Does the Probability of Survival Calculated by the Trauma and Injury Severity Score Method Accurately Reflect the Severity of Neurotrauma Patients Admitted to Regional Trauma Centers in Korea?

BACKGROUND

Assessing and improving the quality of trauma care is crucial in modern trauma systems and centers. In Korea, evaluations of regional trauma centers are conducted annually to assess and improve trauma management quality. This includes using the Trauma and Injury Severity Score (TRISS) method to calculate the W-score and mortality Observed-to-Expected ratio (O:E ratio), which are used to evaluate the quality of care. We analyzed the potential for overestimation of the probability of survival using TRISS method for patients with neurotrauma, as well as the potential for errors when evaluating and comparing regional trauma centers.

METHODS

We included patients who visited the regional trauma center between 2019 and 2021 and compared their probability of survival of the TRISS method, W-score, mortality O:E ratio, and misclassification rates. The patient groups were further subdivided into smaller subgroups based on age, Glasgow Coma Scale (GCS), and Injury Severity Score, and comparisons were made between the neurotrauma and non-neurotrauma groups within each subgroup.

RESULTS

A total of 4,045 patients were enrolled in the study, with 1,639 of them having neurotrauma. The neurotrauma patient group had a W-score of -0.68 and a mortality O:E ratio of 1.044. The misclassification rate was found to be 13.3%, and patients with a GCS of 8 or less had a higher misclassification rate of 37.4%.

CONCLUSION

The limitations of using the TRISS method for predicting outcomes in patients with severe neurotrauma are exposed in this study. The TRISS methodology demonstrated a high misclassification rate of approximately 40% in subgroups of patients with GCS less than 9, indicating that it may be less reliable in predicting outcomes for severely injured patients with low GCS. Clinicians and researchers should be cautious when using the TRISS method and consider alternative methods to evaluate patient outcomes and compare the quality of care provided by different trauma centers.

Relationship Between Facial Bone Fractures and the Risk of Posttraumatic Complications: A Hypothesis on the Cushion Effect of the Facial Skeletons in Temporal Bone Fractures

BACKGROUND

This study investigated whether concomitant facial bone (FB) fractures reduce temporal bone (TB) injuries, such as posttraumatic facial palsy and vertigo, through an impact absorbing effect, so-called "cushion effect," in severe trauma patients.

METHODS

A total of 134 patients with a TB fracture were included. They were divided into two groups according to their concomitant facial fractures: group I (no FB fracture) and group II (FB fracture). We compared clinical characteristics, such as brain injury, trauma severity, and complications of TB fracture, between the two groups.

RESULTS

In group II, immediate facial palsy was more frequent (11.6% vs. 1.5% in group I), and the Injury Severity Score was higher (19.0 ± 5.9 vs. 16.7 ± 7.3, P = 0.020). Delayed facial palsy (12.3% in group I vs. 4.3% in group II) and posttraumatic vertigo (24.6% vs. 7.2%) occurred more often in group I. FB fractures significantly decreased the incidence of posttraumatic vertigo (odds ratio [OR], 0.276; 95% confidence interval [CI], 0.083-0.914). Intraventricular hemorrhage (OR, 20.958; 95% CI, 2.075-211.677), facial nerve canal injury (OR, 12.229; 95% CI, 2.465-60.670), and FB fractures (OR, 16.420; 95% CI, 1.298-207.738) increased the risk of immediate facial palsy.

CONCLUSION

Concomitant FB fractures reduced the risk of the occurrence of delayed facial palsy and posttraumatic vertigo in injured patients with TB fracture. Particularly, an anterior force may be reduced by the cushion effect of the bony fracture.

Feasibility and Clinical Outcomes of Resuscitative Endovascular Balloon Occlusion of the Aorta in Patients with Traumatic Shock: A Single-Center 5-Year Experience

Background

Resuscitative endovascular balloon occlusion of the aorta (REBOA) has recently gained popularity as an adjunct to resuscitation of patients with traumatic shock. However, the effectiveness of REBOA is still debated because of inconsistent indications across centers and the lack of medical records. The purpose of this study was to investigate the effectiveness and feasibility of REBOA by analyzing clinical results from a single center.

Methods

This study included 96 patients who underwent REBOA between August 2016 and September 2021 at a regional trauma center according to the center's treatment algorithm for traumatic shock. Medical records, including the time of the decision to conduct the REBOA procedure, time of operation, type of aortic occlusion, and clinical outcomes, were collected prospectively and analyzed retrospectively. Patients were classified by REBOA protocol (group 1, 2, or 3) and survival status (survivor or non-survivor) for analysis.

