The Australian Traumatic Brain Injury Initiative: Systematic Review of Clinical Factors Associated with Outcomes in People with Moderate-Severe Traumatic Brain Injury.

The aim of the Australian Traumatic Brain Injury Initiative (AUS-TBI) is to design a data dictionary to inform data collection and facilitate prediction of outcomes for moderate-severe traumatic brain injury (TBI) across Australia. The process has engaged diverse stakeholders across six areas: social, health, clinical, biological, acute interventions, and long-term outcomes. Here, we report the results of the clinical review. Standardized searches were implemented across databases to April 2022. English-language reports of studies evaluating an association between a clinical factor and any clinical outcome in at least 100 patients with moderate-severe TBI were included. Abstracts, and full-text records, were independently screened by at least two reviewers in Covidence. The findings were assessed through a consensus process to determine inclusion in the AUS-TBI data resource. The searches retrieved 22,441 records, of which 1137 were screened at full text and 313 papers were included. The clinical outcomes identified were predominantly measures of survival and disability. The clinical predictors most frequently associated with these outcomes were the Glasgow Coma Scale, pupil reactivity, and blood pressure measures. Following discussion with an expert consensus group, 15 were recommended for inclusion in the data dictionary. This review identified numerous studies evaluating associations between clinical factors and outcomes in patients with moderate-severe TBI. A small number of factors were reported consistently, however, how and when these factors were assessed varied. The findings of this review and the subsequent consensus process have informed the development of an evidence-informed data dictionary for moderate-severe TBI in Australia.

The prognostic importance of traumatic axonal injury on early MRI: the Trondheim TAI-MRI grading and quantitative models.

OBJECTIVES: We analysed magnetic resonance imaging (MRI) findings after traumatic brain injury (TBI) aiming to improve the grading of traumatic axonal injury (TAI) to better reflect the outcome. METHODS: Four-hundred sixty-three patients (8-70 years) with mild (n = 158), moderate (n = 129), or severe (n = 176) TBI and early MRI were prospectively included. TAI presence, numbers, and volumes at predefined locations were registered on fluid-attenuated inversion recovery (FLAIR) and diffusion-weighted imaging, and presence and numbers on T2*GRE/SWI. Presence and volumes of contusions were registered on FLAIR. We assessed the outcome with the Glasgow Outcome Scale Extended. Multivariable logistic and elastic-net regression analyses were performed. RESULTS: The presence of TAI differed between mild (6%), moderate (70%), and severe TBI (95%). In severe TBI, bilateral TAI in mesencephalon or thalami and bilateral TAI in pons predicted worse outcomes and were defined as the worst grades (4 and 5, respectively) in the Trondheim TAI-MRI grading. The Trondheim TAI-MRI grading performed better than the standard TAI grading in severe TBI (pseudo-R2 0.19 vs. 0.16). In moderate-severe TBI, quantitative models including both FLAIR volume of TAI and contusions performed best (pseudo-R2 0.19-0.21). In patients with mild TBI or Glasgow Coma Scale (GCS) score 13, models with the volume of contusions performed best (pseudo-R2 0.25-0.26). CONCLUSIONS: We propose the Trondheim TAI-MRI grading (grades 1-5) with bilateral TAI in mesencephalon or thalami, and bilateral TAI in pons as the worst grades. The predictive value was highest for the quantitative models including FLAIR volume of TAI and contusions (GCS score <13) or FLAIR volume of contusions (GCS score ≥ 13), which emphasise artificial intelligence as a potentially important future tool. CLINICAL RELEVANCE STATEMENT: The Trondheim TAI-MRI grading reflects patient outcomes better in severe TBI than today's standard TAI grading and can be implemented after external validation. The prognostic importance of volumetric models is promising for future use of artificial intelligence technologies. KEY POINTS: Traumatic axonal injury (TAI) is an important injury type in all TBI severities. Studies demonstrating which MRI findings that can serve as future biomarkers are highly warranted. This study proposes the most optimal MRI models for predicting patient outcome at 6 months after TBI; one updated pragmatic model and a volumetric model. The Trondheim TAI-MRI grading, in severe TBI, reflects patient outcome better than today's standard grading of TAI and the prognostic importance of volumetric models in all severities of TBI is promising for future use of AI.

Mortality rates in Norwegian HEMS-a retrospective analysis from Central Norway.

BACKGROUND: Helicopter Emergency Medical Services (HEMS) provide rapid and specialized care to critically ill or injured patients. Norwegian HEMS in Central Norway serves an important role in pre-hospital emergency medical care. To grade the severity of patients, HEMS uses the National Advisory Committee for Aeronautics' (NACA) severity score. The objective of this study was to describe the short- and long term mortality overall and in each NACA-group for patients transported by HEMS Trondheim using linkage of HEMS and hospital data. METHODS: The study used a retrospective cohort design, aligning with the STROBE recommendations. Patient data from Trondheim HEMS between 01.01.2017 and 31.12.2019 was linked to mortality data from a hospital database and analyzed. Kaplan Meier plots and cumulative mortality rates were calculated for each NACA group at day one, day 30, and one year and three years after the incident. RESULTS: Trondheim HEMS responded to 2224 alarms in the included time period, with 1431 patients meeting inclusion criteria for the study. Overall mortality rates at respective time points were 10.1% at day one, 13.4% at 30 days, 18.5% at one year, and 22.3% at three years. The one-year cumulative mortality rates for each NACA group were as follows: 0% for NACA 1 and 2, 2.9% for NACA 3, 10.1% for NACA 4, 24.7% for NACA 5 and 49.5% for NACA 6. Statistical analysis with a global log-rank test indicated a significant difference in survival outcomes among the groups (p < 2⋅10- 16). CONCLUSION: Among patients transported by Trondheim HEMS, we observed an incremental rise in mortality rates with increasing NACA scores. The study further suggests that a one-year follow-up may be sufficient for future investigations into HEMS outcomes.

