Impact of Adapting the Abbreviated Injury Scale (AIS)-2005 from AIS-1998 on Injury Severity Scores and Clinical Outcome

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.

Is reversal of anticoagulants necessary in neurologically intact traumatic intracranial hemorrhage?

INTRODUCTION

Falls are the leading cause of injury in older individuals, with intracranial hemorrhage (ICH) being a common complication. Anticoagulants, such as vitamin K antagonist and direct oral anticoagulants, are increasingly utilized, and clinicians may question the necessity of reversal in patients with minor ICH, especially in the setting of increased risk of adverse events. This study aimed to identify a population of patients with minor traumatic ICH at low risk for poor-neurologic status where anticoagulant reversal may not improve outcomes.

METHODS

This retrospective cohort study utilized data accessed from 35 trauma centers from 2018 to 2021. Patients included had a preinjury anticoagulant regimen, ICH due to blunt trauma, Glasgow Coma Scale score of 15, an Abbreviated Injury Scale (AIS) head score from 2 to 4, and an AIS of ≤1 for non-head regions within 24 h of hospital arrival. Patients were excluded if they required an emergent neurosurgical procedure or were on a preinjury purinergic-P2 receptor-12 protein (P2Y12) inhibitor. The primary outcome was the rate of in-hospital mortality or hospice.

RESULTS

There were 654 patients on preinjury anticoagulation who were included with a minor traumatic ICH without neurologic deficits. Overall, 263 patients were reversed and 391 were not reversed. Twelve (4.6%) patients with in-hospital mortality or hospice were reversed compared with 19 (4.91%) patients who were not reversed (p = 0.861). A composite of hospital complications occurred in 21 (8%) reversed patients and 34 (8.7%) not reversed patients (p = 0.748). The average intensive care unit length of stay was 1.4 ± 3.4 days in the reversed group and 1.1 ± 1.8 days in the not reversed group (p = 0.069).

CONCLUSION

This study found no difference in hospital outcomes between patients with minor traumatic ICH on oral anticoagulants who were neurologically intact that were reversed versus those who were not reversed. Further studies should continue to define the subset of traumatic ICH patients who may not require reversal of anticoagulation.

Postmortem injury evaluation using the Forensic Injury Severity Score Template (FISST): a preliminary study

The Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) are important evaluation tools used in clinical practice to determine the degree of injury in patients with trauma. However, they are not suitable for forensic practice and their use in forensic applications is limited. This study aimed to present a system that can objectively and quantitatively determine the severity of postmortem injuries and that can be applied to forensic medicine. Subsequently, we applied this system to individual postmortem cases and analyzed the injuries identified during autopsy. We performed a retrospective study of 119 autopsies performed between 2018 and 2021. Data were categorized and analyzed using the Forensic Injury Severity Score Template (FISST), a scoring system developed based on the AIS and ISS. The mean FISST scores were as follows: men, 53.6; women, 46.8; 20-65 years old, 55.6; older than 65 years, 41.4; natural death, 13.8; unnatural death, 66.3; and all deaths, 51.8. Statistically significant differences in the FISST scores were found between natural and unnatural deaths, suicidal and accidental deaths, and trauma-related death subtypes. Injuries identified during autopsy can be objectively and quantitatively evaluated using FISST. We suggest that FISST is a useful tool in forensic medicine because it is tailor-made for injury evaluation from a postmortem perspective.

The epidemiology of dog bite injuries in Greece: preliminary results of a surveillance scheme

Background

Dog bite injuries commonly fall under the radar of the public health surveillance systems. Nevertheless, these incidents may result in emotional distress, disfigurement, functional deficit, or exposure to zoonotic agents and therefore may have a considerable impact on public health.

Methods

A pilot surveillance scheme was launched in Greece to assess the epidemiology of dog bite injuries. Physicians in hospital-based emergency room departments and primary health care centers were required to report bite cases via a reporting form. The collected data were analyzed cross-sectionally.