Results

The overall success rate of the procedure was 97.9%, and the survival rate was 32.6%. In survivors, blood pressure was higher than in non-survivors both before the REBOA procedure (p=0.002) and after aortic occlusion (p=0.03). The total aortic occlusion time was significantly shorter (p=0.001) and the proportion of partial aortic occlusion was significantly higher (p=0.014) among the survivors. The non-survivors had more acidosis (p<0.001) and higher lactate concentrations (p<0.001) than the survivors.

Conclusion

REBOA may be a feasible bridge therapy for resuscitation of patients with traumatic shock. Prompt and accurate decision-making to perform REBOA followed by damage control surgery could improve survival rates and clinical outcomes.

Understanding Regional Trauma Centers and managing a trauma care system in South Korea: a systematic review

The Korean government initiated a plan to designate and establish Regional Trauma Centers to reduce the preventable trauma death rate to <20% so as to be on par with advanced countries by 2020. This initiative was undertaken because the reported preventable trauma death rate was close to 40% in South Korea from 1997 to 2009. This review aimed to provide an overview of these Regional Trauma Centers and discuss further development of the trauma care system to assess its performance. As of September 2021, 15 Regional Trauma Centers had been established through a metropolitan-based designation process. Each center has been equipped with Level-I facilities. These Regional Trauma Centers have had 2 positive effects; namely, an increase in the number of severely injured patients attending these centers and a decrease in the national preventable trauma death rate from 30.5% in 2015 to 19.9% in 2017. The establishment of Regional Trauma Centers can lead to improved performance, maximal efficiency, and reduction of preventable deaths in trauma patients. They can also play a key role in prehospital triage and transportation in the trauma care system.

Association between the participation of the plastic surgery department and qualitative prognoses in severe trauma patients: A retrospective observational study

Catastrophic incidents would necessitate the intervention of multiple specializations with plastic surgery (PS) as an indispensable area of expertise. In view of PS, prognostic assessment of trauma patients should be focused on the qualitative value rather than mortality because plastic surgeons rarely handled patients' vital signs in actual. Thus, we explored the association between the involvement of the PS department and qualitative prognoses for severe trauma patients. From November 2014 to December 2019, we enrolled total 529 trauma patients with an injury severity score (ISS) over 15 points. We set the prognostic factors that the rate of admission in intensive care unit (ICU), total or ICU duration of hospitalization, post-discharge progress and disability diagnosis which were regarded as qualitative prognoses. The analysis was performed with logistic regression analysis or regression analysis adjusted for age, sex, past medical history, cause of trauma, and frequency of operation. Among total of 529 patients, 290 patients in PS group and 239 patients in non-PS group were analyzed. In both groups, the under-65-year ages and male patients were significantly predominant. The rate of going home showed 2.082 times higher in PS group than non-PS group after adjusting for covariates, while there was no significant difference in diagnosis of disability. Meanwhile, overall prognoses were highly correlated with either higher ISS or lower Glasgow Coma Scale (GCS). In conclusion, higher severity generally affected to the severe trauma patient's prognoses, and the PS treatment only contributes to discharge disposition to home.

The use of machine learning for investigating the role of plastic surgeons in anatomical injuries: A retrospective observational study

While plastic surgeons have been historically indispensable in the reconstruction of posttraumatic defects, their role in trauma centers worldwide has not been clearly defined. Therefore, we aimed to investigate the contribution of plastic surgeons in trauma care using machine learning from an anatomic injury viewpoint. We conducted a retrospective study reviewing the data for all trauma patients of our hospital from March 2019 to February 2021. In total, 4809 patients were classified in duplicate according to the 17 trauma-related departments while conducting the initial treatment. We evaluated several covariates, including age, sex, cause of trauma, treatment outcomes, surgical data, and severity indices, such as the Injury Severity Score and Abbreviated Injury Scale (AIS). A random forest algorithm was used to rank the relevance of 17 trauma-related departments in each category for the AIS and outcomes. Additionally, t test and chi-square test were performed to compare two groups, which were based on whether the patients had received initial treatment in the trauma bay from the plastic surgery department (PS group) or not (non-PS group), in each AIS category. The department of PS was ranked first in the face and external categories after analyzing the relevance of the 17 trauma-related departments in six categories of AIS, through the random forest algorithm. Of the 1108 patients in the face category of AIS, the PS group was not correlated with all outcomes, except for the rate of discharge to home (P < .0001). Upon re-verifying the results using random forest, we found that PS did not affect the outcomes. In the external category in AIS, there were 30 patients in the PS group and 56 patients in the non-PS group, and there was no statistically significant difference between the two groups when comparing the outcomes. PS has contributed considerably to the face and external regions among the six AIS categories; however, there was no correlation between plastic surgical treatment and the outcome of trauma patients. We investigated the plastic surgeons' role based on anatomical injury, using machine learning for the first time in the field of trauma care.

