|Year : 2015 | Volume
| Issue : 3 | Page : 65-69
Trauma scores and outcomes: A study of 2541 patients in level I trauma center of a developing country
Sandeep Rathore, Maneesh Singhal, Sunil Chumber, Subodh Kumar, Amit Gupta
Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||14-Mar-2016|
Dr. Maneesh Singhal
Department of Surgical Disciplines, All India Institute of Medical Sciences, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Background: This study was undertaken with an aim to study the efficacy of trauma scores in predicting the outcome. Developing countries have higher number of automobile accidents due to increasing use of faster automobiles. Prehospital care and transportation victims have its limitations. We hypothesized the existing trauma scores devised in the developed nations will not be useful in the developing countries. Subjects and Methods: This prospective observational study of 1 year was done in the Emergency Department of a Tertiary Care Centre in which 2541 trauma victims were studied. The demographic profile and pattern of injuries with outcome were studied and the data were analyzed on the basis of trauma score-injury severity score (TRISS). Appropriate statistical tests were used for analysis, and P < 0.05 was considered significant. Observations and Results: Young male patients with a mean age of 30.49 years formed the commonest group. Road traffic crashes were the most common cause of trauma which was followed by injuries due to fall from height. Head injury was responsible for the death of the highest number of victims. Spleen was the most common organ injured in abdominal injuries. In our study, 41.1% deaths could not be explained by the TRISS methodology. We had four victims who survived contrary to the predictions of the methodology. TRISS was found to be less reliable in severely injured groups (ISSs >20 and Glasgow Coma Scale ≥12). Conclusion: This study supported the view that pre-hospital care received by the victim at the accident site or during transportation to a tertiary care center should also be considered in predicting the outcome by any ISS. We propose that larger studies are required to devise a newer scoring system for the evaluation of outcome of trauma care.
Keywords: Head injury, road traffic crashes, trauma score-injury severity score
|How to cite this article:|
Rathore S, Singhal M, Chumber S, Kumar S, Gupta A. Trauma scores and outcomes: A study of 2541 patients in level I trauma center of a developing country. Saudi Surg J 2015;3:65-9
|How to cite this URL:|
Rathore S, Singhal M, Chumber S, Kumar S, Gupta A. Trauma scores and outcomes: A study of 2541 patients in level I trauma center of a developing country. Saudi Surg J [serial online] 2015 [cited 2020 Apr 8];3:65-9. Available from: http://www.saudisurgj.org/text.asp?2015/3/3/65/178676
| Introduction|| |
Worldwide rise in the trauma-related morbidity and mortality has become a major health problem. Trauma is the principal cause of mortality in young population. The efficiency of a health provider is scrutinized by the quality of trauma care. Various injury scores have been devised to quantify the type and severity of trauma resulting mainly from automobile accidents in addition to other modes of injuries. These trauma scores are devised in developed countries with excellent prehospital care, transportation of victims with advanced life support and state of art tertiary care. Developing countries have limitations such as lack of proper prehospital care and delay in tertiary care services. Delay in starting the treatment in "the golden hour of trauma" can increase the severity of injury and can be a cause of poorer outcome. We hypothesized that trauma scores devised in the settings of developed nations may not be appropriate for the developing nations.
| Subjects and Methods|| |
This observational prospective study was conducted in the emergency department of a tertiary care center for 1 year. This state of art tertiary care center is catering to 16 million populations out of which 14 million reside in the near vicinity of the metro where the center is situated. This center aims at providing the highest standard of trauma care and is equipped with all sophisticated equipment and staffed by consultants and paramedics round the clock. The study commenced after the clearance by the Institutional Ethics Review Board.
All the patients of trauma except burns, hanging, rape, drowning, and animal bites were included in the study. Unfortunate victims of trauma who were brought dead were not included. The demographic profile, pattern of injury, time taken to reach hospital by various modes of transportation and clinical parameters on arrival were entered on a proforma for the study. The patient was further followed, and outcome of the injury was recorded. In the event of death, the details of complications and the cause of death were recorded. At the end of our study, the collected data was analyzed, various scores were assigned by appropriate statistical methods with institutional biostatician.
In this study, following injury scores were used for analysis.
Anatomical injury score
Anatomical injury score (AIS), in which injuries are ranked in a scale of 1-6 (1 being minor injury, whereas 5 is severe and 6 is unsuvivable).  This scoring system was introduced in 1969. The AIS is regularly monitored by Association for the Advancement of Automotive Medicine from the USA and has been revised in 2005 and 2008. It provides reasonably accurate grading of the severity of injury as now it includes survival also.
Injury severity score
The injury severity score (ISS) is an anatomical scoring system that provides an overall score of patient with multiple injuries. Each injury is assigned and is allocated to one of the six body regions (head, face, chest, abdomen, extremities including pelvis, and external). Only the highest AIS score of each body region is used. The three most severely injured regions have their scores squared and added together to produce the ISS. The ISS score takes values of 0-75. If an injury is assigned six in AIS, then it will be 75 in ISS. 
