Predictive Value of the Geriatric Trauma Outcome Score in Older Patients After Trauma: A Retrospective Cohort Study

Efficacy of the Geriatric Trauma Outcome Score (GTOS) in Predicting Mortality in Trauma Patients: A Retrospective Cross-Sectional Study

BACKGROUND

Trauma has a profound impact on mortality as well as short- and long-term health outcomes. For trauma patients to receive medical care in a timely manner, early identification and risk assessment are essential. The Geriatric Trauma Outcome Score (GTOS), which was created by combining age, the Injury Severity Score (ISS), and the requirement for packed red blood cell transfusion, has proven to be a valuable prognostic tool for elderly trauma patients, though its applicability to general trauma patients is still understudied.

METHODS

This retrospective study analyzed data from the Trauma Registry System at a Level I trauma center in southern Taiwan, covering the period from 1 January 2009 to 31 December 2021. This study included 40,068 trauma patients aged 20 years and older. Statistical analyses included chi-square tests, ANOVA, Mann-Whitney U tests, and multivariate analyses to identify independent risk factors for mortality. The predictive performance of the GTOS was assessed using the area under the curve (AUC) of the receiver operating characteristic curve.

RESULTS

The final study population included 40,068 patients, with 818 deaths and 39,250 survivors. Deceased patients had higher GTOS scores (mean 132.8 vs. 76.1, p < 0.001) and required more blood transfusions (mean 4.0 vs. 0.3 units, p < 0.001) compared to survivors. The optimal GTOS cut-off value for predicting mortality was 104.5, with a sensitivity of 82.6% and a specificity of 84.3% (AUC = 0.917). A high GTOS score was associated with increased mortality (9.6 vs. 0.4%, p < 0.001) compared with a low GTOS score, even after adjusting for confounding factors (adjusted mortality rate of 2.86, p < 0.001), and a longer hospital stay (14.0 vs. 7.7 days, p < 0.001).

CONCLUSIONS

The GTOS is a valuable prognostic tool for predicting mortality in trauma patients, providing a simple and rapid assessment method. Its high predictive accuracy supports its use in broader trauma patient populations beyond the elderly. Further studies are recommended to refine and validate the GTOS in diverse trauma settings to enhance its clinical utility.

The impact of age and intensity of treatment on the outcome of traumatic brain injury

Background

Approximately one-third of trauma-related deaths are due to traumatic brain injury (TBI), particularly among young adults and elderly patients. Management strategies may vary across different age groups, potentially influencing short-term neurological outcomes. This study aims to investigate age-related disparities in treatment approaches and 3-month neurological outcomes among TBI patients.

Methods

We conducted a retrospective study on TBI patients requiring Intensive Care Unit (ICU) admission from January 1, 2015, to January 1, 2024, in a tertiary University hospital. Patient demographics, major comorbidities, ICU admission parameters, interventions and ICU complications were collected. An unfavorable neurological outcome at 3 months (UO) was defined as a Glasgow Outcome Scale (GOS) score of 1-3. A high therapy intensity level (TIL) was defined as a TIL basic of 3-4. A multivariable logistic regression model and a Cox proportional Hazard Regression model were used to assess the association of age and TIL with neurological outcome and mortality. A sensitivity analysis on low TIL (0-2) and high TIL subgroups was also conducted.

Results

We enrolled 604 TBI patients, of which 240 (40%) had UO. The highest prevalence of UO was found in patients aged ≥80 years (53/94, 56%), followed by patients aged 50-79 years (104/255, 41%). The age group 35-49 years had the lowest rate of UO (38/127, 30%). Older patients (age ≥ 80 years) received less frequently high TIL than others (p = 0.03). In the multivariable analysis, age ≥ 80 years [OR: 3.42 (95% CI 1.72-6.81)] was independently associated with UO, while age ≥ 80 years [HR 5.42 (95% CI 3.00-9.79)] and age 50-79 years [HR 2.03, (95% CI 1.19-3.48)] were independently associated with mortality. Although there was no interaction between age groups and TIL on outcome, an exploratory analysis showed that in the high TIL subgroup of patients, age had no independent impact on the outcome, whereas, in the low TIL group, age ≥ 80 years was independently associated with UO [OR: 3.65 (95% CI: 1.64-8.14)].

