Research and Opinion in Anesthesia & Intensive Care

ORIGINAL ARTICLE
Year
: 2017  |  Volume : 4  |  Issue : 3  |  Page : 108--116

Experience at a Critical Care Department with trauma patients: a 5-year registry study


Amr A.E.E Amin Abd Allah1, Nashwa A Alamir2, Abdou M Alazab2, Lamiaa H Mohammed2,  
1 Department of Surgery, Faculty of Medicine, Cairo University, Cairo, Egypt
2 Department of Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt

Correspondence Address:
Abdou M Alazab
Kasr Elini Old Medical School, Critical Care Departement, Postal code 11562
Egypt

Abstract

Background and objective Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually. Mortality can be grouped into immediate, early, and late deaths. Recognition of these patterns has led to the development of Advanced Trauma Life Support, which is the standard of care for trauma patients, and it is built around a consistent approach to patient evaluation. The aim of our study was to assess and find a way to predict outcomes in trauma patients admitted to the Critical Care Department using admission data (clinical and laboratory) and scoring systems. Patients and methods This was a prospective–retrospective study carried out between January 2010 and December 2014 on 67 trauma patients. Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were obtained. Revised Trauma Score (RTS) was calculated using data collected within the first 24 h of admission. Results Nonsurvivors were relatively younger than survivors (29.16±12.83 vs. 39.69±19.83, P=0.036), and they had more dangerous penetrating injuries compared with survivors. Road traffic accidents were more common among nonsurvivors compared with survivors (penetrating injuries: 16% in survivors vs. 56.2% in nonsurvivors; road traffic accidents: 68% in survivors vs. 37% in nonsurvivors, P=0.025). pH, PaCO2, random blood sugar, and serum sodium were significantly higher in nonsurvivors compared with survivors. Nonsurvivors had a significantly lower Glasgow Coma Score, lower RTS, and higher APACHE II scores than survivors. A receiver operating characteristic curve analysis was carried out, and an APACHE II score of 20 was significant in predicting mortality with an area under the curve of 91.6%, sensitivity of 81.3%, and specificity of 87.2%. In addition, an RTS cutoff score of 6 had an area under the curve of 91.4%, sensitivity of 74.4%, and specificity of 87.5% for predicting mortality. Conclusion Both APACHE II and RTS are better predictors of mortality in trauma patients admitted to ICUs.



How to cite this article:
Amin Abd Allah AA, Alamir NA, Alazab AM, Mohammed LH. Experience at a Critical Care Department with trauma patients: a 5-year registry study.Res Opin Anesth Intensive Care 2017;4:108-116


How to cite this URL:
Amin Abd Allah AA, Alamir NA, Alazab AM, Mohammed LH. Experience at a Critical Care Department with trauma patients: a 5-year registry study. Res Opin Anesth Intensive Care [serial online] 2017 [cited 2017 Sep 21 ];4:108-116
Available from: http://www.roaic.eg.net/text.asp?2017/4/3/108/209671


Full Text

 Introduction



Trauma can be defined as an injury to living tissue caused by an extrinsic agent. The word ‘trauma’ is derived from Greek meaning bodily injury. Trauma was estimated to have caused 10% of all deaths occurring in 1990 worldwide [1],[2].

Trauma is the sixth leading cause of death worldwide, resulting in five million or 10% of all deaths annually [3],[4]. It is the fifth leading cause of significant disability [3]. About half of trauma deaths occur in people aged 15–45, and is the leading cause of death in this age group [4]. Males are more susceptible to injuries compared with females: 68% of injuries occur in males [5], and death from trauma is twice as common in males compared with females. This is believed to be because males are more willing to engage in risk-taking activities [4]. Teenagers and young adults are more likely to require hospitalization from injuries than other age groups [6]. Although the elderly are less likely to be injured, they are more likely to die from injuries sustained from various physiological differences that make it harder for the body to compensate [6]. The primary causes of traumatic death are central nervous system injuries and substantial blood loss [3].

Mortality can be grouped into immediate, early, and late deaths. Immediate deaths are caused by a fatal injury to the great vessels, heart, or neurological system [7].