Revised trauma score
The revised trauma score (RTS) is physiological scoring system with high inter-rater reliability and demonstrable accuracy in prediction of death.  It is scored from the first set of data obtained from patients; and consists of Glasgow coma score (GCS), systolic blood pressure and respiratory rate. Values of the RTS are in the range of 0.00-7.8408. The RTS correlates well with the probability of survival (Ps).  The GCS ranges between 3 and 15, three being worse and fifteen the best. The GCS is calculated on the basis of three parameters: Best eye response, best verbal response, and best motor response. 
Trauma and injury severity score
Trauma score-ISS (TRISS) determines the Ps of a patient from the ISS and RTS using the following formula: Where "b" will be calculated by:
B = b0 + b1 (RTS) + b2 (ISS) + b3 (age index)
The coefficients b0-b3 is derived from Walker Duncan regression analysis of the major trauma outcome study (MTOS) database. Age index is 0 if the patient is under 54 years of age or 1 if 55 years and over. b0-b3 are coefficients which are different for blunt and penetrating trauma; If the patient is <15 the blunt index for b3 (age) is used regardless of mechanism. Based on Walker duncan Regression coefficients, a line can be drawn between the coordinate pairs that represent a Ps as 0.5. Deaths occurring in patients who had a calculated Ps 0.5 or more are considered as an "unexpected death." ,
TRISS methodology was employed in evaluating the Ps of all the patients in the study. Mortality was compared within the various trauma scores. The deaths which were unexplained by TRISS methodology were analyzed and discussed. Mann-Whitney test and Chi-square test were also used for statistical analysis. SPSS software for Windows was used for statistical analysis (SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc.). P < 0.05 was considered significant.
| Observations and Results|| |
This prospective observational comprised 2541 patients befitting the inclusion criteria over a period of 1 year. Of these 2541 patients, 1930 (75.95%) were discharged from the emergency department after primary treatment. Six hundred and eleven (24.05%) patients were admitted and treated. Of the admitted patients, 73 (2.87%) died during the treatment in the hospital.
Eighty-one percent patients (2069) were males. Majority of the victims were of the younger age group, i.e., between 21 and 30 years with a mean age of 30.49 years. Five hundred and twenty-two (21%) patients belonged to the pediatric age group. Road traffic crashes (RTCs) observed was the most common cause of trauma (52.4%) in our study which was followed by fall from height (27.6%). Our study showed that police control room vans played the major role in the transportation of the victim from the accident site (34%). A total of 1634 (64%) patients were brought to the hospital within 6 h of injury.
We had 611 admissions, out of which 73 patients died. Fifty-two out of the 73 dead patients died within 6 h of admission, and most of these patients had a head injury. Most injuries were blunt injuries (93%) and had significant mortality. Head injury was the most common cause of death and in this study 235 patients, (38.5%) of admitted patients suffered from head injuries out of which 52 (22.1%) had a fatal outcome.
In this study, 64 patients suffered abdominal trauma. Fifty-nine (81.94%) were solid organ injuries, and 14 (18.06%) were hollow viscus injuries in these cases of abdominal trauma. Spleen (38.5%) was the most commonly injured organ which was followed by liver (35.59%). Of the hollow viscus injuries, 11 (15.23%) had small bowel while 3 (4.17%) had large bowel injuries.
Our study showed that survivors (14.71 ± 1.509) had a better GCS score than nonsurvivors (7.05 ± 4.576). GCS score was found to be a statistically significant variable in terms of the outcome in our study. The mean ISS in our study was 5.14 ± 7.74, and it ranged from 1 to 75. Highly significant P < 0.001 was obtained on comparison of the ISS of survivors with that of nonsurvivors. The overall mean RTS score of our patients was 7.67 ± 0.77. Expired patients showed lower RTS (4.59 ± 2.09) as compared to survivors (7.76 ± 0.445) which show that decreasing RTS score decreases the Ps.
Out of the total of 73 deaths, TRISS methodology could not explain thirty deaths in our study as there Ps value were more than 0.5. Seventeen out of the 30 unexplained deaths were attributed to head injuries. On the contrary, we had four survivors with their Ps < 0.5. Forty-one percent deaths were unexplained by TRISS methodology if we consider Ps 0.5 and more, unexpected deaths were exponentially increased if we lower the threshold of the Ps below 0.5 as shown in the [Table 1].
|Table 1: Unexplained deaths with various range of PS out of total 73 deaths|
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| Discussion|| |
Our study had 81.45 males. Male preponderance has been reported in various MTOS ranging between 71.5 and 85.5% which is comparable to our study.  Seventy-seven percent of our patients were from economically productive age group of 15-54 years, similar results are reported by Goel et al.  and Murlidhar and Roy.  This group is accountable for 3% gross domestic product of our country as compared to 2% in the western countries. Guha  emphasized on the improvement of prehospital services to affect the outcome positively especially in neurotrauma to prevent secondary insults to brain while transportation. Chardoli et al.  found 59.45% of trauma due to RTCs. Higher percentage of patients died due to RTCs as compared to other modes of injuries; this is probably due to high-velocity impacts, dirty environment at the scene of accident and extensive soft tissue injuries which further lead to infection. Fall from height was the common mode of injury among females and pediatric age group in our study. Similar observations are made in a study by Durkin et al.  The confinement of women and children at home is probably the reason in our set up.
