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A New Definition of Major Trauma: Overcoming the Limitations of Anatomic Injury Scoring by Incorporating Trauma Team Actions
Samir Fakhry, *Timothy Scott, *Yan Shen, *Harun Mazunder, *Alessandro Orlando
Center for Trauma and Acue Care Surgery, HCA Healthcare, Nashville, Tennessee
Objective: Major Trauma (MT) is currently defined as an Injury Severity Score (ISS)>15 and was based on a 10% threshold for in-hospital mortality from the 1980s. Research has demonstrated that significant numbers of patients at high risk of mortality and who consume major resources do not meet the ISS-based MT definition. Recently, High-Intensity Time-Sensitive (HITS) interventions, a surrogate for trauma team actions, were found to be highly associated with outcomes. This study aimed to compare the performance of ISS>15, HITS interventions, or the combination to identify MT as it relates to mortality.
Methods: Adult trauma patients (18-89 yrs) from the 2021-23 NTDB PUF files were analyzed. HITS interventions--emergent airway management/ventilation, hemorrhage control surgery, transfusion, ICP monitoring, chest tube placement, angiography--were used to indicate the need for early trauma team involvement. Three definitions of MT were evaluated: (1) ISS>15, (2) receiving a HITS intervention (HITS+), and (3) ISS>15
or HITS+, termed
new Major Trauma (nMT+). The primary outcome was in-hospital mortality. Demographics, injury characteristics, and outcomes were compared across the three MT definitions. The ability of each definition to identify deaths was evaluated using likelihood ratios and area under the receiver operating curves (AUROCs).
Results: Among 2,718,519 patients, 17.5% had ISS>15, 11.3% were HITS+, and 22.0% were nMT+.
The median age was 58 with 60% male, a median ISS=9, a median GCS=15, and in-hospital mortality=4.1%. In-hospital mortality was 15.8% for ISS>15, 22.6% for HITS+, and 14.9% for nMT+ (
p<0.001, Figure). HITS+ had the highest positive likelihood ratio and nMT- had the lowest negative likelihood ratio for in-hospital mortality (Table). Compared to ISS>15 and HITS+, nMT+ exhibited significantly higher discriminatory power for predicting in-hospital mortality (AUROC: 0.76, 0.77, 0.80,
p<0.001). In this cohort, nMT+ identified up to 19,851 (26%) more in-hospital deaths than either ISS>15 or HITS+ alone.
Conclusions: The novel concept of nMT is a more comprehensive definition of major trauma than the existing ISS-based standard, providing the highest overall ability to discriminate survivors from non-survivors. These findings highlight the importance of selecting the appropriate tool for the appropriate purpose in evaluating MT: HITS+ for the highest odds of mortality, and nMT- for the highest odds of survival, while the role of ISS>15 in isolation is unclear. Adding trauma team actions to anatomical injury score thresholding overcomes the known shortcomings of using only anatomic criteria and emphasizes the importance of trauma team actions (e.g. HITS interventions) in defining MT for clinical needs, quality activities and outcome prognostication.
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