Using a severity threshold to improve occupational injury surveillance: Assessment of a severe traumatic injury-based occupational health indicator across the International Classification of Diseases lexicon transition.

BACKGROUND: Traumatic injury is a leading cause of death and disability among US workers. Severe injuries are less subject to systematic ascertainment bias related to factors such as reporting barriers, inpatient admission criteria, and workers' compensation coverage. A state-based occupational health indicator (OHI #22) was initiated in 2012 to track work-related severe traumatic injury hospitalizations. After 2015, OHI #22 was reformulated to account for the transition from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM. This study describes rates and trends in OHI #22, alongside corresponding metrics for all work-related hospitalizations. METHODS: Seventeen states used hospital discharge data to calculate estimates for calendar years 2012-2019. State-panel fixed-effects regression was used to model linear trends in annual work-related hospitalization rates, OHI #22 rates, and the proportion of work-related hospitalizations resulting from severe injuries. Models included calendar year and pre- to post-ICD-10-CM transition. RESULTS: Work-related hospitalization rates showed a decreasing monotonic trend, with no significant change associated with the ICD-10-CM transition. In contrast, OHI #22 rates showed a monotonic increasing trend from 2012 to 2014, then a significant 50% drop, returning to a near-monotonic increasing trend from 2016 to 2019. On average, OHI #22 accounted for 12.9% of work-related hospitalizations before the ICD-10-CM transition, versus 9.1% post-transition. CONCLUSIONS: Although hospital discharge data suggest decreasing work-related hospitalizations over time, work-related severe traumatic injury hospitalizations are apparently increasing. OHI #22 contributes meaningfully to state occupational health surveillance efforts by reducing the impact of factors that differentially obscure minor injuries; however, OHI #22 trend estimates must account for the ICD-10-CM transition-associated structural break in 2015.

Comparison between Injury Severity Score (ISS) and New Injury Severity Score (NISS) in predicting mortality of thoracic trauma in a tertiary hospital / Comparação entre o Injury Severity Score (ISS) e o New Injury Severity Score (NISS) na predição da mortalidade de traumas torácicos atendidos em um hospital terciário

ABSTRACT Introduction: measuring the severity of traumatic injuries is crucial for predicting clinical outcomes. Whereas the Injury Severity Score (ISS) has limitations in assigning scores to injuries at the same site, the New Injury Severity Score (NISS) corrects for this problem by taking into account the three most severe injuries regardless of the region of the body. This study seeks to comprehend the clinical and epidemiological profile of trauma patients while comparing the effectiveness of scales for predicting mortality. Methods: a descriptive, observational and retrospective study using records of patients who underwent thoracotomy at the Hospital das Clínicas of the Federal University of Triângulo Mineiro between 2000 and 2019. Demographic data, mechanisms of injury, affected organs, length of stay and mortality were analyzed. Injury severity was assessed using the ISS and NISS, and statistical analyses were conducted using MedCalc and SigmaPlot. Results: 101 patients were assessed, on average 29.6 years old, 86.13% of whom were men. The average duration of hospitalization was 10.9 days and the mortality rate was 28.7%. The ROC curve analysis revealed a sensitivity of 68.97%, specificity of 80.56% and area under the curve of 0.837 for the ISS, and 58.62%, 94.44% and 0.855 for the NISS, respectively. The Youden index was 0.49 for the ISS and 0.53 for the NISS. Conclusion: the study demonstrated comparable efficacy of NISS and ISS in predicting mortality. These findings hold significance in the hospital setting. Professionals must be familiar with these scales to utilize them competently for each patient.

RESUMO Introdução: a medição da gravidade das lesões traumáticas é essencial para prever os desfechos clínicos. Enquanto o Injury Severity Score (ISS) tem limitações ao atribuir pontuações às lesões no mesmo local, o New Injury Severity Score (NISS) corrige esse problema ao considerar as três lesões mais graves independentemente da região corporal. Este estudo visa entender o perfil clínico-epidemiológico dos pacientes traumatizados, comparando a eficácia das escalas para prever mortalidade. Métodos: estudo descritivo, observacional e retrospectivo utilizando registros de pacientes submetidos à toracotomia no Hospital das Clínicas da Universidade Federal do Triângulo Mineiro entre 2000 e 2019. Dados demográficos, mecanismos de lesão, órgãos afetados, tempo de internação e mortalidade foram analisados. A gravidade das lesões foi avaliada usando o ISS e NISS, e as análises estatísticas foram conduzidas no MedCalc e SigmaPlot. Resultados: Foram avaliados 101 pacientes, em média com 29,6 anos, sendo 86,13% homens. A média da internação foi de 10,9 dias e a taxa de mortalidade foi de 28,7%. A análise da curva ROC revelou uma sensibilidade de 68,97%, especificidade de 80,56% e área sob a curva de 0,837 para o ISS, e 58,62%, 94,44% e 0,855 para o NISS, respectivamente. O índice de Youden indicou 0,49 para o ISS e 0,53 para o NISS. Conclusão: o estudo demonstrou semelhante eficácia entre o NISS e o ISS na previsão de mortalidade. Esses resultados geram implicações importantes na aplicação dessas escalas no ambiente hospitalar. É essencial que os profissionais conheçam tais escalas para aplica-las adequadamente no contexto de cada paciente.