Results

From January to June 2023, 1,656 dog bite victims attended the healthcare settings in Greece. The rate was estimated at 15.8 cases per 100,000 population. The frequency of healthcare visits varied significantly among the regions (p <0.0001), ranging from 0.9 to 45.2 per 100,000 inhabitants. The median number (interquartile range in brackets) of visits concerning dog bite victims for the examined period per reporting hospital was nine (2, 21) and per reporting health center three (1, 10), respectively. The ownerless-to-owned dogs ratio was almost equal (1.04). According to the Abbreviated Injury Scale, 67.3 % of the injuries were classified as minor, 27.7 % as moderate, 4.9 % as serious, and 0.1 % as critical. The lower limb was the most frequently affected anatomical site (50.6 %). Head/neck injuries were associated with younger patients (p <0.0001). Macroscopic tissue loss occurred in 11.9 % of the cases, with the majority presenting areas of damaged or missing skin (50.9 %); partially or completely amputated hand digits occurred in nine of these cases (8.5 %). Among dog bite victims, 2.8 % were hospitalized (inpatients), and 1 % were referred to other hospitals.

Conclusions

Dog bite surveillance offers important epidemiological information on the respective traumatic impact. HIPPOKRATIA 2023, 27 (2):82-88.

Pediatric Trauma in The Netherlands: Incidence, Mechanism of Injury and In-Hospital Mortality

BACKGROUND

In the Netherlands, there are no specialized or certified pediatric trauma centers, especially for severely injured children. National and regional agreements on centralization of pediatric trauma care are scarce. This study aims to describe the incidence, injury mechanism and in-hospital mortality of pediatric trauma in the Netherlands, as a prelude to the further organization of pediatric trauma care.

METHODS

A retrospective cohort analysis of data from the Dutch National Trauma Registry in 2009-2018, concerning all children (0-16 years) hospitalized due to injury in the Netherlands.

RESULTS

The annual number of admitted injured children increased from 8666 in 2009 to 13,367 in 2018. Domestic accidents were the most common cause of non-fatal injury (67.9%), especially in children aged 0-5 years (89.2%). Severe injury (injury severity score ≥  16) accounted for 2.5% and 74% of these patients were treated in level-1 trauma centers. In both deceased and surviving patients with severe injuries, head injuries were the most common (72.1% and 64.3%, respectively). In-hospital mortality after severe injury was 8.2%. Road-traffic accidents (RTAs) were the leading cause of death (46.5%).

CONCLUSIONS

Domestic accidents are the most common cause of injury, especially in younger children, whereas RTAs are the lead cause of fatal injury. Severe pediatric trauma in the Netherlands is predominantly managed in level-1 trauma centers, where a multidisciplinary team of experts is available. Improving the numbers of severely injured patients primarily brought to level-1 trauma centers may help to further reduce mortality.

The Network of miRNA-mRNA Interactions in Circulating T Cells of Patients Following Major Trauma - A Pilot Study

Purpose

Following major trauma, genes involved in adaptive immunity are downregulated, which accompanies the upregulation of genes involved in systemic inflammatory responses. This study investigated microRNA (miRNA)-mRNA interactome dysregulation in circulating T cells of patients with major trauma.

Patients and Methods

This study included adult trauma patients who had an injury severity score ≥16 and required ventilator support for more than 48 h in the intensive care unit. Next-generation sequencing was used to profile the miRNAs and mRNAs expressed in CD3+ T cells isolated from patient blood samples collected during the injury and recovery stages.

Results

In the 26 studied patients, 9 miRNAs (hsa-miR-16-2-3p, hsa-miR-16-5p, hsa-miR-185-5p, hsa-miR-192-5p, hsa-miR-197-3p, hsa-miR-23a-3p, hsa-miR-26b-5p, hsa-miR-223-3p, and hsa-miR-485-5p) were significantly upregulated, while 58 mRNAs were significantly downregulated in T cells following major trauma. A network consisting of 8 miRNAs and 22 mRNAs interactions was revealed by miRWalk, with three miRNAs (hsa-miR-185-5p, hsa-miR-197-3p, and hsa-miR-485-5p) acting as hub genes that regulate the network. Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analysis suggested that “chemokine signaling pathway” was the predominant pathway.

