidity and mortality worldwide with exsanguination being the primary preventable cause through early surgical intervention. We assessed two popular trauma scoring systems, injury severity scores (ISS) and shock index (SI) to determine the optimal cut off values that may predict the need for emergent surgical intervention (ESI) and in-hospital mortality.

Methods

A retrospective analysis of patient records from a tertiary hospital's trauma unit for the year 2019 was done. Descriptive statistics, univariate and multivariate logistic regression analyses were performed. Receiver operator characteristic (ROC) curve analysis was conducted and area under the curve (AUC) reported for predicting the need for ESI in all study participants, as well as in patients with penetrating injuries alone, based on continuous variables of ISS, SI or a combination of ISS and SI. The Youdin Index was applied to determine the optimal ISS and SI cut off values.

Results

A total of 1964 patients’ records were included, 89.0% were male and the median age (IQR) was 30 (26–37) years. Penetrating injuries accounted for 65.9% of all injuries. ISS and SI were higher in the ESI group with median (IQR) 11 (10–17) and 0.74 (0.60–0.95), respectively. The overall mortality rate was 4.5%. The optimal cut-off values for ESI and mortality by ISS (AUC) were 9 (0.74) and 12 (0.86) (p = 0.0001), with optimal values for SI (AUC) being 0.72 (0.60), and 0.91 (0.68) (p = 0.0001), respectively.

Conclusion

ISS and SI are significant, independent prognosticators for the need of ESI and in-hospital mortality.

•

The ISS cut-off of 15 for severe trauma may underestimate the severity of trauma within our local South African population.

•

Our study reports an optimal SI cut off value of ≥0.72 for emergency surgical intervention.

•

At an optimal SI cut off of ≥0.91 for in-hospital mortality, the odds of demise were 6.7 times higher.

•

ISS was a stronger predictor than SI of both ESI and in-hospital mortality in our study.

Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting outcomes of blunt trauma abdomen

PURPOSE

Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen.

MATERIALS AND METHODS

A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality.

RESULTS

The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality.

CONCLUSIONS

Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other couldn't be proved.

Epidemiology of injured patients in rural Uganda: A prospective trauma registry's first 1000 days

Trauma is a leading cause of morbidity and mortality worldwide. Data characterizing the burden of injury in rural Uganda is limited. Hospital-based trauma registries are a critical tool in illustrating injury patterns and clinical outcomes. This study aims to characterize the traumatic injuries presenting to Soroti Regional Referral Hospital (SRRH) in order to identify opportunities for quality improvement and policy development. From October 2016 to July 2019, we prospectively captured data on injured patients using a locally designed, context-relevant trauma registry instrument. Information regarding patient demographics, injury characteristics, clinical information, and treatment outcomes were recorded. Descriptive, bivariate, and multivariate statistical analyses were conducted. A total of 4109 injured patients were treated during the study period. Median age was 26 years and 63% were male. Students (33%) and peasant farmers (31%) were the most affected occupations. Falls (36%) and road traffic injuries (RTIs, 35%) were the leading causes of injury. Nearly two-thirds of RTIs were motorcycle-related and only 16% involved a pedestrian. Over half (53%) of all patients had a fracture or a sprain. Suffering a burn or a head injury were significant predictors of mortality. The number of trauma patients enrolled in the study declined by five-fold when comparing the final six months and initial six months of the study. Implementation of a context-appropriate trauma registry in a resource-constrained setting is feasible. In rural Uganda, there is a significant need for injury prevention efforts to protect vulnerable populations such as children and women from trauma on roads and in the home. Orthopedic and neurosurgical care are important targets for the strengthening of health systems. The comprehensive data provided by a trauma registry will continue to inform such efforts and provide a way to monitor their progress moving forward.