Trauma Registry: Trauma Quality indicators analysis in hospitalized patients / Registro de Trauma: análise dos Filtros de Qualidade nos pacientes internados

ABSTRACT Purpose: to consolidate a Trauma Register (TR) trough REDCap data acquisition platform and to validate, in this context, local Quality Indicators (QI) as improvement opportunities in trauma management. Methods: continuous data acquisition of all patients admitted in Irmandade da Santa Casa de Misericórdia de São Paulo adult Trauma bay and it's validation in REDCap platform; 6 months retrospective cohort of QI impact in length of hospitalar stay, complications and mortality. Fisher, Chi-squared, Wilcoxon and Kruskal-Wallis tests were used to correlate QIs fails with the endpoints, considering p<0.05 and CI <95% as statically significant. Results: 465 were admitted in Trauma bay, with 137 patients hospitalized (29.5%); the number of QIs compromised were related with more complications (p=0.075) and increased length of stay (p=0.028), especially the delay in open fracture's surgical management, which increased the severe complications' incidence (p=0.005). Conclusion: the REDCap data acquisition platform is useful as a tool for multi center TR implementation, from ethical and logistical point of view; nevertheless, the proposed QIs are validated as attention points in trauma management, allowing improvements in traumatized patients treatment.

RESUMO Objetivo: implementação de Registro de Trauma (RT) através da plataforma REDCap e validação dos Filtros de Qualidade (FQ) desenvolvidos como pontos de melhora no atendimento ao traumatizado. Métodos: implementação de coleta contínua dos dados de todos os pacientes adultos admitidos na sala de Trauma da Irmandade da Santa Casa de Misericórdia de São Paulo e validação destes na plataforma REDCap; realizada coorte retrospectiva dos dados validados em um período de 6 meses e o impacto dos FQ desenvolvidos no tempo de internação hospitalar, complicações e mortalidade dos pacientes. A correlação do comprometimento dos FQ com os desfechos foi obtida através dos testes de Fisher, Qui-Quadrado, Wilcoxon e Kruskal-Wallis, considerando p<0,05 e IC 95% como significativos. Resultados: incluídos no estudo 465 pacientes admitidos no período de estudo, com necessidade de internação em 137 casos (29,5%); o número de FQs comprometidos relacionou-se com maior número de complicações (p=0,075) e maior tempo de internação (p=0,028), sobretudo o atraso na ida ao Centro Cirúrgico de fraturas expostas, que aumentou a incidência de complicações graves (p=0,005). Conclusão: a plataforma REDCap é adequada e útil na implementação de RT, permitindo o uso ético e multicêntrico de dados; os FQs propostos determinam pontos de atenção a serem revistos no atendimento do trauma, permitindo melhorias na qualidade de atendimento ao paciente traumatizado.

Performance of severity indices for admission and mortality of trauma patients in the intensive care unit: a retrospective cohort study.

BACKGROUND: Little is known about the performance of severity indices for indicating intensive care and predicting mortality in the Intensive Care Unit (ICU) of trauma patients. This study aimed to compare the performance of severity indices to predict trauma patients' ICU admission and mortality. METHODS: A retrospective cohort study which analyzed the electronic medical records of trauma patients aged ≥ 18 years, treated at a hospital in Brazil, between 2014 and 2017. Physiological [Revised Trauma Score (RTS), New Trauma Score (NTS) and modified Rapid Emergency Medicine Score (mREMS)], anatomical [Injury Severity Score (ISS) and New Injury Severity Score (NISS)] and mixed indices [Trauma and Injury Severity Score (TRISS), New Trauma and Injury Severity Score (NTRISS), Base-deficit Injury Severity Score (BISS) and Base-deficit and New Injury Severity Score (BNISS)] were compared in analyzing the outcomes (ICU admission and mortality) using the Area Under the Receiver Operating Characteristics Curves (AUC-ROC). RESULTS: From the 747 trauma patients analyzed (52.5% female; mean age 51.5 years; 36.1% falls), 106 (14.2%) were admitted to the ICU and 6 (0.8%) died in the unit. The ISS (AUC 0.919) and NISS (AUC 0.916) had better predictive capacity for ICU admission of trauma patients. The NISS (AUC 0.949), TRISS (AUC 0.909), NTRISS (AUC 0.967), BISS (AUC 0.902) and BNISS (AUC 0.976) showed excellent performance in predicting ICU mortality. CONCLUSIONS: Anatomical indices showed excellent predictive ability for admission of trauma patients to the ICU. The NISS and the mixed indices had the best performances regarding mortality in the ICU.

The Role of Dual-Energy CT in Solid Organ Injury.