Early deaths may occur from minutes to hours after the injury. These patients frequently arrive at the hospital before death, which usually occurs because of hemorrhage and cardiovascular collapse. Late trauma mortality peaks from days to weeks after the injury and is primarily due to sepsis and multiple organ failure. Organized systems for trauma care are focused on the recovery of patients from early trauma mortality, whereas critical care is designed to avert late trauma mortality [8],[9].

Early trauma deaths result from failed oxygenation to the vital organs, massive central nervous system injury, or both. The mechanisms of failed tissue oxygenation include inadequate ventilation, impaired oxygenation, circulatory collapse, and insufficient end-organ perfusion. Massive central nervous system trauma leads to inadequate ventilation and/or disruption of brainstem regulatory centers. Injuries that cause early trauma mortality occur in predictable patterns based on the mechanism of injury, the patient’s age, sex, and body habitus, or environmental conditions. Recognition of these patterns has led to the development of the Advanced Trauma Life Support (ATLS) approach by the American College of Surgeons. ATLS is the standard of care for trauma patients, and it is built around a consistent approach to patient evaluation. This protocol ensures that the most immediate life-threatening conditions are quickly identified and addressed in the order of their risk potential [10].

 Aim



The aim of this study was to assess and find a way to predict outcomes of trauma patients admitted to the Critical Care Department at Cairo University.

 Patients and methods



The study population consisted of 67 trauma patients (retrospective and prospective), and was carried out from January 2010 to December 2014 at the Critical Care Department of Kasr El-Aini Hospital, Cairo University. The study protocol was approved by the institutional ethical committee and local review board.

Inclusion criteria

Patients admitted for trauma care to the Critical Care Department from January 2010 until the end of December 2014 were included.

Exclusion criteria

Patients who died within 12 h of admission.Patients not admitted to the ICU.

Methods

The present study was a retrospective–prospective cohort study.

Data collection

Medical records of 67 patients were reviewed. All data that might be correlated to the trauma outcome were collected. These data included the following:Personal history (age, sex, and comorbidities).Mechanism of injury [road traffic accident (RTA), penetrating injury, and fall].Clinical data in the first 24 h of admission to the ICU (systolic blood pressure, diastolic blood pressure, mean arterial pressure, heart rate, respiratory rate, and temperature).Laboratory data in the first 24 h of admission to the ICU.Comorbidities (pneumonia and sepsis) developed during ICU stay.Surgical intervention (urgent).Mechanical ventilation (MV).Length of ICU stay.Patient outcome.

For each patient, the following scores were calculated on the basis of data obtained in the first 24 h of admission to the ICU:Glasgow Coma Score (GCS).Acute Physiology and Chronic Health Evaluation II (APACHE II) score.Revised Trauma Score (RTS).

 Results



Our study population (67 trauma patients) was divided into two groups:Survivors: 49 patients.Nonsurvivors: 18 patients.

Demographic and clinical data

There was no statistically significant difference regarding variables except for age, as patients who died were significantly younger compared with patients who survived ([Table 1]).{Table 1}

Mechanism of injury

There was a significantly higher incidence of RTA among survivors compared with nonsurvivors.There was a significantly higher incidence of penetrating injuries in nonsurvivors compared with survivors ([Table 2] and [Figure 1]).{Table 2}{Figure 1}

Laboratory data

There was no statistically significant difference regarding laboratory data between nonsurvivors and survivors except for the following:pH in nonsurvivors was significantly lower compared with survivors.PaCO2 was significantly higher in nonsurvivors compared with survivors.Random blood sugar was significantly higher in nonsurvivors compared with survivors.Serum sodium was significantly higher in nonsurvivors compared with survivors ([Table 3] and [Figure 2],[Figure 3],[Figure 4],[Figure 5]).{Table 3}{Figure 2}{Figure 3}{Figure 4}{Figure 5}

Scoring systems

There was a statistically significant difference regarding the following in both groups:The mean value of GCS was significantly lower in nonsurvivors compared with survivors.The mean value of APACHE II was significantly higher in nonsurvivors compared with survivors.The mean value of expected risk for mortality by APACHE II (mortality%) was significantly higher in nonsurvivors compared with survivors.The mean value of RTS was significantly lower in nonsurvivors compared with survivors ([Table 4] and [Figure 6] and [Figure 7]).{Table 4}{Figure 6}{Figure 7}

