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Existing Trauma and Critical Care Scoring Systems Underestimate Mortality Among Vascular Trauma Patients

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Existing Trauma and Critical Care Scoring Systems Underestimate Mortality Among Vascular Trauma Patients From the Society for Clinical Vascular Surgery Existing trauma and critical care scoring systems underestimate mortality among vascular trauma patients Shang A. Loh, MD, Caron B. Rockman, MD, Christine Chung, BS, Thomas S. Maldonado, MD, Mark A. Adelman, MD, Neal S. Cayne, MD, H. Leon Pachter, MD, and Firas F. Mussa, MD, New York, NY Background: The impact of vascular injuries on patient mortality has not been well evaluated in multi-trauma patients. This study seeks to determine (1) whether the presence of vascular trauma negatively affects outcome compared with nonvascular trauma (NVT) and (2) the utility of existing severity scoring systems in predicting mortality among vascular trauma (VT) patients. Methods: A retrospective review of our trauma database from January 2005 to December 2007 was conducted. Demographics, Injury Severity Scores (ISS), Revised Trauma Scores (RTS), Trauma Score–Injury Severity Scores (TRISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and mortality rates were compared. Control patients were selected from a matching cohort based on ISS. Comparisons were made between groups based on the above scoring systems. Statistical analysis used ␹2 analysis and Student t-tests. Results: Fifty VT and 50 NVT patients were identified with no significant differences in age, gender, mechanism of injury, ISS, RTS, or TRISS. The mean APACHE II score was higher in VT compared with NVT (12.3 vs 8.8, P < .05). Overall VT .(108. ؍ mortality was higher in VT compared with NVT but did not reach statistical significance (24% vs 11.8%, P VT patients with an ISS score >24 had .(007. ؍ patients with RTS score >5 had a higher mortality rate (26% vs 2.2%, P VT patients with an APACHE II score <14 also .(04. ؍ a higher mortality compared with NVT patients (61% vs 28.6%, P Finally, VT patients with a TRISS probability of survival of >80% .(007. ؍ had a higher mortality rate (18.2% vs 0%, P .(05. ؍ had a higher mortality rate (13.9% vs 0%, P Conclusions: In multi-trauma patients, the presence of vascular injury was associated with increased mortality in less severely injured patients based on the RTS, TRISS, and APACHE II scores. These scoring systems underestimated mortality in patients with vascular trauma. Level of care and future trauma algorithms should be adjusted in the presence of vascular trauma. (J Vasc Surg 2011;53:359-66.) Trauma is the leading cause of mortality in the first four ters to determine injury severity,8-10 have not been vali- decades of life.1 While the epidemiology and outcomes of dated specifically for vascular trauma. The aim of this study nonvascular trauma have been well studied, vascular trauma was to examine mortality in patients with vascular trauma at has not been well characterized outside of the military an urban level I trauma center compared with patients with 1, 2 experience. More than 10 years ago, Caps reported that nonvascular trauma and matching Injury Severity Scores the incidence of vascular trauma had significantly increased (ISS). Furthermore, we sought to evaluate the usefulness of over the previous 5 decades, contributing to overall trauma common injury severity scoring systems in predicting mor- morbidity and mortality.2 Furthermore, studies have tality for patients with vascular injuries. shown that abdominal vascular trauma has been associated with higher overall mortality and poorer functional out- METHODS comes than seen in the general trauma population.3-7 Study design. A retrospective analysis of the trauma However, none of these studies matched patients based on database from January 2005 to December 2007 at an urban severity of injury. In addition, current trauma scoring sys- level I trauma center was conducted. Vascular trauma (VT) tems, which utilize either physiologic or anatomic parame- patients were identified based on International Classifica- tion of Disease–9 (ICD-9) diagnoses codes and repre- From the New York University School of Medicine, Department of Surgery, sented all vascular trauma for this time frame. A contempo- Division of Vascular and Endovascular Surgery. Competition of interest: none. rary cohort of multi-trauma patients with nonvascular Presented at the Thirty-eighth Annual Symposium of the Society for Clinical trauma (NVT) and matching ISS was selected as a control Vascular Surgery, April 7-10, 2010, Scottsdale, Ariz. group. The study was approved by the Institutional Review Reprint requests: Firas F. Mussa, MD, Division of Vascular and Endovascu- Board. Parameters collected included: age, sex, vital signs, lar Surgery, New York University Langone Medical Center, 530 First Avenue, Suite 6F, New York, NY 10016 (e-mail: fi[email protected]). Glasgow Coma Scale (GCS), mechanism of injury, location The editors and reviewers of this article have no relevant financial relation- and severity of