The liver, spleen, and kidneys are the commonest injured solid organs in blunt and penetrating trauma. The American Association for the Surgery of Trauma (AAST) Organ Injury Scale (OIS) is the most widely accepted system for categorizing traumatic injuries. Grading systems allow clear communication of findings between clinical teams and assign a measurable severity of injury, which directly correlates with morbidity and mortality. The 2018 revised AAST OIS emphasizes reliance on CT for accurate grading; in particular regarding vascular injuries. Dual-Energy CT (DECT) has emerged as a promising tool with multiple clinical applications already demonstrated. In this review article, we summarize the basic principles of CT attenuation to refresh the minds of our readers and we scrutinize DECT's technology as opposed to conventional Single-Energy CT (SECT). This is followed by outlining the benefits of various DECT postprocessing techniques, which authors of this article refer to as the 3Ms (Mapping of Iodine, Material decomposition, and Monoenergetic virtual imaging), in aiding radiologists to confidently assign an OIS as well as problem solve complex injury patterns. In addition, a thorough discussion of changes to the revised AAST OIS focusing on definitions of key terms used in reporting injuries is described.

Is post-traumatic stress disorder related to the severity of physical trauma?

SUMMARY OBJECTIVE: Trauma can cause physical morbidity and even result in death. Besides, it can lead to serious mental problems as well. The most well-known mental health problem is post-traumatic stress disorder. Through this study, it was primarily aimed to find out whether the severity of physical trauma is effective on post-traumatic stress disorder and other risk factors if any. METHODS: The reports of the patients who were transferred to the Turkish Council of Forensic Medicine Third Speciality Board between January 01, 2019, and December 31, 2020, for post-traumatic invalidity or disability evaluation and whose psychiatric examinations were performed were retrospectively analyzed in the electronic environment. RESULTS: It was found that 34 (26.4%) of the patients had a diagnosis of post-traumatic stress disorder (under treatment for at least 6 months), while 76 (58.9%) of them did not have a psychiatric disease and 19 (14.7%) of them had mental disorders not associated with trauma (i.e., affective disorder, anxiety disorder, etc.). No significant correlation was found between trauma scores and post-traumatic stress disorder (p>0.05). CONCLUSION: Based on the results of our study, post-traumatic stress disorder and the severity of physical trauma are not significantly correlated. Being of female gender, sustaining a non-accidental injury, and witnessing a fatal event stand out as significant risk factors.

Comparing Predictive Utility of Head Computed Tomography Scan-Based Scoring Systems for Traumatic Brain Injury: A Retrospective Study.

This study compared the predictive utility of Marshall, Rotterdam, Stockholm, Helsinki, and NeuroImaging Radiological Interpretation System (NIRIS) scorings based on early non-contrast brain computed tomography (CT) scans in patients with traumatic brain injury (TBI). The area under a receiver operating characteristic curve (AUROC) was used to determine the predictive utility of scoring systems. Subgroup analyses were performed among patients with head AIS scores > 1. A total of 996 patients were included, of whom 786 (78.9%) were males. In-hospital mortality, ICU admission, neurosurgical intervention, and prolonged total hospital length of stay (THLOS) were recorded for 27 (2.7%), 207 (20.8%), 82 (8.2%), and 205 (20.6%) patients, respectively. For predicting in-hospital mortality, all scoring systems had AUROC point estimates above 0.9 and 0.75 among all included patients and patients with head AIS > 1, respectively, without any significant differences. The Marshall and NIRIS scoring systems had higher AUROCs for predicting ICU admission and neurosurgery than the other scoring systems. For predicting THLOS ≥ seven days, although the NIRIS and Marshall scoring systems seemed to have higher AUROC point estimates when all patients were analyzed, five scoring systems performed roughly the same in the head AIS > 1 subgroup.

Frequency of posttrauma complications during hospital admission and their association with Injury Severity Score.

OBJECTIVE: Multiple trauma is associated with a remarkable risk of in-hospital complications, which harm healthcare services and patients. This study aimed to assess the incidence of posttrauma complications, their relationship with poor outcomes, and the effect of the Injury Severity Score (ISS) on their occurrence. METHODS: This retrospective cohort study was conducted at a pair of trauma centers, between January 2020 and December 2022. All hospitalized adult patients with multiple trauma were included in this study. Multivariable logistic regression was used to identify factors related to posttrauma complications. RESULTS: Among 727 multiple trauma patients, 90 (12.4%) developed in-hospital complications. The most frequent complications were pneumonia (4.8%), atelectasis (3.7%), and superficial surgical site infection (2.5%). According to multivariable logistic regression, ISS, the length of stay in the intensive care unit (ICU), the length of stay in the hospital, and mortality were significantly associated with complications. The complication rate increased by 17% with every single-unit increase in ISS (adjusted odds ratio [OR], 1.17; 95% confidence interval [CI], 1.00-1.38). Per every 1-day increase in the ICU or hospital stay, the complication rate increased by 65% (adjusted OR, 1.65; 95% CI, 1.00-2.73) and 20% (adjusted OR, 1.20; 95% CI, 1.03-1.41), respectively. Posttrauma complications were also significantly more common in patients with mortality (adjusted OR, 163.30; 95% CI, 3.04-8,779.32). In multiple trauma patients with a higher ISS, the frequency, severity, and number of complications were significantly increased. CONCLUSION: In-hospital complications in multiple trauma patients are frequent and associated with poor outcomes and mortality. ISS is an important factor associated with posttrauma complications.

