Abstract
Introduction:
Trauma scores are often used for prognostication and the adjustment of mortality data. The appropriate consideration of identified prognostic factors is mandatory for a valid score with good outcome prediction properties. The Trauma Registry of the German Society for Trauma Surgery (TR-DGU) initially used the Trauma and Injury Severity Score (TRISS) but various reasons led to the development of a new scoring system, the Revised Injury Severity Classification (RISC).
Patients and Methods:
A total of 2,008 severely injured patients with complete data documented in the TR-DGU during the period 1993–2000 were used to develop a new score. Patients were split into a development sample (n = 1,206) and a validation sample (n = 802). Multivariate logistic regression analysis was applied, and the results were compared with existing score systems. The quality of prediction was determined regarding discrimination (disparity, sensitivity, specificity, receiver operating characteristic [ROC] curve), precision (predicted versus observed mortality), and calibration (Hosmer–Lemeshow goodness-of-fit).
Results:
Existing score systems (ISS, NISS, RTS, ASCOT, TRISS, Rixen) revealed areas under the ROC curve ranging from 0.767 to 0.877. The RISC combines 11 different components: age, NISS, head injury, severe pelvic injury, Glasgow Coma Scale, partial thromboplastin time (PTT), base excess, cardiac arrest, and indirect signs of bleeding (shock, mass transfusion, and low hemoglobin). The new RISC score reached significantly higher values of above 0.90 for the area under the ROC curve in both development and validation samples. Application to data from 2001 confirmed these results.
Conclusion:
Outcome prediction including initial laboratory values was able to significantly improve the ability to discriminate between survivors and nonsurvivors. The adjustment of mortality rates should be based on the best available prediction model.
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References
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;14:187–196.
Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Crit Care Med 1981;9:672–676.
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the trauma score. J Trauma 1989;29:623–629.
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;30:539–545.
Champion HR, Copes WS, Sacco WJ, Lawnick MM, Keast SL, Bain LW Jr, Flanagan ME, Frey CF. The major trauma outcome study: establishing national norms for trauma care. J Trauma 1990;30:1356–1365.
Gabbe BJ, Cameron PA, Wolfe R. TRISS: does it get better than this? Acad Emerg Med 2004;11:181–186.
Westhoff J, Hildebrand F, Grotz M, Richter M, Pape HC, Krettek C. Trauma care in Germany. Injury 2003;34:674–683.
Roudsari BS, Nathens AB, Arreola-Risa C, Cameron P, Civil I, Grigoriou G, Gruen RL, Koepsell TD, Lecky FE, Lefering RL, Liberman M, Mock CN, Oestern HJ, Petridou E, Schildhauer TA, Waydhas C, Zargar M, Rivara FP. Emergency medical service (EMS) systems in developed and developing countries. Injury 2007;38:1001–1013.
Raum MR, Bouillon B, Rixen D, Lefering R, Tiling T, Neugebauer E; German Polytrauma Study Group of the German Trauma Society. The prognostic value of prothrombin time in predicting survival after major trauma: a prospective analysis of 1351 patients from the German trauma registry. Eur J Trauma 2001;27:110–116.
Rixen D, Raum M, Bouillon B, Lefering R, Neugebauer E; Atbeitsgemeinschaft “Polytrauma” of the Deutsche Gesellschaft für Unfallchirurgie. Base deficit development and its prognostic significance in posttrauma critical illness: an analysis by the trauma registry of the Deutsche Gesellschaft für Unfallchirurgie. Shock 2001;15:83–89
Association for the Advancement of Automotive Medicine. The abbreviated injury scale 1990 revision — update 1998. AAAM: Barlington, 1998.
Osler T, Baker SP, Long W. A modification of the injury severity score that both improves accuracy and simplifies scoring. J Trauma 1997;43:922–926.
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974;2:81–84.
Rixen D, Raum M, Bouillon B, Schlosser LE, Neugebauer EAM; AG Polytrauma der DGU. Prognoseabschätzung des Schwerverletzten — Eine Analyse von 2069 Patienten des Traumaregisters der DGU. Unfallchirurg 2001;104:230–239.
Lefering R. Scoring beim Polytrauma. In: Oestern HJ, ed. Das Polytrauma: Präklinisches und klinisches management. Urban & Fischer: München, 2007:41–54.
Senkowski CK, McKenney MG. Trauma score systems: a review. J Am Coll Surg 1999;189:491–503.
Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. J Trauma 1987;27:370–378.
Hollis S, Yates DW, Woodford M, Foster P. Standardized comparison of performance indicators in trauma: a new approach to case-mix variation. J Trauma 1995;38:763–766.
Hosmer DW, Lemeshow S. Goodness of fit tests for the multiple logistic regression model. Commun Stat 1980;A9:1043–1069.
Lefering R, Paffrath T, Linker R, Bouillon B, Neugebauer E; German Society for Trauma Surgery. Head injury and outcome — what influence do concomitant injuries have? J Trauma 2008;65:1036–1044.
McMahon CG, Yates DW, Campbell FM, Hollis S, Woodford M. Unexpected contribution of moderate traumatic brain injury to death after major trauma. J Trauma 1999;47:891–895.
Kroezen F, Bijlsma TS, Liem MSL, Meeuwis JD, Leenen LPH. Base deficit-based predictive modeling of outcome in trauma patients admitted to intensive care units in Dutch trauma centers. J Trauma 2007;63:908–913.
Malone DL, Dunne J, Tracy JK, Putnam T, Scalea TM, Napolitano LM. Blood transfusion, independent of shock severity, is associated with worse outcome in trauma. J Trauma 2003;54:898–907.
Yücel N, Lefering R, Maegele M, Vorweg M, Tjardes T, Ruchholtz S, Neugebauer EAM, Wappler F, Bouillon B, Rixen D; “Polytrauma Working Group” of the German Trauma Society. Trauma associated severe hemorrhage (TASH)-score: probability of mass transfusion as surrogate for life threatening hemorrhage after multiple trauma. J Trauma 2006;60:1228–1237
Newgard CD. The validity of using multiple imputation for missing out-of-hospital data in a state trauma registry. Acad Emerg Med 2006;13:314–324.
Ruchholtz S, Lefering R, Paffrath T, Oestern HJ, Neugebauer E, Nast-Kolb D, Pape HC, Bouillon B. Rückgang der Traumaletalität. Ergebnisse des Traumaregisters der Deutschen Gesellschaft für Unfallchirurgie. Dt Ärzteblatt 2008;105:225–231.
Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG; Working Group on Polytrauma of the German Trauma Society. Effect of wholebody CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373:1455–1461.
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Lefering, R. Development and validation of the revised injury severity classification score for severely injured patients. Eur J Trauma Emerg Surg 35, 437–447 (2009). https://doi.org/10.1007/s00068-009-9122-0
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DOI: https://doi.org/10.1007/s00068-009-9122-0