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Trauma models to identify major trauma and mortality in the prehospital setting.

ABSTRACT: BACKGROUND:Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting. METHODS:Prognostic models were identified through a systematic literature search up to October 2017. Injured patients transported by Emergency Medical Services to an English hospital from the Trauma Audit and Research Network between 2013 and 2016 were included. Outcome measures were major trauma (ISS over 15) and in-hospital mortality. The performance of the models was assessed in terms of discrimination (concordance index, C-statistic) and net benefit to assess the clinical usefulness. RESULTS:A total of 154?476 patients were included to validate six previously proposed prediction models. Discriminative ability ranged from a C-statistic value of 0·602 (95 per cent c.i. 0·596 to 0·608) for the Mechanism, Glasgow Coma Scale, Age and Arterial Pressure model to 0·793 (0·789 to 0·797) for the modified Rapid Emergency Medicine Score (mREMS) in predicting in-hospital mortality (11?882 patients). Major trauma was identified in 52?818 patients, with discrimination from a C-statistic value of 0·589 (0·586 to 0·592) for mREMS to 0·735 (0·733 to 0·737) for the Kampala Trauma Score in predicting major trauma. None of the prediction models met acceptable undertriage and overtriage rates. CONCLUSION:Currently available prehospital trauma models perform reasonably in predicting in-hospital mortality, but are inadequate in identifying patients with major trauma. Future research should focus on which patients would benefit from treatment in a major trauma centre.

SUBMITTER: Sewalt CA

PROVIDER: S-EPMC7079101 | biostudies-literature | 2020 Mar

REPOSITORIES: biostudies-literature

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Trauma models to identify major trauma and mortality in the prehospital setting.

Sewalt C A CA Venema E E Wiegers E J A EJA Lecky F E FE Schuit S C E SCE den Hartog D D Steyerberg E W EW Lingsma H F HF

The British journal of surgery 20190910 4

<h4>Background</h4>Patients with major trauma might benefit from treatment in a trauma centre, but early identification of major trauma (Injury Severity Score (ISS) over 15) remains difficult. The aim of this study was to undertake an external validation of existing prognostic models for injured patients to assess their ability to predict mortality and major trauma in the prehospital setting.<h4>Methods</h4>Prognostic models were identified through a systematic literature search up to October 20 ...[more]

PMID: 31503341

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Project description:Survival after major trauma is considered to be time dependent. Efficient prehospital care with rapid transport is the norm in developed countries, which is not available in many lower middle and low-income countries. The aim of this study was to assess the effect of prehospital time and primary treatment given on survival of major trauma patients in a setting without prehospital care.This prospective observational study was carried out in a university hospital in Mumbai, from January to December 2014. The hospital has a trauma service but no organized prehospital care or defined interhospital transfer protocols. All patients with life- and/or limb-threatening injuries were included in the study. Injury time and arrival time were noted and the interval was defined as "prehospital time" for the directly arriving patients and as "time to tertiary care" for those transferred. Primary outcome measure was in-hospital death (or discharge).Of 1181 patients, 352 were admitted directly from the trauma scene and 829 were transferred from other hospitals. In-hospital mortality was associated with age, mechanism and mode of injury, shock, Glasgow Coma Score <9, Injury Severity Score ≥16, need for intubation, and ventilatory support on arrival; but neither with prehospital time nor with time to tertiary care. Transferred patients had a significantly higher mortality (odds ratio = 1.869, 95% confidence interval = 1.233-2.561, P = 0.005) despite fewer patients with severe injury. Two hundred and ninety-four (35%) of these needed airway intervention while 108 (13%) needed chest tube insertion on arrival to the trauma unit suggesting inadequate care at primary facility.Mortality is not associated with prehospital time but with transfers from primary care; probably due to deficient care. To improve survival after major trauma, enhancement of resources for resuscitation and capacity building of on-duty doctors in primary centers should be a priority in countries with limited resources.

