Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers. J Trauma Acute Care Surg 2019 Sep;87(3):658-665
Date
06/18/2019Pubmed ID
31205214DOI
10.1097/TA.0000000000002402Scopus ID
2-s2.0-85071710821 (requires institutional sign-in at Scopus site) 36 CitationsAbstract
BACKGROUND: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.
METHODS: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).
RESULTS: The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.
CONCLUSION: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.
LEVEL OF EVIDENCE: Prognostic, level IV.
Author List
Roden-Foreman JW, Rapier NR, Foreman ML, Zagel AL, Sexton KW, Beck WC, McGraw C, Coniglio RA, Blackmore AR, Holzmacher J, Sarani B, Hess JC, Greenwell C, Adams CA Jr, Lueckel SN, Weaver M, Agrawal V, Amos JD, Workman CF, Milia DJ, Bertelson A, Dorlac W, Warne MJ, Cull J, Lyell CA, Regner JL, McGonigal MD, Flohr SD, Steen S, Nance ML, Campbell M, Putty B, Sherar D, Schroeppel TJAuthors
Jeremy H. Levin MD Assistant Professor in the Surgery department at Medical College of WisconsinDavid J. Milia MD Professor in the Surgery department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AdolescentAdult
Age Factors
Aged
Female
Humans
Injury Severity Score
Male
Middle Aged
Prognosis
Trauma Centers
Trauma Severity Indices
United States
Wounds and Injuries
Young Adult