The Relationship Between Trauma Scoring Systems and Outcomes in Patients With Severe Traumatic Brain Injury

OBJECTIVE

This study investigated the relationship between trauma scoring systems and outcomes in patients with severe traumatic brain injury (TBI).

METHODS

From January 2018 to June 2021, 1,122 patients with severe TBI were registered in the Korean Neuro-Trauma Data Bank System. Among them, 697 patients with data on trauma scoring systems were included in the study. According to the Glasgow Outcome Scale-Extended score, the patients were divided into unfavorable and favorable outcome groups. The abbreviated injury scale (AIS), injury severity score (ISS), revised trauma score (RTS), and trauma and injury severity score (TRISS) were evaluated.

RESULTS

The AIS head score was higher in the unfavorable outcome group than in the favorable outcome group (4.39 vs. 4.06, p<0.001). ISS was also higher in the unfavorable outcome group (27.27 vs. 24.22, p=0.001). The RTS and TRISS were higher in the favorable outcome group (RTS, 4.74 vs. 5.45, p<0.001; TRISS, 48.05 vs. 71.02, p<0.001). In comparing the survival and death groups, the ISS was lower in the survival group (25.76 vs. 27.29, p=0.036). Furthermore, RTS was higher in the survival group (5.26 vs. 4.54, p<0.001), as was TRISS (62.11 vs. 44.91, p<0.001).

CONCLUSION

Trauma scoring systems, including ISS, RTS, and TRISS, provide tools for quantifying posttraumatic risk and can be used to predict prognosis. Among these, TRISS is an indicator of the predicted survival rate and is considered a clinically useful tool for predicting unfavorable and favorable outcomes in patients with severe TBI.

Epidemiology and clinical characteristics of posttraumatic hospitalized patients with symptoms related to venous thromboembolism: a single-center retrospective study

Purpose: The aim of this study was to investigate the epidemiology of trauma inpatients with venous thromboembolism (VTE) symptoms diagnosed using computed tomographic angiography (CTA) in KoreaMethods: In total, 7,634 patients admitted to the emergency department of Gachon University Gil Medical Center, a tertiary hospital, and hospitalized between July 1, 2018 and December 31, 2020 were registered for this study. Of these patients, 278 patients who underwent CTA were enrolled in our study. Results: VTE was found in 120 of the 7,634 patients (1.57%), and the positive diagnosis rate of the 278 patients who underwent CTA was 43.2% (120 of 278). The incidence of VTE was statistically significantly higher among those with severe head and neck injuries (Abbreviated Injury Scale, 3–5) than among those with nonsevere head and neck injuries (Abbreviated Injury Scale, 0–2; P=0.038). In a subgroup analysis, the severe and nonsevere head and neck injury groups showed statistically significant differences in known independent risk factors for VTE. In logistic regression analysis, the adjusted odds ratio of severe head and neck injury (Abbreviated Injury Scale, 3–5) for VTE was 1.891 (95% confidence interval, 1.043–3.430). Conclusions: Trauma patients with severe head and neck injuries are more susceptible to VTE than those with nonsevere head and neck injuries. Thus, physicians must consider CTA as a priority for the diagnosis of VTE in trauma patients with severe head and neck injuries who show VTE-associated symptoms.

A quantitative analysis of trauma patients having undergone plastic surgery

Purpose

While plastic surgeons have been historically indispensable in reconstruction of posttraumatic defects, their role in Level I trauma centers around the world has not yet been clearly approved. This study aims to assess the contribution of plastic surgeons in major trauma care by evaluating the characteristics of trauma patients underwent plastic surgery at a Level I trauma center.