Conclusion

Older age, especially in the setting of low intensity treatment, may impact short-term neurological outcome of traumatic brain-injured patients.

Association between clinical factors and mortality in older adult trauma patients: A systematic review and meta-analysis

BACKGROUND

This study reviews and meta-analysis factors affecting mortality in older adult trauma patients, addressing previously unidentified heterogeneity and risk burden.

METHODS

Databases (PubMed, Embase, Cochrane and Scopus) were searched for studies from January 1, 2000, to April 30, 2024. Inclusion criteria were patients aged ≥65 years with trauma, assessing survival or death outcomes. Two authors independently screened and extracted data using the PRISMA checklist; disagreements were resolved by a third author.

RESULTS

Eighteen retrospective studies were included (425,355 patients), showing an overall mortality rate of 9.6 ​%. Falls were the predominant cause of injury. Demographic mortality risk factors included advanced age, frailty, male sex, and comorbidities (blood/bleeding disorders, liver disease, cancer, kidney disease, and lung disease). Injury risk factors were identified as contributing to the outcome, including low systolic blood pressure, Glasgow Coma Scale, Injury Severity Score, Revised Trauma Score, and surgical intervention.

CONCLUSION

Trauma significantly elevates the mortality rate in older adults, with advanced age, gender, comorbidities, injury severity, frailty, and surgical intervention being key factors.

Evaluation of the Geriatric Trauma Outcome Score (GTOS) as a Prognostic Tool in Intensive Care Unit Trauma Patients

BACKGROUND

Existing prognostic scoring systems for intensive care unit (ICU) trauma patients require extensive data collection. The Geriatric Trauma Outcome Score (GTOS), which is based on age, injury severity, and transfusion need, has been validated for predicting mortality in elderly patients with trauma; however, its utility in the general ICU trauma population remains unexplored.

METHODS

This retrospective study included 2952 adult ICU trauma patients admitted between 2016 and 2021. The GTOS was calculated as follows: age + (Injury Severity Score × 2.5) + 22 (if transfused within 24 h). The area under the receiver operating characteristic curve (AUROC) was used to assess GTOS's ability to predict mortality. The optimal GTOS cutoff was determined using Youden's index. Mortality rates were compared between the high and low GTOS groups, including a propensity score-matched analysis adjusted for baseline characteristics.

RESULTS

This study included 2952 ICU trauma patients, with an overall mortality rate of 11.0% (n = 325). GTOS demonstrated good predictive accuracy for mortality (AUROC 0.80). The optimal cutoff was 121.8 (sensitivity, 0.791; specificity, 0.685). Despite adjustments, patients with GTOS ≥ 121.8 had significantly higher mortality (17.4% vs. 6.2%, p < 0.001) and longer hospital stays (20.3 vs. 15.3 days, p < 0.001) compared to GTOS < 121.8.

CONCLUSIONS

GTOS showed a reasonable ability to predict mortality in ICU trauma patients across all ages, although not as accurately as more complex ICU-specific models. With its simplicity, the GTOS may serve as a rapid screening tool for risk stratification in acute ICU trauma settings when combined with other data.

Geriatric Trauma Outcome Score as a Mortality Predictor in Isolated Moderate to Severe Traumatic Brain Injury: A Single-Center Retrospective Study

BACKGROUND

Traumatic brain injury (TBI) is a major cause of mortality and disability worldwide, with severe cases significantly increasing the risk of complications and long-term mortality. The Geriatric Trauma Outcome Score (GTOS), based on age, injury severity, and transfusion need, has been validated for predicting mortality in older trauma patients, but its utility in predicting mortality for TBI patients remains unexplored.

METHODS

This retrospective study included 5543 adult trauma patients with isolated moderate to severe TBI, defined by head Abbreviated Injury Scale (AIS) scores of ≥ 3, from 1998 to 2021. GTOS was calculated with the following formula: age + (Injury Severity Score × 2.5) + 22 (if transfused within 24 h). The area under the receiver operating characteristic curve (AUROC) assessed GTOS's ability to predict mortality. The optimal GTOS cutoff value was determined using Youden's index. Mortality rates were compared between high- and low-GTOS groups, separated by the optimal GTOS cutoff value, including a propensity score-matched analysis adjusting for baseline characteristics.