Conclusion

The study revealed a miRNA-mRNA interactome consisting of 8 miRNAs and 22 mRNAs that are predominantly involved in chemokine signaling in circulating T cells of patients following major trauma.

Impact of AIS 2015 versus 1998 on injury severity scoring and mortality prediction - single centre retrospective comparison study

BACKGROUND

A key component of trauma system evaluation is the Injury Severity Score (ISS). The ISS is dependent on the AIS, and as AIS versions are updated this effects the number of patients within a health system which are considered severely injured (ISS >15). This study aims to analyse the changes comparing AIS1998 and AIS2015, and its impact on injury severity scoring and survival prediction model in a major trauma centre.

METHODS

This retrospective study reviewed all blunt trauma admissions from 1 January 2020 to 31 December 2020 from the trauma registry of Prince of Wales Hospital, Hong Kong. Patients were manually double coded with AIS1998 and AIS2015 by the same experienced trauma nurse who have completed both AIS 1998 and AIS 2015 Courses. AIS patterns and Injury Severity Scores (ISS) derived from AIS 1998 and 2015 were compared using the Wilcoxon Signed Rank Test. The area under the receiving operator curve (AUROC) was compared based on the Trauma and Injury Severity Score (TRISS) model using AIS 1998 and AIS 2015.

RESULTS

739 patients were included. There were 34 deaths within 30 days (30-day mortality rate 4.6%). Patients coded with AIS2015 compared with AIS1998 had significant reductions in the classification of serious, severe and critical categories of AIS, with a substantial increase in the mild and moderate categories. The largest reduction was observed in the head and neck region (Z = -11.018, p < 0.001), followed by the chest (Z = -6.110, p < 0.001), abdomen (Z = -4.221, p < 0.001) and extremity regions (Z = -4.252, p < 0.001). There was a 27% reduction in number of cases with ISS >15 in AIS2015 compared with AIS1998. Rates of 30-day mortality, ICU admission, emergency operation and trauma team activation of ISS > 15 using AIS 1998 were similar to the cut off for New Injury Severity Score (NISS) >12 using AIS 2015. The AUROC from the TRISS (AIS2015) was 0.942, and not different from the AUROC for TRISS (AIS1998) of 0.936. The sensitivity and specificity were 93.9% and 82.1% for TRISS (AIS2015), and 93.9% and 76.0% for TRISS (AIS1998).

CONCLUSION

Trauma centres should be aware of the impact of the AIS2015 update on the benchmarking of trauma care, and consider the need for updating the ISS cut off for major trauma definitions.

The Association between Skull Bone Fractures and the Mortality Outcomes of Patients with Traumatic Brain Injury

Introduction

Skull fractures are often found in patients with traumatic brain injury (TBI). Although skull fractures may indicate greater force impact and are associated with local or diffuse brain injuries, the prognostic value of skull fractures remains unclear. This retrospective study aimed to assess the association between skull fractures and mortality in patients with TBI.

Methods

This study included 5,430 TBI patients registered in the trauma registry system from January 2009 to December 2018. Clinical and demographic data including age, sex, trauma mechanisms, comorbidities, Glasgow Coma Scale (GCS) score, abbreviated injury score (AIS)-head, injury severity score (ISS), and in-hospital mortality were acquired. Multiple logistic regression and propensity score matching were used to elucidate the effect of skull fractures on mortality outcomes of TBI patients.

Results

Compared to TBI patients without skull fracture, patients with skull fractures were predominantly male, younger, had lower GCS upon arrival at the emergency room, and had higher AIS-head, ISS, and in-hospital mortality. The patients with skull fracture had 1.7-fold adjusted odds of mortality (95% confidence interval (CI): 1.27–2.25; p < 0.001) than those without skull fracture, controlling for age, sex, comorbidities, and AIS-head. Additionally, the propensity score-matched analysis of 1,023 selected paired patients revealed that skull fracture was significantly associated with increased 1.4-fold odds of risk for mortality (95% CI: 1.02–1.88; p=0.036).

