The sequential trauma score - a new instrument for the sequential mortality prediction in major trauma*

European Journal of Medical Research

R Lefering¹  KG Kanz²  W Mutschler²  E Euler²  T Paffrath³  P Mathonia²  J Stegmaier²  S Huber-Wagner² 

[1] IFOM - Institute for Research in Operative Medicine, University of Witten/Herdecke, Cologne-Merheim Medical Center, Cologne, Germany;Munich University Department of Trauma Surgery - Campus Innenstadt, Ludwig-Maximilians-University, Munich, Germany;Department of Trauma and Orthopedic Surgery, University of Witten/Herdecke, Cologne-Merheim Medical Center, Cologne, Germany

关键词: STS;    RISC;    TRISS;    ISS;    dynamic score;    polytrauma;    severely injured patients;    score;    scoring;    prognosis;    outcome;    Major trauma;   

Others  :  1093175
DOI  :  10.1186/2047-783X-15-5-185

 received in 2009-11-21, accepted in 2009-01-27,  发布年份 2010

【 摘 要 】

Background

There are several well established scores for the assessment of the prognosis of major trauma patients that all have in common that they can be calculated at the earliest during intensive care unit stay. We intended to develop a sequential trauma score (STS) that allows prognosis at several early stages based on the information that is available at a particular time.

Study design

In a retrospective, multicenter study using data derived from the Trauma Registry of the German Trauma Society (2002-2006), we identified the most relevant prognostic factors from the patients basic data (P), prehospital phase (A), early (B1), and late (B2) trauma room phase. Univariate and logistic regression models as well as score quality criteria and the explanatory power have been calculated.

Results

A total of 2,354 patients with complete data were identified. From the patients basic data (P), logistic regression showed that age was a significant predictor of survival (AUC_{model p}, area under the curve = 0.63). Logistic regression of the prehospital data (A) showed that blood pressure, pulse rate, Glasgow coma scale (GCS), and anisocoria were significant predictors (AUC_{model A} = 0.76; AUC_{model P + A} = 0.82). Logistic regression of the early trauma room phase (B1) showed that peripheral oxygen saturation, GCS, anisocoria, base excess, and thromboplastin time to be significant predictors of survival (AUC_{model B1} = 0.78; AUC_{model P +A + B1} = 0.85). Multivariate analysis of the late trauma room phase (B2) detected cardiac massage, abbreviated injury score (AIS) of the head ≥ 3, the maximum AIS, the need for transfusion or massive blood transfusion, to be the most important predictors (AUCmodel B2 = 0.84; AUCfinal model P + A + B1 + B2 = 0.90). The explanatory power - a tool for the assessment of the relative impact of each segment to mortality - is 25% for P, 7% for A, 17% for B1 and 51% for B2. A spreadsheet for the easy calculation of the sequential trauma score is available at: http://www.sequential-trauma-score.com webcite

Conclusions

This score is the first sequential, dynamic score to provide a prognosis for patients with blunt major trauma at several points in time. With every additional piece of information the precision increases. The medical team has a simple, useful tool to identify patients at high risk and to predict the prognosis of an individual patient with major trauma very early, quickly and precisely.