Method

From November 2014 to October 2020, we conducted a retrospective review of our hospital’s Trauma Registry System for patients with an Injury Severity Score (ISS) of 9 or higher. Of all of 7174 patients, the plastic surgery (PS) department treated 870 patients; the 6304 patients not treated by the PS were classified as the Non-PS. Then, we performed propensity score matching to reduce the statistical bias, after the death in the emergency room and the missing value were considered exclusion criteria.

Result

The mean ISS showed no significant difference between two groups (16.29 ± 7.04 in the PS vs. 16.68 ± 9.16 in the Non-PS, p = 0.3221). According to investigate the Abbreviated Injury Scale, both head and neck (65.0%) and face (46.4%) categories showed significantly higher in the PS group than the Non-PS group (p < 0.0001), and its contribution ratio was 2.151 and 21.822 times, respectively.

Conclusion

This study revealed the specialty of plastic surgery was face area in trauma care. We thus argue that plastic surgical care is imperative for trauma patients, and expect to be implicated in trauma system planning.

Electric Scooter-Related Trauma in Korea

BACKGROUND

The number of users of electric scooters, which provide swift and convenient mobility options, has increased sharply over recent years as their distribution as a shared service has expanded. Although the number of accidents and related damage has increased accordingly, limited research has analyzed data on the new types of accidents arising from electric scooters. This study aimed to analyze data on trauma characteristics due to accidents that occurred during electric scooter use.

METHODS

A retrospective chart review was conducted for patients who visited the regional trauma center of our institute due to electric scooter accidents from April 2018 to October 2021. Information was extracted on helmet-wearing status, sex, age, drinking status, accident timeframe, accident mechanism, electric scooter proficiency (period of use), injury severity, severe trauma, lethality, admission to the intensive care unit, surgery under general anesthesia, and the trauma region.

RESULTS

Among the 108 patients involved in electric scooter accidents, 92 patients were not wearing a helmet. Eighty-nine patients (85.2%) were male. The average age of the patients without a helmet was 31.3 years, while that of patients with a helmet was 34.1 years. The most frequent causes of accidents were lack of electric scooter operation experience and falling off the scooter due to obstacles (90 cases). Whether surgery was performed under general anesthesia was not associated with helmet use or non-use, although all patients who underwent facial fracture surgery were not wearing a helmet.

CONCLUSION

The craniofacial region was most frequently affected in electric scooter accidents and wearing a helmet was the best way to prevent craniofacial trauma. Although helmet-wearing is mandatory, the majority of treated patients were not wearing a helmet at the time of injury. Thus, there is an urgent need to introduce a helmet rental system, as well as strict legal requirements, to improve this situation.

The relationship between hospital selection by employer and disabilities in occupational accidents in Korea

Background

In the event of an industrial accident, the appropriate choice of hospital is important for worker health and prognosis. This study investigates whether the choice of hospital by the employer in the case of industrial accidents affects the prognosis of injured employees.

Methods

Data from the 2018 Panel Study of Workers’ Compensation Insurance in Korea were used in an unmatched case-controlled study. The exposure variable is “hospital selection by an employer,” and the outcome variable is ‘worker’s disability.” Odds ratios (ORs) were estimated by modified Poisson regression and adjusted for age, gender, underlying disease, injury severity, and workplace size and stratified by industrial classification. The group at increased risk was analyzed and stratified by age, gender, and area.

Results

In the construction industry, hospital selection by the employer was significantly associated with increased risk of disability (adjusted OR 1.26; 95% confidence interval [CI]: 1.20–1.32) and severe disability (adjusted OR 1.38; 95% CI: 1.08–1.76) among the injured. Female and younger workers not living in the Seoul capital area were more at risk of disability and severe disability than those living in the Seoul capital area.

Conclusions

Hospital selection by employers affects the prognosis of workers injured in an industrial accident. For protecting workers’ health and safety, workplace emergency medical systems should be improved, and the selection of appropriate hospitals to supply treatment should be reviewed.

Trauma severity and mandibular fracture patterns in a regional trauma center

BACKGROUND

Mandibular fractures are one of the most common types of facial fractures, the treatment of which can be delayed due to the severity of the trauma resulting in an increase of complications; thus, early evaluation of trauma severity at the time of visit is important. In South Korea, trauma patients are triaged and intensively treated in designated regional trauma centers. This study aimed to analyze the relationship between trauma severity and mandibular fracture patterns.