injury, mode of diagnosis, need for a vascular ships to disclose per the JVS policy that requires reviewers to decline consult, need for vascular intervention, and mortality. Vas- review of any manuscript for which they may have a competition of cular injury severity was graded on a 5-point scale which interest. was a slightly modified version of the original Abbreviated 0741-5214/$36.00 11-13 Copyright © 2011 by the Society for Vascular Surgery. Injury Score (AIS) described by Moore et al. Injury doi:10.1016/j.jvs.2010.08.074 severity ranged from 1 (minor), 2 (moderate), 3 (severe), 4 359 JOURNAL OF VASCULAR SURGERY 360 Loh et al February 2011 (critical), to 5 (unsurvivable).Outcome was also graded on .05 was considered significant. Receiver operator characteris- a 5-point scale from 1 (return to baseline function), 2 (mild tic curves (ROC) were constructed to test the discriminatory functional deficit), 3 (moderate functional deficit), 4 (se- ability of all four trauma scoring systems. The area under the vere functional deficit), to 5 (death). In addition, the curve (AUC) or C-statistic was calculated to determine con- Revised Trauma Score (RTS), Trauma Score–Injury Sever- cordance or discordance. Statistical analysis was performed ity Score (TRISS), and Acute Physiology and Chronic using SPSS statistical software (SPSS, Chicago, Ill). Health Evaluation II (APACHE II) score were calculated based on admission parameters. RESULTS The primary end point was overall mortality. The pre- Patient characteristics. During the study period, a to- dicted mortality based on ISS, RTS, TRISS, and APACHE tal of 2157 patients were evaluated by the trauma service. Fifty II scores was also compared with actual mortality. patients (2.3%) with vascular trauma were identified during Diagnosis of vascular injuries. Upon admission to the study period with an additional 50 ISS-matched, nonvas- the trauma bay, Advanced Trauma Life Support (ATLS) cular trauma patients as controls. Both groups were similar in protocols were observed. All vascular injuries were diag- age and gender. Mechanism of injury was slightly different nosed within the initial hours in the trauma bay or operat- between the two groups but not statistically significant. In the ing room. Clinical suspicion or proximity injuries were VT group, penetrating and pedestrian struck mechanisms evaluated with computed tomography angiogram (CTA). accounted for 38 (75%) of the injuries while the mechanism in Blunt injuries with suspicion of vascular injury were evalu- the NVT group was more evenly distributed (Table I). ated with duplex ultrasonography when anatomically feasi- In the VT group, 13 (26%) had more than one vascular ble during the day and CTA at night. Hard clinical findings injury and 36 (72%) had an injury to a major vascular struc- of vascular injury were evaluated in the operating room ture. Arterial injuries accounted for 42 (82%) of vessels in- (OR) with traditional angiogram or in the interventional volved. Diagnosis was made on clinical grounds in 20 (40%) radiology (IR) suite for pelvic injuries. The APACHE II, and found on angiogram in 23 (46%). The remaining seven RTS, and TRISS trauma scores were calculated from lab (14%) were diagnosed on computed tomography angiogra- values and vital signs upon initial presentation in the trauma phy (CTA) or duplex ultrasound. Thirty-five (70%) patients bay. The ISS system, however, is an anatomic system and had severe to critical injuries posing an imminent danger to the score calculated after injuries was diagnosed. the patient’s life. Patient characteristics are summarized in Calculation of trauma scores. Calculation of the scor- Table I. ing systems has been previously described. Briefly, for the ISS, Vascular surgery consultation. Operative vascular AIS from 1 (minor) to 5 (critical) is assigned to the most intervention was indicated in 28 (56%) patients. Of those, a severe injury in each of six anatomic regions (head and neck, vascular surgeon was involved in 22 (79%). In the remain- face, chest, abdomen, extremity, and external).11-13 If any ing 6 (21%), the injury was repaired primarily by the trauma injury is deemed unsurvivable, it is assigned a value to 6. The service. Injuries repaired by the trauma service involved the top three injuries are squared and summed to calculate the inferior vena cava, portal vein, anterior jugular vein, com- ISS, which can range from 3 (best) to 75 (worst). A score of 6 mon carotid artery, and radial artery. Only two patients in any category automatically gives an ISS of 75.8 (7%) were treated with endovascular techniques precluding The RTS is calculated by assigning a value of 0 (worst) to any meaningful analysis. Both cases were aortic transections 4 (best) to the GCS, systolic blood pressure (SBP), and with placement of a thoracic endograft. Furthermore, the respiratory rate (RR). The score is calculated based on a mortality rate of VT patients requiring operative interven- weighted formula with GCS carrying the most weight fol- tion was 28.6% compared with 18.2% for those VT patients lowed by SBP.
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