Prognostic value of scoring tools in severe trauma patients admitted to the emergency department

##plugins.themes.academic_pro.article.sidebar##

Published Sep 4, 2018
Download
pdf
Vol. 96 No. 3 (2018): Issue Mar 2018

##plugins.themes.academic_pro.article.main##

Rym Hamed
Amel Maaref
Feten Amira
Houssem Aouni
Imen Mekki
Amina Jebali

Abstract

Background: Severe Trauma is a misleading cause of death in young people. Early assessment of prognosis is the cornerstone in the management of such patients. Several prognostic scores have been proposed during the last decade. The aim of this study was to evaluate the prognostic performance of trauma scores in terms of mortality in severe trauma patients admitted to the emergency department.   
Methods: This was a prospective, observational and prognostic study with inclusion of severe trauma patients admitted to the emergency department over a 20 months period. We focused on the predictive value of 4 trauma scores in terms of mortality in severe trauma admitted to the resuscitation room. Four scores were included: ISS, NISS, EMTRAS and GAP score. Univariate and multivariate analysis of mortality at the 30th post-traumatic day were conducted with comparison of ROC curves of the scores. Moreover, Correlation between the several scores was studied.
Results: We included 298 patients. The median age was 40 (15-90) years. The sex ratio was 4,5. Clinical characteristics were n (%): GCS ≤ 8: 62 (21); PAS <90 mm Hg: 32 (11) and pulse oximetry <90%: 44 (15). The median ISS was 17 (1-75) and 176 (59%) trauma patients had a score ISS ≥ 16. The median NISS was 22 (1-75). The median EMTRAS was 3 (0-9). The median GAP was 21 (3-26). The global mortality was 21.5%. Independent predictors of mortality were: EMTRAS score ≥ 3 (adjusted OR 1.80, 95% CI [1.05-3.08], p = 0.0033), ISS ≥ 16 (adjusted OR 2.05; 95% CI [1.26-3.46], p = 0.002), GAP <20 (adjusted OR 1.92, 95% CI [1.268-2.92], p = 0.002) 1.74, 95% CI [1.17-2.592], p = 0.005). The GAP score had the best AUC= 0.811 followed by the EMTRAS with an AUC of 0.789. Finally, all the scores were strongly correlated.
Conclusion: Severe trauma is a dynamic process with a heavy morbidity and mortality. In our study, physiological scores and combined score were correlated with prognosis as well as anatomical scores and could be proposed for early gravity assessment in severe trauma enhancing triage, management and prognosis of polytrauma patients.

Keywords:

