Prehospital Trauma Scoring Systems for Evaluation of Trauma Severity and Prediction of Outcomes

INTRODUCTION

Trauma scoring systems in prehospital settings are supposed to ensure the most appropriate in-hospital treatment of the injured.

AIM OF THE STUDY

To determine the sensitivity and specificity of the CRAMS scale (circulation, respiration, abdomen, motor and speech), RTS score (revised trauma score), MGAP (mechanism, Glasgow Coma Scale, age, arterial pressure) and GAP (Glasgow Coma Scale, age, arterial pressure) scoring systems in prehospital settings in order to evaluate trauma severity and to predict the outcome.

MATERIALS AND METHODS

A prospective, observational study was conducted. For every trauma patient, a questionnaire was initially filled in by a prehospital doctor and these data were subsequently collected by the hospital.

RESULTS

The study included 307 trauma patients with an average age of 51.7 ± 20.9. Based on the ISS (injury severity score), severe trauma was diagnosed in 50 (16.3%) patients. MGAP had the best sensitivity/specificity ratio when the obtained values indicated severe trauma. The sensitivity and specificity were 93.4 and 62.0%, respectively, for an MGAP value of 22. MGAP and GAP were strongly correlated with each other and were statistically significant in predicting the outcome of treatment (OR 2.23; 95% Cl 1.06-4.70; p = 0.035). With a rise of one in the MGAP score value, the probability of survival increases 2.2 times.

CONCLUSION

MGAP and GAP, in prehospital settings, had higher sensitivity and specificity when identifying patients with a severe trauma and predicting an unfavorable outcome than other scoring systems.

UK triage--an improved tool for an evolving threat

INTRODUCTION

A key challenge at a major incident is to quickly identify those casualties most urgently needing treatment in order to survive - triage. The UK Triage Sieve (TS) advocated by the Major Incident Medical Management (MIMMS) Course categorises casualties by ability to walk, respiratory rate (RR) and heart rate (HR) or capillary refill time. The military version (MS) includes assessment of consciousness. We tested whether the MS better predicts need for life-saving intervention in a military trauma population. Ideal HR, RR and Glasgow Coma Score (GCS) thresholds were calculated.

METHODS

A gold standard Priority 1 casualty was defined using resource-based criteria. Pre-hospital data from a military trauma database allowed calculation of triage category, which was compared with this standard, and presented as 2×2 tables. Sensitivity and specificity of each physiological parameter was calculated over a range of values to identify the ideal cut-offs.

RESULTS

A gold standard could be ascribed in 1657 cases. In 1213 both the MS and TS could ascribe a category. MS was significantly more sensitive than TS (59% vs 53%, p<0.001) with similar specificity (89 vs 88%). Varying the limits for each parameter allowed some improvements in sensitivity (70-80%) but specificity dropped rapidly.

DISCUSSION

Previous studies support the inclusion of GCS assessment for blunt as well as penetrating trauma. Optimising the physiological cut-offs increased sensitivity in this sample to only 71% - a Sieve based purely on physiological parameters may not be capable of an acceptable level of sensitivity.

CONCLUSIONS

The MS is more sensitive than the TS. Major incident planners utilising the Sieve should consider adopting the military version as their first line triage tool. If validated, altering the HR and RR thresholds may further improve the tool.