Conclusions

Using a propensity score-matched cohort to attenuate the confounding effect of age, comorbidities, and injury severity, skull fracture was identified as a significant independent risk factor for mortality in patients with TBI.

Road traffic accident-related thoracic trauma: Epidemiology, injury pattern, outcome, and impact on mortality—A multicenter observational study

Background

Thoracic trauma is a major cause of death in trauma patients and road traffic accident (RTA)-related thoracic injuries have different characteristics than those with non-RTA related thoracic traumas, but this have been poorly described. The main objective was to investigate the epidemiology, injury pattern and outcome of patients suffering a significant RTA-related thoracic injury. Secondary objective was to investigate the influence of serious thoracic injuries on mortality, compared to other serious injuries.

Methods

We performed a multicenter observational study including patients of the Rhône RTA registry between 1997 and 2016 sustaining a moderate to lethal (Abbreviated Injury Scale, AIS≥2) injury in any body region. A subgroup (AISThorax≥2 group) included those with one or more AIS≥2 thoracic injury. Descriptive statistics were performed for the main outcome and a multivariate logistic regression was computed for our secondary outcome.

Results

A total of 176,346 patients were included in the registry and 6,382 (3.6%) sustained a thoracic injury. Among those, median age [IQR] was 41 [25–58] years, and 68.9% were male. The highest incidence of thoracic injuries in female patients was in the 70–79 years age group, while this was observed in the 20–29 years age group among males. Most patients were car occupants (52.3%). Chest wall injuries were the most frequent thoracic injuries (62.1%), 52.4% of which were multiple rib fractures. Trauma brain injuries (TBI) were the most frequent concomitant injuries (29.1%). The frequency of MAISThorax = 2 injuries increased with age while that of MAISThorax = 3 injuries decreased. A total of 16.2% patients died. Serious (AIS≥3) thoracic injuries (OR = 12.4, 95%CI [8.6;18.0]) were strongly associated with mortality but less than were TBI (OR = 27.9, 95%CI [21.3;36.7]).

Conclusion

Moderate to lethal RTA-related thoracic injuries were rare. Multiple ribs fractures, pulmonary contusions, and sternal fractures were the most frequent anatomical injuries. The incidence, injury pattern and mechanisms greatly vary across age groups.

A traumatic injury mortality prediction (TRIMP) based on a comprehensive assessment of abbreviated injury scale 2005 predot codes

Abbreviated Injury Scale (AIS)-based systems such as injury severity score (ISS), exponential injury severity score (EISS), trauma mortality prediction model (TMPM), and injury mortality prediction (IMP), classify anatomical injuries with limited accuracy. The widely accepted alternative, trauma and injury severity score (TRISS), improves the prediction rate by combining an anatomical index of ISS, physiological index (the Revised Trauma Score, RTS), and the age of patients. The study introduced the traumatic injury mortality prediction (TRIMP) with the inclusion of extra clinical information and aimed to compare the ability against the TRISS as predictors of survival. The hypothesis was that TRIMP would outperform TRISS in prediction power by incorporating clinically available data. This was a retrospective cohort study where a total of 1,198,885 injured patients hospitalized between 2012 and 2014 were subset from the National Trauma Data Bank (NTDB) in the United States. A TRIMP model was computed that uses AIS 2005 (AIS_05), physiological reserve and physiological response indicators. The results were analysed by examining the area under the receiver operating characteristic curve (AUC), the Hosmer-Lemeshow (HL) statistic, and the Akaike information criterion. TRIMP gave both significantly better discrimination (AUCTRIMP, 0.964; 95% confidence interval (CI), 0.962 to 0.966 and AUCTRISS, 0.923; 95% CI, 0.919 to 0.926) and calibration (HLTRIMP, 14.0; 95% CI, 7.7 to 18.8 and HLTRISS, 411; 95% CI, 332 to 492) than TRISS. Similar results were found in statistical comparisons among different body regions. TRIMP was superior to TRISS in terms of accurate of mortality prediction, TRIMP is a new and feasible scoring method in trauma research and should replace the TRISS.