Severe Trauma, Emergency, Prognosis, Scores

##plugins.themes.academic_pro.article.details##

References

  1. Maegele M, Lefering R, Yucel N, Tjardes T, Rixen D, Paffrath T, et al. Early coagulopathy in multiple injury: An analysis from the German Trauma Registry on 8724 patients.Injury. 2007;38:298-304
  2. World Health Organization. The global burden of disease: 2004 update 2008 [En ligne]. World Health Organization, 2010. [cité le 30/10/2016]. Disponible à l'URL:http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/Inde x.html
  3. MacLeod JBA, Winkler AM, McCoy CC, Hillyer CD, Shaz BH. Early trauma induced coagulopathy: Prevalence across the injury spectrum. Injury. 2014;45:910-5.
  4. Raum MR, Nijsten MWN, Vogelzang M, Schuring F, Lefering R, Bouillon B, et al. Emergency trauma score: an instrument for early estimation of trauma severity. Crit Care. 2009;37:1972-7.
  5. Nwomeh BC, Lowell W, Kable R, Haley K, Ameh EA. History and development of trauma registry: lessons from developed to developing countries. World J Emerg Surg. 2006;1:32.
  6. Wong TH, Krishnaswamy G, Nadkarni NV, Nguyen HV, Lim GH, Bautista DCT, et al. Combining the new injury severity score with an anatomical polytrauma injury variable predicts mortality better than the new injury severity score and the injury severity score: a retrospective cohort study .Scand J Trauma Resusc Emerg Med. [En ligne].2016 Mars [30/10/2016];24(25):[11 pages].Disponible à l'URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4784376/
  7. Baker SP,O'neill B,Haddon W Jr,Long W. The injury severity score : a method for describing patients with multiples injuries and evaluating emergency care. J Trauma.1974;14:187-96.
  8. Joosse P, de Jong W-JJ, Reitsma JB, Wendt KW, Schep NW, Goslings JC. External validation of the Emergency Trauma Score for early prediction of mortality in trauma patients. Crit Care. 2014;42:83-9.
  9. Kondo Y, Abe T, Kohshi K, Tokuda Y, Cook EF, Kukita I. Revised trauma scoring system to predict in-hospital mortality in the emergency department: Glasgow Coma Scale, Age, and Systolic Blood Pressure score. Crit Care. 2011;15:R191.
  10. Riou B, Thicoïpe M, Atain-Kouadio P, Carli P. Le traumatisé grave. Actualités en réanimation préhospitalière. Journées scientifiques des Samu de France. Société française d'éditions médicales; 2002.
  11. Lehmann RK, Arthurs ZM, Cuadrado D, Casey L, Beekley A, Martin M. Trauma Team Activation : Simplified criteria safely reduces overtriage. The American Journal of Surgery.2007;5:630-5
  12. Tamim H, Al Hazzouri AZ, Mahfoud Z, Atoui M, El-Chemaly S. The injury severity score or the new injury severity score for predicting mortality, intensive care unit admission and length of hospital stay: experience from a university hospital in a developing country. Injury. 2008;39:115-20
  13. Restrepo-Ãlvarez CA, Valderrama-Molina CO, Giraldo-Ramírez N, Constain-Franco A, Puerta A, León AL, et al. Trauma severity scores. Colomb J Anesthesiol. 2016;44:317‑23.
  14. Lecky F, Woodford M, Edwards A, Bouamra O, Coats T. Trauma scoring systems and databases. Br J Anaesth. 2014;113:286-94.
  15. Peiniger S, Paffrath T, Mutschler M, Brockamp T, Borgmann M, Spinella PC, et al. The trauma patient in hemorrhagic shock: how is the C-priority addressed between emergency and ICU admission? Scand J Trauma Resusc Emerg Med. 2012;20:78.
  16. Newgard CD, Schmicker RH, Hedges JR, Trickett JP, Davis DP, Bulger EM, et al. Emergency Medical Services Intervals and Survival in Trauma: Assessment of the “Golden Hour” in a North American Prospective Cohort. Ann Emerg Med. 2010;55:235-46.
  17. Hildebrand F, Lefering R, Andruszkow H, Zelle BA, Barkatali BM, Pape HC. Development of a scoring system based on conventional parameters to assess polytrauma patients: Polytrauma Grading Score. Injury. 2015;46:93-8.
  18. Brockamp T, Maegele M, Gaarder C, Goslings JC, Cohen MJ, Lefering R, et al. Comparison of the predictive performance of the BIG, TRISS, and PS09 score in an adult trauma population derived from multiple international trauma registries. Crit Care. 2013;17:R134.
  19. Wynell-Mayow W, Guevel B, Quansah B, O'Leary R, Carrothers AD. Cambridge Polytrauma Pathway: Are we making appropriately guided decisions? Injury. 2016;47:2117-21
  20. Laytin AD, Kumar V, Juillard CJ, Sarang B, Lashoher A, Roy N, et al. Choice of injury scoring system in low- and middle-income countries: Lessons from Mumbai. Injury. 2015;46:2491-7.
  21. Joosse P, de Jong W-JJ, Reitsma JB, Wendt KW, Schep NW, Goslings JC. External validation of the Emergency Trauma Score for early prediction of mortality in trauma patients. Crit Care. 2014;42:83-9.
  22. Danks RR. Triangle of death. How hypothermia acidosis & coagulopathy can adversely impact trauma patients. J Emerg Med Serv. 2002;27:61-6, 68-70.
  23. Thorsen K, Ringdal KG, Strand K, Søreide E, Hagemo J, Søreide K. Clinical and cellular effects of hypothermia, acidosis and coagulopathy in major injury. Br J Surg. 2011;98:894-907.
  24. Tasker A, Hughes A, Kelly M. Managing polytrauma: picking a way through the inflammatory cascade. Orthop Trauma. 2014;28:127-36.