Developed comorbidities and the need for mechanical ventilation

There was a statistically significant higher incidence of pneumonia, sepsis, and need for MV in nonsurvivors compared with survivors ([Table 5] and [Figure 8],[Figure 9],[Figure 10]).{Table 5}{Figure 8}{Figure 9}{Figure 10}

Reciever operating characteristic curve to predict mortality

A univariate regression model was applied to identify potential predictors of mortality. RTS, APACHE II score, and random blood sugar on admission were significant predictors, as shown in [Table 6].{Table 6}

However, the multivariate regression model showed that APACHE II and RTS were significant predictors of mortality, as shown in [Table 7].{Table 7}

A reciever operating characteristic test was applied to determine the APACHE II cutoff for predicting mortality. A cutoff of 20 had an area under the curve (AUC) of 91.6%, sensitivity of 81.3%, and specificity of 87.2%. In addition, a reciever operating characteristic test was applied to identify the RTS cutoff to predict survival. A cutoff of 6 had an AUC of 91.4%, sensitivity of 74.4%, and specificity of 87.5% ([Figure 9] and [Figure 10]).

We also categorized patients into two groups on the basis of their APACHE II sores as follows: group A included patients with scores less than 20, and group B included patients with scores of at least 20. This categorization had a significant impact on 30-day survival as shown by the Cox regression model (hazard ratio: 5.356, P=0.008, 95% confidence interval: 1.538–18.655). Patients with APACHE II less than 20 had a survival rate of 83.9% at 30 days, and patients with APACHE II of at least 20 had a survival rate of 44.0% at 30 days, as shown in [Figure 11].{Figure 11}

 Discussion



Trauma is a major cause of death and disability worldwide. Of more than five million trauma-related deaths that occur each year, more than 90% occur in low-income and middle-income countries. Given the magnitude of this inequality, research efforts over the last decade have highlighted the need for trauma care systems in low-income and middle-income countries [11].

Trauma is the leading cause of death in adults less than 45 years of age in the UK. Trimodal distribution of trauma deaths described by Trunkey also highlighted a high proportion of deaths within the first few hours of trauma, which can be prevented by earlier medical intervention [12].

Our study was conducted on 67 trauma patients admitted to the Critical Care Department of Kasr Al-Aini Hospital, Cairo University, during January 2010 to December 2014.

In our study, occurrence of trauma was higher in males (52, 77.6%) than females (15, 22.4%).

This result is contradictory to the study by Jousi et al. [13] who found no statistically significant difference between both sexes regarding trauma incidence.

However, our study is in agreement with the study by Arslan et al. [14], who found high incidence of trauma among males (76.3%) than among females (23.7%).

In addition, Yeguiayan et al. [15], found that incidence of trauma is more common in males (76%) than in females (24%).

This high rate of trauma in males compared with females can be explained by the high incidence of violence in males.

In our study, age of patients ranged from 22 to 48 with a mean age of 31 years; this is in agreement with most of the trauma studies, as young people are more active, and thus more susceptible to trauma [15],[16],[17].

In our study, RTA occurred in 34%, and this high rate of RTA is mostly related to bad and dangerous roads, high rate of addiction among drivers, and the delay in transfer of patients to hospitals.

Our results showed that pneumonia and sepsis were common complications among the studied patients and were associated with high in-hospital mortality.

Wutzler et al. [18] stated that pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not yet fully understood [18].

Adams [19] reported that more than 150 000 out of two million die as a result of their injuries in ICUs several days after trauma because of septic complications.

DuBose et al. [20] stated that the relationship between post-traumatic ventilator-associated pneumonia (VAP) and outcomes has been studied. The occurrence of VAP in the trauma population has also been associated with significant increase in hospital morbidity and cost [20].

In a study on 4111 patients, VAP was found to be an independent predictor of mortality among less severely injured patients (Injury Severity Score<25) [21].