RESULTS

Among 5543 patients, mortality was 8.3% (462 deaths). Higher mortality is correlated with male sex, older age, higher GTOS, and comorbidities like hypertension, coronary artery disease, and end-stage renal disease. The optimal GTOS cut-off for mortality prediction was 121.5 (AUC = 0.813). Even when the study population was matched by propensity score, patients with GTOS ≥121.5 had much higher odds of death (odds ratio 2.64, 95% confidence interval 1.93-3.61, p < 0.001) and longer hospital stays (mean 16.7 vs. 12.2 days, p < 0.001) than those with GTOS < 121.5.

CONCLUSIONS

These findings support the idea that GTOS is a useful tool for risk stratification of in-hospital mortality in isolated moderate to severe TBI patients. However, we encourage further research to refine GTOS for better applicability in TBI patients.

Markers of Futile Resuscitation in Traumatic Hemorrhage: A Review of the Evidence and a Proposal for Futility Time-Outs during Massive Transfusion

The reduction in the blood supply following the 2019 coronavirus pandemic has been exacerbated by the increased use of balanced resuscitation with blood components including whole blood in urban trauma centers. This reduction of the blood supply has diminished the ability of blood banks to maintain a constant supply to meet the demands associated with periodic surges of urban trauma resuscitation. This scarcity has highlighted the need for increased vigilance through blood product stewardship, particularly among severely bleeding trauma patients (SBTPs). This stewardship can be enhanced by the identification of reliable clinical and laboratory parameters which accurately indicate when massive transfusion is futile. Consequently, there has been a recent attempt to develop scoring systems in the prehospital and emergency department settings which include clinical, laboratory, and physiologic parameters and blood products per hour transfused as predictors of futile resuscitation. Defining futility in SBTPs, however, remains unclear, and there is only nascent literature which defines those criteria which reliably predict futility in SBTPs. The purpose of this review is to provide a focused examination of the literature in order to define reliable parameters of futility in SBTPs. The knowledge of these reliable parameters of futility may help define a foundation for drawing conclusions which will provide a clear roadmap for traumatologists when confronted with SBTPs who are candidates for the declaration of futility. Therefore, we systematically reviewed the literature regarding the definition of futile resuscitation for patients with trauma-induced hemorrhagic shock, and we propose a concise roadmap for clinicians to help them use well-defined clinical, laboratory, and viscoelastic parameters which can define futility.

Prediction of Neurological Outcomes in Elderly Patients With Head Trauma Using the Geriatric Trauma Outcome Score: A Retrospective Observational Study

Introduction Head trauma in elderly people is a problem in today's aging society. Elderly people are susceptible to head trauma because of their declining physical function; this tends to be severe. Outcome prediction is important in decision-making regarding treatment strategies; however, there is no unified method for predicting neurological outcomes in elderly patients with head trauma. Methods Elderly patients with head trauma admitted to the Japan Red Cross Narita Hospital between January 2019 and August 2023 were enrolled in this single-center, retrospective observational study. A favorable neurological outcome was defined as a cerebral performance category scale of 1 or 2. Multivariate logistic regression analysis and receiver operating characteristic curve analysis were performed to investigate the association between geriatric trauma outcome scores and outcomes and to evaluate the predictive value of geriatric trauma outcome scores. The primary outcome was a favorable neurological outcome at discharge, and the secondary outcome was in-hospital mortality. Results A total of 313 elderly patients with head trauma were eligible for analysis. Multivariate logistic regression analysis revealed that the geriatric trauma outcome score was significantly associated with a favorable neurological outcome at discharge (odds ratio 0.94, P <0.0001). In the receiver operating characteristic curve analysis, the geriatric trauma outcome score had a good predictive value for favorable neurological outcomes at discharge (area under the receiver operating characteristic curve 0.83). Conclusions The geriatric trauma outcome score had good predictive value for favorable neurological outcomes at discharge in elderly patients with head trauma and has the potential to aid in decision-making regarding treatment strategies for elderly patients with head trauma.

Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis

PURPOSE

This meta-analysis aimed to evaluate the performance of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and the Geriatric Trauma Outcome Score (GTOS) in predicting mortality in geriatric trauma patients.