Surviving Nonsurvivable Injuries: Patients Who Elude the 'Lethal' Abbreviated Injury Scale (AIS) Score of Six

BACKGROUND

The Abbreviated Injury Scale (AIS) score is used widely to quantify injury severity by body region. The maximal AIS score is 6, which defines a nonsurvivable injury. This study was undertaken to define mortality after AIS-6 injuries in order to determine if they are uniformly lethal and, if not, if differences between survivors and nonsurvivors exist which may aid in prognostication or refinement of the current AIS system.

METHODS

All patients in the National Trauma Data Bank (2007-2017) with ≥1 AIS-6 injury were included. Exclusions were age <16 years, AIS-6 coding in the face/extremities (i.e., coding errors, as there are no AIS-6 injuries in these regions), and missing data. In-hospital mortality defined study groups, i.e., survivors vs. nonsurvivors. Univariable analysis compared clinical/injury data and outcomes. Multivariable analysis examined independent factors associated with mortality.

RESULTS

19,247 patients met inclusion/exclusion criteria. Of these, 25% (n=4,886) survived to hospital discharge and 75% (n=14,361) died. The most common discharge destination among survivors was home (n=2,187,45%) Nonsurvivors had significantly worse GCS in the field (3 vs. 14, p<0.001) and ED (3 vs. 15, p<0.001). Median AIS was higher among nonsurvivors in the Head (5 vs. 3, p<0.001), Abdomen (3 vs. 2, p<0.001), and External regions (1 vs. 1, p<0.001). Median time to death was 0.65h, with maximum time to death 8.76h. Multivariable analysis revealed External AIS-6 injuries were associated with greatest odds of mortality (OR 34.002, p<0.001) followed by Head AIS-6 (OR 10.501, p<0.001).

CONCLUSION

AIS-6 injuries are not uniformly fatal, with 25% of such patients surviving to hospital discharge. Therefore, AIS-6 injuries may not be as catastrophic as previously considered. External and Head AIS-6, i.e. extensive burns and severe traumatic brain injuries, were associated with greatest odds of mortality. When death occurs after AIS-6 injury, it occurs rapidly, with all mortalities in this series occurring <9h after arrival. We suggest that the AIS-6 verbiage be revised to remove 'nonsurvivable'.

Profiling the Expression of Circulating Acute-Phase Proteins, Cytokines, and Checkpoint Proteins in Patients with Severe Trauma: A Pilot Study

Purpose

Severe trauma may lead to the systemic release of inflammatory mediators into the circulation with profound acute-phase responses; however, the understanding of the expression of these mediators remains limited. This study aimed to characterize the alterations in the expression of circulating acute-phase proteins, cytokines, and checkpoint proteins in patients with severe trauma injuries.

Patients and Methods

The study population included trauma patients in the intensive care unit (ICU) with an injury severity score equal to or greater than 16 and who had used a ventilator for 48 hours. A total of 12 female and 28 male patients were recruited for the study; six patients died and 34 survived. Blood samples collected at acute stages were compared with those drawn at the subacute stage, the time when the patients were discharged from the ICU, or before the discharge of the patients from the hospital.

Results

The study identified that the expression of acute-phase proteins, such as alpha-1-acid glycoprotein and C-reactive protein, and cytokines, including granulocyte colony-stimulating factor, interleukin-6, and interleukin-1 receptor antagonist, was elevated in the circulation after severe trauma. In contrast, the levels of acute-phase proteins, such as alpha-2-macroglobulin, serum amyloid P, and von Willebrand factor, and cytokines, including interleukin-4 and interferon gamma-induced protein 10, were reduced. However, there were no significant differences in the expression of checkpoint proteins in the circulation.