METHODS

A medical records review was performed on patients who visited the regional trauma center at our hospital for mandibular fracture between 2009 and 2018. Epidemiologic data and mandibular fracture patterns were analyzed and compared with the conventional facial injury severity scale (FISS).

RESULTS

Among 73 patients, 51 were classified as non-severe trauma patients and 22 as severe trauma patients. A higher trauma severity was associated with older age (odds ratio [OR], 1.164; 95% confidence interval [CI], 1.057-1.404) and lower risk was associated with fractures located in the angle (OR, 0.001; 95% CI, 0-0.022), condylar process (OR, 0.001; 95% CI, 0-0.28), and coronoid process (OR, 0.004; 95% CI, 0-0.985). The risk was lower when the injury mechanism was a pedestrian traffic accident (OR, 0.004; 95% CI, 0-0.417) or fall (OR, 0.004; 95% CI, 0-0.663) compared with an in-car traffic accident. Higher FISS (OR, 1.503; 95% CI, 1.155-2.049) was associated with a higher trauma severity. The proposed model was found to predict the trauma severity better than the model using FISS (p< 0.001).

CONCLUSION

Age, location of mandibular fractures, and injury mechanism showed significant relationships with the trauma severity. Epidemiologic data and patterns of mandibular fractures could predict the trauma severity better than FISS.

Inclusion of lactate level measured upon emergency room arrival in trauma outcome prediction models improves mortality prediction: a retrospective, single-center study

Background

This study aimed to develop a model for predicting trauma outcomes by adding arterial lactate levels measured upon emergency room (ER) arrival to existing trauma injury severity scoring systems.

Methods

We examined blunt trauma cases that were admitted to our hospital during 2010– 2014. Eligibility criteria were cases with an Injury Severity Score of ≥9, complete Trauma and Injury Severity Score (TRISS) variable data, and lactate levels that were assessed upon ER arrival. Survivor and non-survivor groups were compared and lactate-based prediction models were generated using logistic regression. We compared the predictive performances of traditional prediction models (Revised Trauma Score [RTS] and TRISS) and lactate-based models using the area under the curve (AUC) of receiver operating characteristic curves.

Results

We included 829 patients, and the in-hospital mortality rate among these patients was 21.6%. The model that used lactate levels and age provided a significantly better AUC value than the RTS model. The model with lactate added to the TRISS variables provided the highest Youden J statistic, with 86.0% sensitivity and 70.8% specificity at a cutoff value of 0.15, as well as the highest predictive value, with a significantly higher AUC than the TRISS.

Conclusions

These findings indicate that lactate testing upon ER arrival may help supplement or replace traditional physiological parameters to predict mortality outcomes among Korean trauma patients. Adding lactate levels also appears to improve the predictive abilities of existing trauma outcome prediction models.

Comparison of outcomes in severely injured patients between a South Korean trauma center and matched patients treated in the United States

BACKGROUND

The South Korean government recently developed a master plan for establishing a national trauma system based on the implementation of regional trauma centers. We aimed to compare outcomes between severely injured patients treated at a recently established South Korean trauma center and matched patients treated in American level-1 trauma centers.

METHODS

Two cohorts were selected from an institutional trauma database at Ajou University Medical Center (AUMC) and the American National Trauma Data Bank. Adult patients with an Injury Severity Score of ≥9 were included. Patients were matched based on covariates that affect mortality, using 1:1 propensity score matching. We compared outcomes between the two datasets and performed survival analyses.

RESULTS

We created 1,451 and 2,103 matched pairs for the pre-trauma center and post-trauma center periods, respectively. The in-hospital mortality rate was higher in the institutional trauma database pre-trauma center period compared with the American National Trauma Data Bank (11.6% versus 8.1%, P<.001). However, the mortality rate decreased in the institutional trauma database post-trauma center period and was similar to that in the American National Trauma Data Bank (6.9% versus 6.8%, P=.903). Being treated at Ajou University Medical Center Trauma Center was significantly associated with higher mortality during the pre-trauma center period (OR: 1.842, 95% CI: 1.336-2.540; P<.001), although no significant association was observed during the post-trauma center period (OR: 1.102, 95% CI: 0.827-1.468; P=.509).

CONCLUSION

The mortality rate improved after a trauma center was established in a South Korean hospital and is similar to that from matched cases treated at American level-1 trauma centers. Thus, creating trauma centers and a regional trauma system may improve outcomes in major trauma cases.