METHODS

The MEDLINE, Web of Science, and EMBASE databases were searched for studies published from January 2008 to October 2023. Studies assessing the performance of the ISS, TRISS, or GTOS in predicting mortality in geriatric trauma patients (over 60 years old) and reporting data for the analysis of the pooled area under the receiver operating characteristic curve (AUROC) and the hierarchical summary receiver operating characteristic curve (HSROC) were included. Studies that were not conducted in a group of geriatric patients, did not consider mortality as the outcome variable, or had incomplete data were excluded. The Critical Appraisal Skills Programme (CASP) Clinical Prediction Rule Checklist was utilized to assess the risk of bias in included studies. STATA 16.0. was used for the AUROC analysis and HSROC analysis.

RESULTS

Nineteen studies involving 118,761 geriatric trauma patients were included. The pooled AUROC of the TRISS (AUC = 0.82, 95% CI: 0.77-0.87) was higher than ISS (AUC = 0.74, 95% CI: 0.71-0.79) and GTOS (AUC = 0.80, 95%CI: 0.77-0.83). The diagnostic odds ratio (DOR) calculated from HSROC curves also suggested that the TRISS (DOR = 21.5) had a better performance in predicting mortality in geriatric trauma patients than the ISS (DOR = 6.27) and GTOS (DOR = 4.76).

CONCLUSION

This meta-analysis suggested that the TRISS showed better accuracy and performance in predicting mortality in geriatric trauma patients than the ISS and GTOS.

Traumatic Brain Injury as an Independent Predictor of Futility in the Early Resuscitation of Patients in Hemorrhagic Shock

This review explores the concept of futility timeouts and the use of traumatic brain injury (TBI) as an independent predictor of the futility of resuscitation efforts in severely bleeding trauma patients. The national blood supply shortage has been exacerbated by the lingering influence of the COVID-19 pandemic on the number of blood donors available, as well as by the adoption of balanced hemostatic resuscitation protocols (such as the increasing use of 1:1:1 packed red blood cells, plasma, and platelets) with and without early whole blood resuscitation. This has underscored the urgent need for reliable predictors of futile resuscitation (FR). As a result, clinical, radiologic, and laboratory bedside markers have emerged which can accurately predict FR in patients with severe trauma-induced hemorrhage, such as the Suspension of Transfusion and Other Procedures (STOP) criteria. However, the STOP criteria do not include markers for TBI severity or transfusion cut points despite these patients requiring large quantities of blood components in the STOP criteria validation cohort. Yet, guidelines for neuroprognosticating patients with TBI can require up to 72 h, which makes them less useful in the minutes and hours following initial presentation. We examine the impact of TBI on bleeding trauma patients, with a focus on those with coagulopathies associated with TBI. This review categorizes TBI into isolated TBI (iTBI), hemorrhagic isolated TBI (hiTBI), and polytraumatic TBI (ptTBI). Through an analysis of bedside parameters (such as the proposed STOP criteria), coagulation assays, markers for TBI severity, and transfusion cut points as markers of futilty, we suggest amendments to current guidelines and the development of more precise algorithms that incorporate prognostic indicators of severe TBI as an independent parameter for the early prediction of FR so as to optimize blood product allocation.

Application of the Geriatric Trauma Outcome Score in a Rural Setting

OBJECTIVE

To retrospectively apply the Geriatric Trauma Outcome (GTO) score to the patient population of a rural South Central Appalachian level 1 trauma center and identify the potential utility of the GTO score in guiding goals of care discussions.

METHODS

Trauma registry data was extracted for 5,627 patients aged 65+ from 2017 to 2021. GTO score was calculated for each patient. Descriptive statistics were calculated for age, Injury Severity Score (ISS), GTO score, receipt of red blood cells, discharge status, and code status. A simple logistic regression model was used to determine the relationship between GTO score and discharge status. The probability of mortality was then calculated using GTO score, and the distribution of code status among patients with ≤50, 51-75%, and >75% probability of mortality was examined.

RESULTS

For every 10-point increase in GTO score, odds of mortality increased by 79% (OR = 1.79; P < .001). Patients had an estimated 50% probability of mortality with a GTO score of 156, 75% with 174, and 99% with a score of 234, respectively. Seventeen patients had a GTO score associated with >75% probability of mortality. Of those 17 patients, four retained a full code status.