Conclusion

The dysregulated proteins identified in this study may serve as potential therapeutic targets or biomarkers for treating patients with severe trauma. However, the related biological functions of these dysregulated factors require further investigation to validate their functions.

RISC II is superior to TRISS in predicting 30-day mortality in blunt major trauma patients in Hong Kong

PURPOSE

Hong Kong (HK) trauma registries have been using the Trauma and Injury Severity Score (TRISS) for audit and benchmarking since their introduction in 2000. We compare the mortality prediction model using TRISS and Revised Injury Severity Classification, version II (RISC II) for trauma centre patients in HK.

METHODS

This was a retrospective cohort study with all five trauma centres in HK. Adult trauma patients with Injury Severity Score (ISS) > 15 suffering from blunt injuries from January 2013 to December 2015 were included. TRISS models using the US and local coefficients were compared with the RISC II model. The primary outcome was 30-day mortality and the area under the receiver operating characteristic curve (AUC) for tested models.

RESULTS

1840 patients were included, of whom 1236/1840 (67%) were male. Median age was 59 years and median ISS was 25. Low falls were the most common mechanism of injury. The 30-day mortality was 23%. RISC II yielded a superior AUC of 0.896, compared with the TRISS models (MTOS: 0.848; PATOS: 0.839; HK: 0.858). Prespecified subgroup analyses showed that all the models performed worse for age ≥ 70, ASA ≥ III, and low falls. RISC II had a higher AUC compared with the TRISS models in all subgroups, although not statistically significant.

CONCLUSION

RISC II was superior to TRISS in predicting the 30-day mortality for Hong Kong adult blunt major trauma patients. RISC II may be useful when performing future audit or benchmarking exercises for trauma in Hong Kong.

Association between Geriatric Nutritional Risk Index and Mortality in Older Trauma Patients in the Intensive Care Unit

The geriatric nutritional risk index (GNRI) is a simple and efficient tool to assess the nutritional status of patients with malignancies or after surgery. Because trauma patients constitute a specific population that generally acquires accidental and acute injury, this study aimed to identify the association between the GNRI at admission and mortality outcomes of older trauma patients in the intensive care unit (ICU). Methods: The study population included 700 older trauma patients admitted to the ICU between 1 January 2009 and 31 December 2019. The collected data included age, sex, body mass index (BMI), albumin level at admission, preexisting comorbidities, injury severity score (ISS), and in-hospital mortality. Multivariate logistic regression analysis was conducted to identify the independent effects of univariate predictive variables resulting in mortality in our study population. The study population was categorized into four nutritional risk groups: a major-risk group (GNRI < 82; n = 128), moderate-risk group (GNRI 82 to <92; n = 191), low-risk group (GNRI 92–98; n = 136), and no-risk group (GNRI > 98; n = 245). Results: There was no significant difference in sex predominance, age, and BMI between the mortality (n = 125) and survival (n = 575) groups. The GNRI was significantly lower in the mortality group than in the survival group (89.8 ± 12.9 vs. 94.2 ± 12.0, p < 0.001). Multivariate logistic regression analysis showed that the GNRI (odds ratio—OR, 0.97; 95% confidence interval (CI) 0.95–0.99; p = 0.001), preexisting end-stage renal disease (OR, 3.6; 95% CI, 1.70–7.67; p = 0.001), and ISS (OR, 1.1; 95% CI, 1.05–1.10; p < 0.001) were significant independent risk factors for mortality. Compared to the patients in group of GNRI > 98, those patients in group of GNRI < 82 presented a significantly higher mortality rate (26.6% vs. 13.1%; p < 0.001) and length of stay in hospital (26.5 days vs. 20.9 days; p = 0.016). Conclusions: This study demonstrated that GNRI is a significant independent risk factor and a promising simple screening tool to identify the subjects with malnutrition associated with higher risk for mortality in those ICU elderly trauma patients.