Puntuación de trauma revisado como predictor de mortalidad intrahospitalaria en pacientes politraumatizados atendidos en el Hospital Belén de Trujillo, Perú

Objetivo: Determinar si el score de trauma revisado es predictor de mortalidad intrahospitalaria en pacientes politraumatizados atendidos en el Hospital Belén de Trujillo. Material y métodos: Se realizó un estudio observacional, analítico, retrospectivo, transversal de pruebas diagnósticas, se identificaron pacientes que fueron admitidos por politraumatismo y fueron hospitalizados en el Departamento de Cirugía General durante el periodo comprendido entre enero del 2017 a diciembre del 2021; en una muestra de 100 pacientes se evaluó la mortalidad. Resultados: La edad promedio fue 47,18 ± 20,40 vs 41,13 ± 18,37 en aquellos que fallecieron y sobrevivieron; el 55% y 63,33% de los fallecidos y sobrevivientes fueron varones en los grupos de estudio. La coagulopatía, acidosis metabólica y SRIS estuvieron asociadas a la mortalidad. Se observó una proporción de 72,50% y 3,33% de RTS < 6 en los pacientes politraumatizados que fallecieron y sobrevivieron (p = 0,001); se obtuvieron valores de sensibilidad: 73% IC 95% (59% - 86%), especificidad: 97% IC 95% (92% - 100%), valor predictivo positivo: 94% IC 95% (85% - 100%) y valor predictivo negativo: 84% IC 95% (75% - 93%). El área bajo la curva fue del 96,50% en la predicción de mortalidad por el RTS en pacientes con politraumatismo. Conclusión: El score de trauma revisado es un buen predictor de mortalidad en politraumatizados.

Objective: To determine whether the revised trauma score is a predictor of in-hospital mortality in polytrauma patients treated at Hospital Belén de Trujillo. Material and methods: An observational, analytical, retrospective, cross-sectional study of diagnostic tests was conducted, identifying patients who were admitted for polytrauma and were hospitalized in the Department of General Surgery during the period from January 2017 to December 2021; mortality was assessed in a sample of 100 patients. Results: Mean age was 47.18 ± 20.40 vs 41.13 ± 18.37 in those who died and survived; 55% and 63.33% of the deceased and survivors were male in the study groups. Coagulopathy, metabolic acidosis and SIRS were associated with mortality. A proportion of 72.50% and 3.33% STR < 6 was observed in polytrauma patients who died and survived (p = 0.001); sensitivity: 73% CI 95% (59% - 86%), specificity: 97% CI 95% (92% - 100%), positive predictive value: 94% CI 95% (85% - 100%) and negative predictive value: 84% CI 95% (75% - 93%). The area under the curve was 96.50% in predicting mortality by RTS in polytrauma patients. Conclusion: The revised trauma score is a good predictor of mortality in polytrauma patients.

Association Between Neutrophil Density and Survival in Trauma Patients Admitted to the Intensive Care Unit; a Retrospective Cohort Study.

Introduction: Altered immune responses, in particular neutrophil changes, are perceived to play a key role in immune responses to trauma. This study aimed to evaluate the association of neutrophil changes with patients' survival in severe multiple trauma cases. Methods: The current retrospective cohort study was conducted using data from patients admitted in the intensive care unit (ICU) of a trauma center in Shiraz, Iran, between 2016 and 2021. Patients were divided into three groups (i.e., normal, neutropenia, and neutrophilia) based on neutrophil count at the time of ICU admission, and the association of neutrophil count with in-hospital mortality was analyzed. Results: 2176 patients with the mean age of 37.90 ± 18.57 years were evaluated (84.04% male). The median trauma severity based on injury severity score (ISS) in this series was 9 (4 -17). Patients were divided in to three groups of neutrophilia (n = 1805), normal (n = 357), and neutropenia (n = 14). There were not any significant differences between groups regarding age distribution (p = 0.634), gender (p = 0.544), and trauma severity (p = 0.197). The median survival times for the normal, neutropenia, and neutrophilia groups were 49 (IQR: 33 -47) days, 51 (IQR: 8- 51) days, and 38 (IQR: 26 - 52) days, respectively (p = 0.346). The log-rank test showed a statistically significant difference between the three groups adjustment for ISS (p ≤ 0.001). For each unit increase in ISS, the hazard ratio increased by 2%. In ISS 9-17, the hazard ratio increased by 11% compared to ISS<4. Also, in ISS>17, the hazard ratio increased by 76% compared to ISS<4 in ICU-hospitalized patients. Conclusions: In general, the findings of the present study showed that the survival rate of patients in the normal group after ISS adjustment was higher than the other two groups. Also, the Cox model showed that the mortality risk ratio in the neutropenia group was 15 times higher than the normal group.

In-hospital complications after trauma due to road traffic accidents.