CONCLUSIONS

Our analysis demonstrates that the GTO score is a validated measure in a rural setting and can be an easily calculated metric to help determine a geriatric patient's probability of mortality following a trauma. The results of our study also found that GTO score can be used to inform goals of care discussions with patients.

Clinical characteristics and mortality risk factors among trauma patients by age groups at a single center in Korea over 7 years: a retrospective study

Purpose

In this study, we aimed to compare the characteristics of patients with trauma by age group in a single center in Korea to identify the clinical characteristics and analyze the risk factors affecting mortality.

Methods

Patients aged ≥18 years who visited the Chungbuk National University Hospital Regional Trauma Center between January 2016 and December 2022 were included. The accident mechanism, severity of the injury, and outcomes were compared by classifying the patients into group A (18-64 years), group B (65-79 years), and group C (≥80 years). In addition, logistic regression analysis was performed to identify factors affecting death.

Results

The most common injury mechanism was traffic accidents in group A (40.9%) and slipping in group B (37.0%) and group C (56.2%). Although group A had the highest intensive care unit admission rate (38.0%), group C had the highest mortality rate (9.5%). In the regression analysis, 3 to 8 points on the Glasgow Coma Scale had the highest odds ratio for mortality, and red blood cell transfusion within 24 hours, intensive care unit admission, age, and Injury Severity Score were the predictors of death.

Conclusions

For patients with trauma, the mechanism, injured body region, and severity of injury differed among the age groups. The high mortality rate of elderly patients suggests the need for different treatment approaches for trauma patients according to age. Identifying factors affecting clinical patterns and mortality according to age groups can help improve the prognosis of trauma patients in the future.

Development and validation of a nomogram for predicting persistent inflammation, immunosuppression, and catabolism syndrome in trauma patients

Background

Persistent Inflammation, Immunosuppression, and Catabolism Syndrome (PIICS) is a significant contributor to adverse long-term outcomes in severe trauma patients.

Objective

The objective of this study was to establish and validate a PIICS predictive model in severe trauma patients, providing a practical tool for early clinical prediction.

Patients and methods

Adult severe trauma patients with an Injury Severity Score (ISS) of ≥16, admitted between October 2020 and December 2022, were randomly divided into a training set and a validation set in a 7:3 ratio. Patients were classified into PIICS and non-PIICS groups based on diagnostic criteria. LASSO regression was used to select appropriate variables for constructing the prognostic model. A logistic regression model was developed and presented in the form of a nomogram. The performance of the model was evaluated using calibration and ROC curves.

Results

A total of 215 patients were included, consisting of 155 males (72.1%) and 60 females (27.9%), with a median age of 51 years (range: 38-59). NRS2002, ISS, APACHE II, and SOFA scores were selected using LASSO regression to construct the prognostic model. The AUC of the ROC analysis for the predictive model in the validation set was 0.84 (95% CI 0.72-0.95). The Hosmer-Lemeshow test in the validation set yielded a χ2 value of 14.74, with a value of p of 0.098.

Conclusion

An accurate and easily implementable PIICS risk prediction model was established. It can enhance risk stratification during hospitalization for severe trauma patients, providing a novel approach for prognostic prediction.

Melatonin: A potential adjuvant therapy for septic myopathy

Septic myopathy, also known as ICU acquired weakness (ICU-AW), is a characteristic clinical symptom of patients with sepsis, mainly manifested as skeletal muscle weakness and muscular atrophy, which affects the respiratory and motor systems of patients, reduces the quality of life, and even threatens the survival of patients. Melatonin is one of the hormones secreted by the pineal gland. Previous studies have found that melatonin has anti-inflammatory, free radical scavenging, antioxidant stress, autophagic lysosome regulation, mitochondrial protection, and other multiple biological functions and plays a protective role in sepsis-related multiple organ dysfunction. Given the results of previous studies, we believe that melatonin may play an excellent regulatory role in the repair and regeneration of skeletal muscle atrophy in septic myopathy. Melatonin, as an over-the-counter drug, has the potential to be an early, complementary treatment for clinical trials. Based on previous research results, this article aims to critically discuss and review the effects of melatonin on sepsis and skeletal muscle depletion.