Geriatric Nutritional Risk Index as a Screening Tool to Identify Patients with Malnutrition at a High Risk of In-Hospital Mortality among Elderly Patients with Femoral Fractures-A Retrospective Study in a Level I Trauma Center

BACKGROUND

Malnutrition is frequently underdiagnosed in geriatric patients and is considered to be a contributing factor for worse outcomes during hospitalization. In addition, elderly patients who undergo trauma are often malnourished at the time of incurring fractures. The geriatric nutritional risk index (GNRI), calculated based on the serum albumin level and the ratio of present body weight to ideal body weight, was proposed for the assessment of the nutritional status of elderly patients with various illnesses. This study aimed to investigate whether the GNRI has a prognostic value that links the nutritional status and mortality outcomes of elderly patients who have previously undergone trauma with femoral fractures.

METHODS

From January 1, 2009 to December 31, 2019, a total of 678 elderly patients with femoral fractures were categorized into four nutritional risk groups: a major-risk group (GNRI <82; group 1, n = 127), moderate-risk group (GNRI 82- <92; group 2, n = 179), low-risk group (GNRI 92-98; group 3, n = 123), and no-risk group (GNRI >98; group 4, n = 249). To minimize the confounding effects of sex, age, preexisting comorbidities, and injury severity of patients on outcome measurements, propensity score-matched patient cohorts were created to assess the impact of patients being in different nutritional risk groups on the in-hospital mortality outcomes against the no-risk group.

RESULTS

The patients in groups 1-3 were significantly older and presented a significantly lower body mass index and lower serum albumin levels than those in group 4. Compared with patients in group 4 (3.6%), a significantly higher mortality rate was found in the patients in group 1 (17.3%, p < 0.001), but not in those in group 2 (6.7%) or group 3 (2.4%). The study of propensity score-matched patient cohorts provided similar results; group 1 patients had significantly higher odds of mortality than group 4 patients (odds ratio, 6.3; 95% confidence interval, 1.34-29.37; p = 0.009), but there were no significant differences in mortality risks among patients in groups 2 and 3 compared with those in group 4.

CONCLUSIONS

This preliminary study suggested that the GNRI may be used as a screening tool to identify patients with malnutrition at a high risk of mortality among elderly patients with femoral fractures. A prospective study is needed to validate the suggestion.

Trauma-team-activation in Germany: how do emergency service professionals use the activation due to trauma mechanism? Results from a nationwide survey

BACKGROUND

Trauma team activation (TTA) requires significant human and financial resources. The implemented German guidelines reduced the mortality of severe injured patients significantly over the last decade. Up to now there is no two-tier trauma team activation protocol in Germany. A two-tier TTA [often activated due to trauma mechanism (TM)] is thought to be a reasonable way to maintain patient safety while increasing cost efficiency.

METHODS

We created an online survey addressed at the Emergency Medical Service in Germany to conduct a cross-sectional study. Both physicians and rescue service professionals (RSPs) were included. A minimum of 1550 participants answered questions in 4 different categories concerning the aspects of limited-TTA (L-TTA). Case studies were presented to evaluate the usage of TTA due to TM in the daily routine.

RESULTS

Eighty percent (n:1233) of the respondents wish for a possibility to activate a limited trauma team. Seventy-two percent (n: 1109) of the participants consider a L-TTA due to TM to be adequate. There were significant differences (p < 0.05) in the assessment and opinion on L-TTA among physicians and RSPs as well as different medical professions. The evaluated case studies showed diverse answers: depending on the profession, the same patient was ranked as severely injured by 54% and as minorly injured by 46% of the 1550 participants.

CONCLUSIONS

Members of the German Emergency Medical Service call for a two-tier TTA-protocol. Up to now we cannot fully recommend an automatic reduction of the trauma team when activated due to TM in Germany with the guidelines implemented. The profession might affect the L-TTA-behavior. Criteria for a L-TTA in Germany have to be defined and evaluated.

LEVEL OF EVIDENCE

IV, cross-sectional study.