Our results showed high levels of blood glucose in nonsurvivors than in survivors group.

This is agreement with the study by Thompson et al. [22] who found that the presence of diabetes represents a clear example of the potential synergy between comorbid conditions and traumatic brain injury.

Our results showed greater base deficit, which is mostly related to the state of shock in the nonsurvivor group than among survivors.

Mutschler et al. [23] also found increased base deficit in his patients with increased degree of shock and accordingly with deterioration of the patient’s condition.

In our study, there was an increase in serum sodium levels in nonsurvivors than in survivors.

This was in agreement with the retrospective cohort study of Maggiore et al. [24], where they verified that hypernatremia is common, occurring in 51.5% of patients for 31% of the duration of their ICU stay. Hypernatremia was associated with a three-fold increase in the risk of ICU death, even after adjustment for baseline risk factors [24].

Our results showed that pneumonia and sepsis are common complications among the studied patients and are associated with high in-hospital mortality.

Wutzler et al. [18] stated that pulmonary complications are common in multiple trauma patients with chest injury. Factors predisposing these critically ill patients to respiratory organ failure are not yet fully understood [18].

In our study, 63.6% patients required MV, and the statistical analysis revealed that MV is a highly significant risk factor for mortality, as 100% of the patients who died in our study were mechanically ventilated.

Our study showed high GCS and RTS in survivors than in nonsurvivors and high APACHE II scores in nonsurvivors than in survivors.

This is in agreement with Yeguiayan et al. [15] who found bad outcomes with lesser GCS and good prognosis with GCS of at least 14.

In contrast to our results, the study by Giannopoulos et al. [25] showed that there was a controversy in the prognostic value of GCS in trauma patients.

Rutledge et al. [26] reported in their study that the APACHE II score was the best predictor of both ICU and hospital outcomes in these critically ill trauma patients.

Naved et al. [27] found in his study an insignificant but inverse correlation between APACHE II score and length of ICU stay (this is because of the bad prognosis of patients with high APACHE II scores).

In agreement with our study, Cernea et al. [28] noticed the presence of an inverse relationship between RTS on arrival and mortality, where with every point decrease in the RTS mortality increased.

Ahmad [29] found in his study that the higher the RTS the better the prognosis of polytrauma patients and vice versa. RTS less than 8 turned out to be an indicator of severe injury with high mortality and morbidity, and the overall mortality in polytraumatized patients was 26.66%. However, RTS-6 was associated with 50% mortality [29].

Our patients showed a survival rate of 71.6% and a death rate of 28.4%.

This is similar to the results obtained by Giannopoulos et al. [25], who found mortality of 37.5% in their study group, especially among those who required surgical interference.

Band [30] in his study reported that the overall mortality was 27.4%. In his study, over three-quarters (77.9%) of the victims suffered gunshot wounds, and under a quarter (22.1%) of patients suffered stab wounds.

Yeguiayan et al. [15] found in his group of patients that mortality was indirectly proportional to the level of GCS − that is, when GCS decreases mortality increases and vice versa.

Jousi et al. [13] found an overall mortality of 8% in their study.

This heterogenecity in mortality between studies may be related to different types of injury, transfer status, and level of care of patients.

Our results showed that scoring systems are the best predictors of mortality among trauma patients.

A cutoff of 20 of APACHE II had an AUC of 91.6%, sensitivity of 81.3%, and specificity of 87.2% for predicting mortality. In addition, a cutoff of RTS of 6 had an AUC of 91.4%, sensitivity of 74.4%, and specificity of 87.5% for predicting mortality.

Using scoring systems, one can compare actual outcomes with expected outcomes for a group of patients. This may form the basis of a within-institution audit and quality control program and permit one to follow a clinical group or institutional experience over time. In addition, it may facilitate a comparative evaluation of regional, national, or international differences in ICU care and outcome. Finally, as the scoring system will capture the acuity of illness in a unit, this information may also be used for resource management.

 Conclusion



Despite the good prognostic value of some ICU admission laboratory measures in critically ill trauma patients, using scoring systems such as APACHE II and RTS are the best way to predict mortality in such patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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