Project description:ImportanceA scoring tool to identify which adults with traumatic injury will require early laparotomy could help improve prehospital triage and system readiness.ObjectiveTo develop and validate a prediction model using prehospital information for early laparotomy following trauma.Design, setting, and participantsThis retrospective cohort study analyzed data from the 2017 version of the American College of Surgeons Trauma Quality Improvement Program database. All adult patients with traumatic injury aged 18 years or older who were admitted to a US trauma center in 2017 were included. Patients were randomly assigned to a derivation or validation cohort. Data were collected and analyzed between July 2020 and September 2020.Main outcomes and measuresThe primary outcome was laparotomy within 2 hours of hospital arrival. A scoring system was developed to predict early laparotomy using a logistic regression model in the derivation cohort. This was validated in the validation cohort using the area under the receiver operating characteristic curve.ResultsA total of 379 890 US adults with traumatic injury were included; 190 264 patients were in the derivation cohort and 189 626 patients were in the validation cohort. The cohorts had the same proportion of laparotomy within 2 hours of hospital arrival (1.1%). The median (IQR) age was 32 (25-46) years in the early laparotomy group and 54 (33-72) years in the group with no early laparotomy. The early laparotomy group contained 113 776 of 188 211 (60.5%) male patients, while the group with no early laparotomy contained 1702 of 2053 (82.9%) male patients. The variable most strongly associated with early laparotomy was penetrating injury to the head, neck, torso, or extremities proximal to the elbow or knee (odds ratio, 13.47; 95% CI, 12.22-14.86) with a point value of 10 (maximum overall score 20). Other variables included in the scoring system were the male sex, a systolic blood pressure less than 90 mm Hg, a Glasgow Coma Scale of less than or equal to 13, having chest wall instability or deformity, pelvic fracture, and high-risk blunt mechanism. In the validation cohort, the C statistic of the scoring system was 0.78 (95% CI, 0.77-0.79).Conclusions and relevanceIn this study, a novel scoring tool using prehospital information was derived and validated to identify which adults with traumatic injury will require laparotomy within 2 hours of hospital arrival. This tool may help trauma professionals allocate operative team resources before patient arrival.

Project description:ImportanceThe association between total prehospital time and mortality in physician-staffed trauma systems remains uncertain.ObjectiveTo describe the association of total prehospital time and in-hospital mortality in prehospital, physician-staffed trauma systems in France, with the hypothesis that total prehospital time is associated with increased mortality.Design, setting, and participantsThis cohort study was conducted from January 2009 to December 2016. Data for this study were derived from 2 distinct regional trauma registries in France (1 urban and 1 rural) that both have a physician-staffed emergency medical service. Consecutive adult trauma patients admitted to either of the regional trauma referral centers during the study period were included. Data analysis took place from March 2018 to September 2018.Main outcomes and measuresThe association between death and prehospital time was assessed with a multivariable model adjusted with confounders. Total prehospital time was the primary exposure variable, recorded as the time from the arrival of the physician-led prehospital care team on scene to the arrival at the hospital. The main outcome of interest was all-cause in-hospital mortality.ResultsA total of 10 216 patients were included (mean [SD] age, 41 [18] years; 7937 men [78.3%]) affected by predominantly nonpenetrating injuries (9265 [91.5%]), with a mean (SD) Injury Severity Score of 17 (14) points. Of the patients, 6737 (66.5%) had at least 1 body region with an Abbreviated Injury Scale score of 3 or more. A total of 1259 patients (12.4%) presented in shock (with systolic pressure <90 mm Hg) and 2724 (26.9%) with severe head injury (Abbreviated Injury Scale score ≥3 points). On unadjusted analysis, increasing prehospital times (in 30-minute categories) were associated with a markedly and constant increase in the risk of in-hospital death. The odds of death increased by 9% for each 10-minute increase in prehospital time (odds ratio, 1.09 [95% CI, 1.07-1.11]) and after adjustment by 4% (odds ratio, 1.04 [95% CI, 1.01-1.07]).Conclusions and relevanceIn this study, an increase in total prehospital time was associated with increasing in-hospital all-cause mortality in trauma patients at a physician-staffed emergency medical system, after adjustment for case complexity. Prehospital time is a management objective in analogy to physiological targets. These findings plead for a further streamlining of prehospital trauma care and the need to define the optimal intervention-to-time ratio.