【 授权许可】

   
2010 I. Holzapfel Publishers

【 图 表 】

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【 参考文献 】

• [1]Kung H-C, Hoyert DL, Xu J, Murphy SL: Deaths: Final Data for 2005. National Vital Statistics Reports of the CDC 2008, 56(10):1-121.
• [2]Lefering R: Trauma Score Systems for Quality Assessment. Eur J Trauma 2002, 28:52-63.
• [3]Bouillon B, Lefering R, Vorweg M, Tiling T, Neugebauer E, Troidl H: Trauma score systems: cologne Validation Study. J Trauma 1997, 42(4):652-658.
• [4]Senkowski CK, McKenney MG: Trauma scoring systems: a review. J Am Coll Surg 1999, 189(5):491-503.
• [5]Baker SP, O'Neill B, Haddon W Jr, Long WB: The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974, 14(3):187-196.
• [6]Rating the severity of tissue damage. I. The abbreviated scale JAMA 1971, 215(2):277-280.
• [7]Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ: Trauma score. Crit Care Med 1981, 9(9):672-676.
• [8]Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME: A revision of the trauma score. J Trauma 1989, 29(5):623-629.
• [9]Boyd CR, Tolson MA, Copes WS: Evaluating trauma care: the TRISS method. Trauma score and the injury severity score. J Trauma 1987, 27(4):370-378.
• [10]Osler T, Rutledge R, Deis J, Bedrick E: ICISS: an international classification of disease-9 based injury severity score. J Trauma 1996, 41(3):380-386; discussion 386-388.
• [11]Rutledge R, Fakhry S, Baker C, Oller D: Injury severity grading in trauma patients: a simplified technique based upon ICD-9 coding. J Trauma 1993, 35(4):497-506; discussion 506-507.
• [12]Osler T, Baker SP, Long W: A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997, 43(6):922-925; discussion 925-926.
• [13]Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, Gennarelli T, Mackenzie E, Schwaitzberg S: A new characterization of injury severity. J Trauma 1990, 30(5):539-545; discussion 545-546.
• [14]Rixen D, Raum M, Bouillon B, Schlosser LE, Neugebauer E: Predicting the outcome in severe injuries: an analysis of 2069 patients from the trauma register of the German Society of Traumatology (DGU). Unfallchirurg 2001, 104(3):230-239.
• [15]Rixen D, Raum M, Bouillon B, Lefering R, Neugebauer E: Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft fur unfallchirurgie. Shock 2001, 15(2):83-89.
• [16]Kroezen F, Bijlsma TS, Liem MS, Meeuwis JD, Leenen LP: Base deficit-based predictive modeling of outcome in trauma patients admitted to intensive care units in Dutch trauma centers. J Trauma 2007, 63(4):908-913.
• [17]Annual Report of the Trauma Registry of the German Trauma Society (DGU). Working Group on Polytrauma German Trauma Society (DGU) 2003 [http://www.traumaregister.de] webcite
• [18]Ruchholtz S, Lefering R, Paffrath T, Oestern HJ, Neugebauer E, Nast-Kolb D, Pape H-C, Bouillon B: Reduction in mortality of severely injured patients in Germany. Dtsch Arztebl 2008, 105(13):225-231.
• [19]Lefering R: Revised Injury Severity Classification (RISC) - Development and validation of a classification system for severely injured patients based on a large trauma registry. In [Revised Injury Severity Classification (RISC) - Entwicklung und Validierung eines Schweregrad-Klassifikationssystems für schwerverletzte Patienten zur Anwendung in einem nationalen Traumaregister] (Habilitationsschrift). IFOM - Institut für Forschung in der Operativen Medizin. Cologne: University Witten/Herdecke, Faculty of Medicine, Germany; 2007:1-131.
• [20]Huber-Wagner S, Lefering R, Qvick L, Körner M, Kay M, Pfeifer K, Reiser M, Mutschler W, Kanz K: Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009, 373:1455-1461.
• [21]Lefering R: Development and validation of the Revised Injury Severity Classification (RISC) score for severely injured patients. Eur J Trauma Emerg Surg 2009, 35:437-447.
• [22]Osler T, Glance L, Buzas JS, Mukamel D, Wagner J, Dick A: A trauma mortality prediction model based on the anatomic injury scale. Ann Surg 2008, 247(6):1041-1048.
• [23]Ruchholtz S: The Trauma Registry of the German Society of Trauma Surgery as a basis for interclinical quality management. A multicenter study of the German Society of Trauma Surgery. Unfallchirurg 2000, 103(1):30-37.
• [24]Nagelkerke NJD: A note on a general definition of the coefficient of determination. Biometrika 1991, 78:691-692.
• [25]Lemeshow S, Hosmer DW: A review of goodness of fit statistics for use in the development of logistic regression models. Am J Epidemiol 1982, 115:92-106.
• [26]Zimmerman JE, Kramer AA, McNair DS, Malila FM, Shaffer VL: Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV. Crit Care Med 2006, 34(10):2517-2529.
• [27]Raux M, Thicoipe M, Wiel E, Rancurel E, Savary D, David JS, Berthier F, Ricard-Hibon A, Birgel F, Riou B: Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients. Intensive Care Med 2006, 32(3):405-412.
• [28]Schynoll W, Overton D, Krome R, Wesolowski D, Wang AM, Wilson A, Coffey M: A prospective study to identify high-yield criteria associated with acute intracranial computed tomography findings in head-injured patients. Am J Emerg Med 1993, 11(4):321-326.
• [29]Murray GD, Butcher I, McHugh GS, Lu J, Mushkudiani NA, Maas AI, Marmarou A, Steyerberg EW: Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007, 24(2):329-337.
• [30]Mushkudiani NA, Hukkelhoven CW, Hernandez AV, Murray GD, Choi SC, Maas AI, Steyerberg EW: A systematic review finds methodological improvements necessary for prognostic models in determining traumatic brain injury outcomes. J Clin Epidemiol 2008, 61(4):331-343.
• [31]Hukkelhoven CW, Steyerberg EW, Habbema JD, Farace E, Marmarou A, Murray GD, Marshall LF, Maas AI: Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics. J Neurotrauma 2005, 22(10):1025-1039.
• [32]National Trauma Data Bank: Annual Report. 2007.
• [33]Annual Report of the Trauma Registry of the German Trauma Society (DGU). Working Group on Polytrauma German Trauma Society (DGU) 2007.
• [34]Advanced Trauma Life Support for Doctors - Student Course Manual 7th edition. Chicago: American College of Surgeons; 2004.
• [35]Martin RS, Kilgo PD, Miller PR, Hoth JJ, Meredith JW, Chang MC: Injury-associated hypothermia: an analysis of the 2004 National Trauma Data Bank. Shock 2005, 24(2):114-118.
• [36]Shafi S, Elliott AC, Gentilello L: Is hypothermia simply a marker of shock and injury severity or an independent risk factor for mortality in trauma patients? Analysis of a large national trauma registry. J Trauma 2005, 59(5):1081-1085.