Various studies have shown that the GCS scores could be crucial variable in prediction of mortality related to polytrauma. Our study clearly shows the difference between the GCS score of survivors (14.71 ± 1.509) and nonsuvivor (7.05 ± 4.5760). A study done by Matis and Birbilis.  shows GCS score of 6.81 for survivors and 5.55 for nonsurvivors. These figures can be explained by the fact that Matis and Birbilis.  have studied only head injuries. Our study has included all types of injuries and head injuries as well. That is why survivors in our study show a higher GCS score. Udekwu et al.  and Cho and Wang.  show results which are similar to our study.
The mean ISS in our study was 5.14 ± 0.77; lower ISS score can be attributed to inclusion of less severe injuries in our study. The mean ISS was significantly higher among those who died (30.16 ± 11.753) as compared to those who survived. Murlidhar and Roy.  and Koo et al.  reported a mean ISS of 16.7 in survivors and 16.9 in nonsurvivors. Our study had lower mean ISS. When ISS of survivors and nonsurvivors were compared with the outcome, a significant P < 0.001 was obtained. The general trend is that with increasing ISS the percentage survival is reduced. Baker and O'Neill.  in his study showed similar results. The majority of our patients were in the ISS group of 1-8 and almost all are survivors. Similarly, in MTOS, the majority of patients were in the ISS group of 1-8.
The overall mean RTS score of our patients was 7.67 ± 0.77. The patients who expired showed a significantly lower RTS (4.59 ± 2.09) as compared to that among the survivors (7.76 ± 0.445). In the MTOS the mean RTS was seven. Murlidhar and Roy.  and Koo et al.  reported a mean RTS comparable to ours, While Kuhls et al.  showed the mean RTS of the patients is 7.65. The average patients in our study were therefore physiologically similar to the other studies. Underdeveloped prehospital care could be responsible for a low mean RTS of expired patients as delay in transportation could affect the physiological parameters of the victims. [Table 2] shows compare our study with MTOS and other studies by Murlidhar and Roy.  and Norouzi et al. 
|Table 2: Comparisons of Our study with MTOS, Murlidhar V 7 and Nourouzi V 17|
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Gabbe et al.  has emphasized on the shortcomings of TRISS. Patients with a calculated Ps more than 50% still have up to 50% probability of death, and therefore, the term "unexpected death" is not correct. The greatest variation in the reliability of TRISS calculations has been shown to be in the middle range. Therefore, identification of cases for audit, based on the Ps 50 isobar is likely to be inaccurate due to poor reliability of TRISS calculations in this range. In our study, 30 (41.1% of total died) deaths are not explained by conventional TRISS methodology. We also had four unexpected survivors.
The shortcomings of ISS in describing injuries of the same body region have been highlighted in the literature. ISS can incorporate only one injury per body region. For example, if a patient had a grade 5 splenic injury with a grade 5 liver injuries, the ISS would still be calculated as 25. Another patient with a simple splenic laceration and bilateral Le Fort fractures (which is considered a nonfatal injury) would have an ISS of 29 which is high. Considering that the physiological characters were the same for both these patients, the patient with maxillofacial injury will have a poorer Ps calculated according to TRISS. Lavoie et al.  formulated new ISS (NISS) to overcome this shortcoming of ISS. NISS is calculated as the sum of the squares of the top three scores regardless of the body region. The NISS has been found to statistically outperform in comparison to ISS. In this study, we calculated NISS in those nine patients who were appropriate for it. Out of these nine patients, we could explain two deaths which were unexplained by traditional ISS.
Adoga and Ozoilo.  proposed that public education is important in the prevention of trauma. Public perception of the risks, of risks of injury, is necessary to adapt and apply prevention campaigns that have proven to be successful elsewhere in the world. Facilities for prehospital and hospital emergency care of the injured are inadequate in developing countries like us. Severely injured are at risk because of inadequate facilities for faster transportation from the accident site to medical care, poor prehospital care and lack of properly trained medical and paramedical staff at all trauma centers. Improvement of the health sector with proper and judicious funding for equipment and training of health personnel is needed to improve outcomes. 
Our study supported the well-known fact that young and economically productive age groups are adversely affected by the impact of trauma. Patients in our study were anatomically less severely injured with little physiological derangements in comparison to worldwide studies on outcome of trauma on the basis of ISS and RTS. TRISS methodology has been used worldwide for evaluation of outcome but has various drawbacks. The noteworthy drawback of TRISS is the overestimation of probability of survival among severe head and spinal injuries; however, all the explained deaths cannot be attributed to limitations of TRISS alone.
The limitation of our study was that most of our patients had less severe injury. We applied logistic regression analysis to compare various trauma scores of outcome but got statistically insignificant results except ISS. This shows that more patients are needed for statistically significant results to compare outcomes with trauma scores and generate new scores for developing nations. Although we had many referrals. However, ours is a single center study. Multi-center studies are required for further evaluation for an authentic new trauma score. Due to delay in transportation and poor prehospital care some patients died during transfer from accident site to trauma care center and were not included in the study.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]