PURPOSE: The study aimed to verify the association between in-hospital complications and characterization and clinical variables including hospital care and trauma severity. METHODS: This analysis with the prospective cohort data was conducted at a municipal hospital in São Paulo, Brazil, and included participants aged 14 years or older, with traumatic injuries from traffic accidents. Data was collected from January 2015 to July 2016 and included demographics variables, type of traumatic event, clinical parameters, length of stay in the Emergency department and in the Intensive Care Unit, length of hospital stay, survival probability, trauma severity and mortality. RESULTS: Of the 327 patients, 25.1% had in-hospital complications and their occurrence was statistically associated with higher mean age, run-overs and higher trauma severity. The length of stay in the emergency room, hospital stay, ICU stay, percentage of deaths, and hospital readmission were higher in patients with complications. The number of complications was correlated with trauma severity, ICU stay, and mortality. CONCLUSION: Complications were associated with older age, run-overs, greater trauma severity, length of stay and readmission after hospital discharge.

Prognostic value of metabolic parameters measured by first responders attending patients with severe trauma: associations with the New Injury Severity Score and mortality. / Valor pronóstico de los parámetros metabólicos medidos en la asistencia inicial a pacientes con trauma grave: asociación con la puntuación de la escala NISS y la mortalidad.

OBJECTIVES: Patients with severe or potentially severe trauma must be identified early, a challenge in prehospital settings. This study aimed to analyze the possible diagnostic and prognostic usefulness of analytical markers recorded in the early moments of care. MATERIAL AND METHODS: Observational study of information extracted from the prospective multicenter Code Trauma database for 2016-2019, excluding data for isolated head injuries. Using the New Injury Severity Score (NISS), we classified cases into 4 levels of severity. NISS and mortality were considered the dependent variables in inferential analyses. We calculated the areas under receiver operating characteristic curves, identified optimal cutoff points (Youden index), and calculated positive (PPV) and negative predictive values.. RESULTS: Of the 1039 trauma patients in the registry, 709 were included in the study. Their mean (SD) age was 40.4 (17.3) years, and 77.3% were men. Motorcycle accidents were the most common causes of trauma (in 21%), and mortality was 12.1%. Lactate concentration, pH, PCO2, hemoglobin concentration, hematocrit, and blood sugar were significantly associated with severity and mortality. The PPVs corresponding to pH for the 4 NISS score groups (34-41, 42-49, 50-59, and $ 60) and mortality, respectively, were 61.2, 64.1, 70.7, 62.2, and 66.6. The PPVs of traditionally used clinical variables were lower. CONCLUSION: Patients with more severe trauma had lower pH values and higher PCO2, lactate, and base excess values. PCO2, pH, and blood sugar findings were the best predictors of severity. Metabolic variables are better predictors than traditionally recorded hemodynamic variables.

OBJETIVO: En entornos de emergencia prehospitalarios, la detección temprana de un paciente con trauma grave o potencialmente crítico es un desafío. El objetivo es analizar las posibilidades diagnósticas y pronóstico de los parámetros analíticos obtenidos en los primeros momentos de la asistencia inicial. METODO: Estudio observacional multicéntrico de la base de datos prospectiva "Código Trauma" de 2016-2019 excluyendo el trauma craneoencefálico aislado. La evaluación de las lesiones se realizó utilizando el New Injury Severity Score (NISS). Los pacientes fueron clasificados en 4 grupos según nivel de gravedad. Para el análisis inferencial, las puntuaciones NISS y el resultado de mortalidad se consideraron variables dependientes. Se realizó el análisis de la curva ROC, puntos de corte óptimos mediante el índice de Youden y se calcularon los valores predictivos positivo (VPP) y negativo. RESULTADOS: De los 1.039 pacientes traumatizados del registro, 709 fueron incluidos en el estudio, con una edad media de 40,4 años (DE 17,3), 77,3% eran varones, el mecanismo lesional principal accidentes de moto (21%) y la mortalidad del 12,1%. El pH, lactato, pCO2, hemoglobina, hematocrito y glucemia influyeron significativamente en gravedad y mortalidad. El VPP de mortalidad para pH fue 61,2, 64,1, 70,7, 62,2 y 66,6 para los grupos de NISS 34- 41, 42-49, 50-59 y $ 60 puntos la mortalidad, respectivamente. Las variables clínicas clásicas obtuvieron valores más bajos. CONCLUSIONES: Los pacientes con mayor gravedad presentaron menor pH y concentraciones más altas de pCO2, lactato y exceso de bases. El pH, la pCO2 y la glucemia tuvieron la mayor capacidad predictiva de gravedad. La capacidad predictiva de los valores metabólicos es superior a la de los valores hemodinámicos clásicos.

Trauma severity predictors / Preditores de gravidade no trauma

This review aimed to determine which are the indexes for early detection and evaluation of clinical and physiological deterioration of traumatized patients. A Scoping Review according to the methods proposed by Joanna Briggs Institute (JBI) was performed from February 2018 to December 2018 on LILACS (Literatura Latino-Americana e do Caribe em Ciências da Saúde), National Library of Medicine (PubMed), and SCOPUS databases. Sixty-two studies were included, of which 43 evaluated patients with general trauma. A variety of physiological variables, such as Glasgow Coma Score, Glucose, Days in the Intensive Care Unit, Lactate, and predictor indexes - Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), Revisited Trauma Score (RTS), and APACHE II were identified. The values observed in the studies among patients were compared to the ones determined by the basic literature, being called Critical Values (CV). The group of gravity indexes, besides clinical and regulatory protocols, found in this review are the solidification of the healthcare process involving the traumatized patient's responses to the actions of the healthcare team. The analysis of these indexes must be emphasized to determine, with greater reliability, the prognosis of the patient. With these data, it may be possible to effectively predict mortality rates (AU).

