TRISS methodology: an inappropriate tool for comparing outcomes between trauma centers.

BACKGROUND: The TRISS methodology has been used for comparison of survival outcomes between trauma centers. The purpose of this study was to evaluate the role of TRISS in comparing outcomes between a small and a large trauma center and evaluate its usefulness in various groups of patients. STUDY DESIGN: Trauma registry study that compared the survival outcomes between a large academic level I trauma center and a small community level II center. The comparison was made with the standard TRISS probability of survival, M value, and Z score. In the second part of the study the patients from the small center were matched for age, gender, injury severity score, Glasgow Coma Scale, head Abbreviated Injury Score, BP, prehospital respiratory assistance, and transport mode with an equal number of patients from the large center. The Z scores were calculated for each center. In the third part of the study the TRISS usefulness and limitations were evaluated in various subgroups of patients by calculating its sensitivity, specificity, positive predictive value, negative predictive value, and misclassification rate. RESULTS: The Z value of the large center (3,315 patients) was 2.24, indicating a considerably higher mortality than expected when compared with the Major Trauma Outcomes Study population. The Z value of the small center (331 patients) was -0.92, indicating fewer than the Major Trauma Outcomes Study expected deaths. In the second part of the study, 297 patients from the small center were matched with an equal number from the large center. The Z scores were -0.40 and -0.95, respectively, indicating slightly better outcomes than those of the Major Trauma Outcomes Study. Additional evaluation of the TRISS prediction of survival in various subgroups of patients showed a high misclassification rate in severe trauma, in some groups higher than 25%. CONCLUSIONS: The TRISS methodology is not a reliable tool for comparing outcomes between trauma centers and has an unacceptably high misclassification rate in patients with severe trauma.

Factors associated with sudden death of individuals requiring restraint for excited delirium.

The purpose of this article is to identify and rank factors associated with sudden death of individuals requiring restraint for excited delirium. Eighteen cases of such deaths witnessed by emergency medical service (EMS) personnel are reported. The 18 cases reported were restrained with the wrists and ankles bound and attached behind the back. This restraint technique was also used for all 196 surviving excited delirium victims encountered during the study period. Unique to these data is a description of the initial cardiopulmonary arrest rhythm in 72% of the sudden death cases. Associated with all sudden death cases was struggle by the victim with forced restraint and cessation of struggling with labored or agonal breathing immediately before cardiopulmonary arrest. Also associated was stimulant drug use (78%), chronic disease (56%), and obesity (56%). The primary cardiac arrest rhythm of ventricular tachycardia was found in 1 of 13 victims with confirmed initial cardiac rhythms, with none found in ventricular fibrillation. Our findings indicate that unexpected sudden death when excited delirium victims are restrained in the out-of-hospital setting is not infrequent and can be associated with multiple predictable but usually uncontrollable factors.

Prehospital endotracheal tube airway or esophageal gastric tube airway: a critical comparison.

This study compares two similar groups of patients in cardiopulmonary arrest with ventricular fibrillation (VF). In the survival study group of 296 patients, 148 patients received an endotracheal tube airway (ETA) and 148 patients received an esophageal gastric tube airway (EGTA), the improved version of the esophageal obturator airway (EOA). Survival rates, both short term (ETA = 35.8%, EGTA = 39.1%) and long term (ETA = 11.5%, EGTA = 16.2%), and neurological sequelae of survivors showed no statistically significant difference between the two groups (P greater than .05). In addition, we found that success and complication rates of intubation were similar. Training time was longer for the ETA. We conclude that both airways have a place in the prehospital setting.