Project description:BackgroundAlthough the results of previous studies suggested the effectiveness of physician-led prehospital trauma management, it has been uncertain because of the limited number of high-quality studies. Furthermore, the advantage of physician-led prehospital management might have been overestimated due to the shortened prehospital time by helicopter transportation in some studies. The present study aimed to evaluate the effect of physician-led prehospital management independent of prehospital time. Also, subgroup analysis was performed to explore the subpopulation that especially benefit from physician-led prehospital management.MethodsThis retrospective cohort study analyzed the data of Japan's nationwide trauma registry. Severe blunt trauma patients, defined by Injury Severity Score (ISS) ≥16, who were transported directly to a hospital between April 2009 and March 2019 were evaluated. In-hospital mortality was compared between groups dichotomized by the occupation of primary prehospital healthcare provider (i.e., physician or paramedic), using 1:4 propensity score-matched analysis. The propensity score was calculated using potential confounders including patient demographics, mechanism of injury, vital signs at the scene of injury, ISS, and total time from injury to hospital arrival. Subpopulations that especially benefit from physician-led prehospital management were explored by assessing interaction effects between physician-led prehospital management and patient characteristics.ResultsA total of 30,551 patients (physician-led: 2976, paramedic-led: 27,575) were eligible for analysis, of whom 2690 propensity score-matched pairs (physician-led: 2690, paramedic-led: 10,760) were generated and compared. Physician-led group showed significantly decreased in-hospital mortality than paramedic-led group (in-hospital mortality: 387 [14.4%] and 1718 [16.0%]; odds ratio [95% confidence interval] = 0.88 [0.78-1.00], p = 0.044). Patients with age < 65 years, ISS ≥25, Abbreviated Injury Scale in pelvis and lower extremities ≥3, and total prehospital time < 60 min were likely to benefit from physician-led prehospital management.ConclusionsPhysician-led prehospital trauma management was significantly associated with reduced in-hospital mortality independent of prehospital time. The findings of exploratory subgroup analysis would be useful for the future research to establish efficient dispatch system of physician team.

Project description:ImportanceTime to definitive care following injury is important to the outcomes of trauma patients. Prehospital trauma care is provided based on policies developed by individual trauma systems and is an important component of the care of injured patients. Given a paucity of systems-level trauma research, considerable variability exists in prehospital care policies across trauma systems, potentially affecting patient outcomes.ObjectiveTo evaluate whether private vehicle prehospital transport confers a survival advantage vs ground emergency medical services (EMS) transport following penetrating injuries in urban trauma systems.Design, setting, and participantsRetrospective cohort study of data included in the National Trauma Data Bank from January 1, 2010, through December 31, 2012, comprising 298 level 1 and level 2 trauma centers that contribute data to the National Trauma Data Bank that are located within the 100 most populous metropolitan areas in the United States. Of 2 329 446 patients assessed for eligibility, 103 029 were included in this study. All patients were 16 years or older, had a gunshot wound or stab wound, and were transported by ground EMS or private vehicle.Main outcome and measureIn-hospital mortality.ResultsOf the 2 329 446 records assessed for eligibility, 103 029 individuals at 298 urban level 1 and level 2 trauma centers were included in the analysis. The study population was predominantly male (87.6%), with a mean age of 32.3 years. Among those included, 47.9% were black, 26.3% were white, and 18.4% were Hispanic. Following risk adjustment, individuals with penetrating injuries transported by private vehicle were less likely to die than patients transported by ground EMS (odds ratio [OR], 0.38; 95% CI, 0.31-0.47). This association remained statistically significant on stratified analysis of the gunshot wound (OR, 0.45; 95% CI, 0.36-0.56) and stab wound (OR, 0.32; 95% CI, 0.20-0.52) subgroups.Conclusions and relevancePrivate vehicle transport is associated with a significantly lower likelihood of death when compared with ground EMS transport for individuals with gunshot wounds and stab wounds in urban US trauma systems. System-level evidence such as this can be a valuable tool for those responsible for developing and implementing policies at the trauma system level.