O objetivo desta revisão é determinar os índices para detecção precoce e avaliação clínica e fisiológica para deterioração de pacientes do trauma. Conduziu-se uma revisão de escopo de acordo com os métodos propostos pelo Joanna Briggs Institute (JBI) entre fevereiro de 2018 a dezembro de 2018 nas bases de dados LILACS (Literatura Latina-Americana e do Caribe em Ciências da Saúde), National Library of Medicine (PubMed) e SCOPUS. Foram incluídos 62 estudos, dos quais 43 sobre trauma geral. Encontrou-se grande diversidade de variáveis fisiológicas, como Escala de Coma de Glasgow, Glicose, dias em Unidade de Terapia Intensiva, lactato e índices preditores­Injury Severity Score (ISS), Trauma Injury Severity Score (TRISS), Reviseted Trauma Score (RTS) e APACHE II. Os valores observados nos pacientes dos estudos encontrados foram comparados com os da literatura básica, sendo denominados Valores Críticos (CV). O grupo de índices de gravidade encontrados neste estudo, além de protocolos reguladores e clínicos, são a solidificação do processo de cuidado envolvendo a resposta das ações da equipe em saúde ao paciente de trauma. A análise desses índices deve ser enfatizada para determinar com maior confiabilidade o prognóstico do paciente. Com esses dados, pode ser possível predizer a taxa de mortalidade com maior acurácia (AU).

Valor pronóstico de los parámetros metabólicos medidos en la asistencia inicial a pacientes con trauma grave: asociación con la puntuación de la escala NISS y la mortalidad / Prognostic value of metabolic parameters measured by first responders attending patients with severe trauma: associations with the New Injury Severity Score and mortality

Objetivos. En entornos de emergencia prehospitalarios, la detección temprana de un paciente con trauma grave o potencialmente crítico es un desafío. El objetivo es analizar las posibilidades diagnósticas y pronóstico de los parámetros analíticos obtenidos en los primeros momentos de la asistencia inicial. Métodos. Estudio observacional multicéntrico de la base de datos prospectiva “Código Trauma” de 2016-2019 excluyendo el trauma craneoencefálico aislado. La evaluación de las lesiones se realizó utilizando el New Injury Severity Score (NISS). Los pacientes fueron clasificados en 4 grupos según nivel de gravedad. Para el análisis inferencial, las puntuaciones NISS y el resultado de mortalidad se consideraron variables dependientes. Se realizó el análisis de la curva ROC, puntos de corte óptimos mediante el índice de Youden y se calcularon los valores predictivos positivo (VPP) y negativo. Resultados. De los 1.039 pacientes traumatizados del registro, 709 fueron incluidos en el estudio, con una edad media de 40,4 años (DE 17,3), 77,3% eran varones, el mecanismo lesional principal accidentes de moto (21%) y la mortalidad del 12,1%. El pH, lactato, pCO2, hemoglobina, hematocrito y glucemia influyeron significativamente en gravedad y mortalidad. El VPP de mortalidad para pH fue 61,2, 64,1, 70,7, 62,2 y 66,6 para los grupos de NISS 34-41, 42-49, 50-59 y $ 60 puntos la mortalidad, respectivamente. Las variables clínicas clásicas obtuvieron valores más bajos. Conclusiones. Los pacientes con mayor gravedad presentaron menor pH y concentraciones más altas de pCO2, lactato y exceso de bases. El pH, la pCO2 y la glucemia tuvieron la mayor capacidad predictiva de gravedad. La capacidad predictiva de los valores metabólicos es superior a la de los valores hemodinámicos clásicos. (AU)

Background and objective: Patients with severe or potentially severe trauma must be identified early, a challenge in prehospital settings. This study aimed to analyze the possible diagnostic and prognostic usefulness of analytical markers recorded in the early moments of care. Methods: Observational study of information extracted from the prospective multicenter Code Trauma database for 2016-2019, excluding data for isolated head injuries. Using the New Injury Severity Score (NISS), we classified cases into 4 levels of severity. NISS and mortality were considered the dependent variables in inferential analyses. We calculated the areas under receiver operating characteristic curves, identified optimal cutoff points (Youden index), and calculated positive (PPV) and negative predictive values. Results: Of the 1039 trauma patients in the registry, 709 were included in the study. Their mean (SD) age was 40.4 (17.3) years, and 77.3% were men. Motorcycle accidents were the most common causes of trauma (in 21%), and mortality was 12.1%. Lactate concentration, pH, PCO2, hemoglobin concentration, hematocrit, and blood sugar were significantly associated with severity and mortality. The PPVs corresponding to pH for the 4 NISS score groups (34-41, 42-49, 50-59, and $ 60) and mortality, respectively, were 61.2, 64.1, 70.7, 62.2, and 66.6. The PPVs of traditionally used clinical variables were lower. Conclusions: Patients with more severe trauma had lower pH values and higher PCO2, lactate, and base excess values. PCO2, pH, and blood sugar findings were the best predictors of severity. Metabolic variables are better predictors than traditionally recorded hemodynamic variables. (AU)

Comparing Comorbidity Polypharmacy Score and Charlson Comorbidity Index in predicting outcomes in older trauma patients.