Project description:BackgroundFew ocular trauma studies have addressed mortality outcomes. We sought to determine characteristics of mortality-related ocular trauma admissions and compared them with non-fatal injuries.MethodsA retrospective study was conducted using de-identified data of patients admitted with major trauma from the National Trauma Data Bank (2008-2014). Patients with ocular injury were identified using ICD- 9CM codes. Demographics, intention and mechanism, types of ocular and head injuries, and injury severity were documented. Mortality was determined using post-admission disposition. Statistical analysis using student t-test, chi-square, and odds ratios (OR) calculations were performed with STATA-17 software. Significance was set at P < 0.05.ResultsOf 316,485 patients admitted with ocular trauma, 12,233 (3.86%) were mortality related. Expired patients were older than survivors: mean (SD) of 50.1(25.5) vs. 41.5(22.8) years. White (OR = 1.32; P < 0.001), ≥ 65years old (OR = 2.25; P < 0.001), and male (OR = 1.05; P = 0.029) patients were most likely to expire than their counterparts. Common mechanisms of injury in survivors were falls (25.3%), motor vehicle traffic-occupant, MVTO (21.8%) and struck by/against (18.1%) and for fatal injuries, falls (29.7%), MVTO (21.9%) and firearms (11.5%). Traumatic brain injury (TBI) was documented in 88.2% of mortality-related admissions. Very severe injury severity scores (ISS > 24) (OR = 19.19; P < 0.001) and severe Glasgow Coma Score (GCS < 8) (OR = 19.22; P < 0.001) were most associated with mortality than survival. Firearms were most associated with very severe ISS (OR = 3.73; P < 0.001), severe GCS (OR = 4.68; P < 0.001) and mortality (OR = 5.21; P < 0.001) than other mechanisms. Patients with cut/pierce injuries had the greatest odds of survival (OR = 13.48; P < 0.001). Optic nerve/visual pathways injuries (3.1%) had the highest association with very severe ISS (OR = 2.51; P < 0.001), severe GCS (OR = 3.64; P < 0.001) and mortality (OR = 2.58; P < 0.001) than other ocular injuries. Black patients with very severe ISS (OR = 32.14; P < 0.001) and severe GCS (OR = 31.89; P < 0.001) were more likely to expire than other race/ethnicities with similar injury severity.ConclusionsMortality-related admissions were older, male, and mostly of White race than ocular trauma admissions of survivors. Firearms were the deadliest mechanism. TBI was commonly associated and patients with optic nerve/pathway injuries, very severe ISS and severe GCS had higher mortality rates. Characteristics and demographic variations identified in this study may be useful in developing focused measures aimed at preventing trauma-related deaths.

Project description:BackgroundAcute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP ? 90 mmHg) with or without the presence of shock in the prehospital and ED setting.MethodsWe performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality.ResultsSix observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies.ConclusionThere is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described.

Project description:Current prehospital traumatic brain injury guidelines use a systolic blood pressure threshold of less than 90 mm Hg for treating hypotension for individuals 10 years and older based on studies showing higher mortality when blood pressure drops below this level. However, the guidelines also acknowledge the weakness of the supporting evidence.To evaluate whether any statistically supportable threshold between systolic pressure and mortality emerges from the data a priori, without assuming that a cut point exists.Observational evaluation of a large prehospital database established as a part of the Excellence in Prehospital Injury Care Traumatic Brain Injury Study. Patients from the preimplementation cohort (January 2007 to March 2014) 10 years and older with moderate or severe traumatic brain injury (Barell Matrix Type 1 classification, International Classification of Diseases, Ninth Revision head region severity score of 3 or greater, and/or Abbreviated Injury Scale head-region severity score of 3 or greater) and a prehospital systolic pressure between 40 and 119 mm Hg were included. The generalized additive model and logistic regression were used to determine the association between systolic pressure and probability of death, adjusting for significant/important confounders.The main outcome measure was in-hospital mortality.Among the 3844 included patients, 2565 (66.7%) were male, and the median (range) age was 35 (10-99) years. The model revealed a monotonically decreasing association between systolic pressure and adjusted probability of death across the entire range (ie, from 40 to 119 mm Hg). Each 10-point increase of systolic pressure was associated with a decrease in the adjusted odds of death of 18.8% (adjusted odds ratio, 0.812; 95% CI, 0.748-0.883). Thus, the adjusted odds of mortality increased as much for a drop from 110 to 100 mm Hg as for a drop from 90 to 80 mm Hg, and so on throughout the range.We found a linear association between lowest prehospital systolic blood pressure and severity-adjusted probability of mortality across an exceptionally wide range. There is no identifiable threshold or inflection point between 40 and 119 mm Hg. Thus, in patients with traumatic brain injury, the concept that 90 mm Hg represents a unique or important physiological cut point may be wrong. Furthermore, clinically meaningful hypotension may not be as low as current guidelines suggest. Randomized trials evaluating treatment levels significantly above 90 mm Hg are needed.

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Trauma models to identify major trauma and mortality in the prehospital setting.

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Trauma models to identify major trauma and mortality in the prehospital setting.

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