BACKGROUND: The Charlson Comorbidity Index (CCI) and Comorbidity Polypharmacy Score (CPS) may potentially risk-stratify older trauma patients more accurately than traditional trauma severity scores. We aim to evaluate if CCI or CPS are better predictors of mortality and discharge venue in such patients. METHODS: We conducted a retrospective study using registry data from two tertiary trauma centres. Patients aged 65 years and above who presented to the emergency departments (EDs) between January 2011 and December 2015 with traumatic injuries were included. Charts were reviewed for demographics, injury mechanism and severity, discharge outcomes, and types of comorbidities and medications used. Primary outcome was overall mortality; secondary outcomes included ED disposition and hospital discharge venue. Discriminatory power of the score(s) were compared using area under the receiver operating characteristic (AUROC) curve. RESULTS: There were 2,750 patients, with overall female predominance (56.7%, 1,560/2,750) and median age of 78 years (interquartile range [IQR] 72 to 84 years). Median CCI score was 1 (IQR 0 to 2) and median CPS was 8 (IQR 4 to 12). Overall mortality was 9.4% (259/2,750). Every 1-point increase in CCI score resulted in increased odds of death by 16% (adjusted odds ratio 1.16, 95% confidence interval 1.07 to 1.26, p<0.001). Addition of CCI to the Injury Severity Score (ISS) increased the discriminatory power for mortality (AUROC for ISS = 0.832; AUROC for ISS with CCI = 0.843). Every 1-point increase in CCI was significantly associated with decreased odds of admission to a rehab facility by 8%. CPS did not predict mortality and discharge venue. CONCLUSION: CCI, but not CPS, was a predictor of mortality. A higher CCI was associated with decreased odds of discharge to a subacute facility, likely related to underlying rehabilitation potential. Further studies should be undertaken to explore an integrated scoring system that considers injury severity, comorbidities, and polypharmacy.

Extracting the Factors Affecting the Survival Rate of Trauma Patients Using Data Mining Techniques on a National Trauma Registry.

Introduction: Thousands of people die due to trauma all over the world every day, which leaves adverse effects on families and the society. The main objective of this study was to identify the factors affecting the mortality of trauma patients using data mining techniques. Methods: The present study includes six parts: data gathering, data preparation, target attributes specification, data balancing, evaluation criteria, and applied techniques. The techniques used in this research are all from the decision tree family. The output of these techniques are patterns extracted from the trauma patients dataset (National Trauma Registry of Iran). The dataset includes information on 25,986 trauma patients from all over the country. The techniques that were used include random forest, CHAID, and ID3. Results: Random forest performs better than the other two techniques in terms of accuracy. The ID3 technique performs better than the other two techniques in terms of the dead class. The random forest technique has performed better than other techniques in the living class. The rules with the most support, state that if the Injury Severity Score (ISS) is minor and vital signs are normal, 98% of people will survive. The second rule, in terms of support, states that if ISS is minor and vital signs are abnormal, 93% will survive. Also, by increasing the threshold of the patient's arrival time from 10 to 15 minutes, no noticeable difference was observed in the death rate of patients. Conclusion: Transfer time of less than ten minutes in patietns whose ISS is minor, can increase the chance of survival. Impaired vital signs can decrease the chance of survival in traffic accidents. Also, if the ISS is minor in non-penetrating trauma, regardless of vital signs and if the victim is transported in less than ten minutes, the patient will survive with 99% certainty.

Predictive validity of the Westmead Post-Traumatic Amnesia Scale for functional outcomes in school-aged children who sustained traumatic brain injury.

The Westmead Post-Traumatic Amnesia Scale (WPTAS) is routinely used for the assessment of post-traumatic amnesia (PTA) in children who sustained traumatic brain injury (TBI). Yet, the WPTAS' predictive validity for functional outcomes is largely unknown. We aimed to determine whether PTA duration measured by the WPTAS (i) differentially predicts functional outcomes and (ii) contributes to predictions of outcomes beyond the Glasgow Coma Scale (GCS) in children who sustained TBI. Participants were children and adolescents with moderate-to-severe TBI (n = 55) aged 8-15 years. PTA duration was assessed with the WPTAS. Outcomes at the first outpatient follow-up were scored on the Kings Outcome Scale for Childhood Head Injury (KOSCHI) and the TBI Outcome Domain Scale-Extended (ODS-E). Longer PTA and lower GCS were both significantly correlated with worse (i) global outcomes: presence of disability on the KOSCHI and lower score on the ODS-E and (ii) select specific outcomes on the ODS-E: mobility, mood and cognition. PTA duration predicted cognitive outcome on the ODS-E independently, beyond GCS. Together, PTA duration and GCS, predicted the global KOSCHI outcome, as well as the ODS-E mobility and mood outcomes. Neither GCS nor PTA duration correlated with the ODS-E communication, impulsivity/disinhibition, headache, fatigue, sensory impairments or somatic complaints outcomes. PTA duration measured by the WPTAS is a significant unique predictor of functional cognitive outcomes in children who sustained moderate-to-severe TBI, and in combination with the GCS, a significant predictor of global, and several specific functional outcomes.