Injury, Int. J.

Care Injured 46 (2015) 18751877

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Injury
j ou rna l h ome p a ge : w ww . e l se v i e r . co m/ l oc a te / i n j ury

Editorial

Patient assessment in polytrauma: Current trends rely on multiple parameters to

improve the prediction of complications and mortality

Introduction historical aspects of patient assessment

Multiple attempts have been made to perform reliable patient assessment
early after injury and admission to the hospital.
On one hand, the terminology in regards to the multiply injured patient
has been an issue and before national norms had been established, it remained
vague and inconsistent for decades [13]. Many authors used descriptions
such as critically injured, severely injured, or critically ill with multiple
injuries inter-changeably [2,3]. To our knowledge, the term polytrauma was
first used by Tscherne et al. in 1966 for patients that demonstrated a
combination of at least 2 severe injuries of the head, chest or abdomen or
one of them in association with an extremity injury [4]. In 1975, Border et
al. defined the polytrauma patient as any patient with two or more
significant injuries [5]. Oestern et al. then distinguished the entity
polytrauma as a patient with two or more injuries, one of them being
potentially life threatening from isolated, but potentially life threatening
injuries, for which he coined the term barytrauma [6].

On the other hand, despite the availability of anatomic scoring systems in

the 1970s, the Injury Severity Score (ISS) was not used as part of any initial
definition of polytrauma. Yet, it continues to be a global standard parameter
and is used to assess multiply injured patients [7]. Multiple organisations,
such as the American College of Surgeons Committee of Trauma (ACSCOT),
The Trauma Outcome Research Network (TARN, GB), the German Trauma
Registry (GTR), and the Australasian Trauma Society (ATS) use the ISS to
categorise trauma patients in the data collection process. Anatomical scales
have been used as well to predict complications during the clinical course.
One of the best examples for achieving improved score options is the revision
of the Trauma Score [8]. Based on assessment of the variables used, the
revised version was changed to include the Glasgow Coma Scale, Systolic
blood pressure and the respiratory rate, the combination of which was proven
to be of higher accuracy than each parameter in isolation [9,10]. While the
timing to treatment and rescue time continues to be an issue, it appears to be
difficult to incorporate in a score [11,12].

Subsequently, the same authors developed a further scoring system that

included Glasgow Coma Scale, systolic blood pressure, respiratory rate,
patient age, and AIS-85 anatomic injury scores [13]. Physiology-based
scoring systems also included the descrip-tion of the lethal triad to
differentiate stable from unstable and in-extremis patients [14]. Moreover,
the calculation of NISS and
http://dx.doi.org/10.1016/j.injury.2015.09.001 0020
1383/ 2015 Published by Elsevier Ltd.

TRISS lead to a more global view and TRISS included systolic pressure,
pulse rate, Maximum AIS and age. Milham then modified the TRISS and
added parameters of the acid base system, namely the pH [15].
Paffrath et al. differentiated multiply injured patients, poly-trauma and
severely injured patients. They tried to define these terms by analyzing a
trauma registry. At first, they graded these patients on an anatomical basis
according to the ISS or NISS. Then, used a polytrauma definition with two
body regions affected and combined with a physiological component. 45,350
patients met the inclusion criteria and the overall hospital mortality rate was
20.4%. They report a good prediction in mortality up to an 86% rate in
patients with all five factors present. [16].
Coslovsky et al. looked at acutely ill patients admitted to the emergency
department (ED) of a tertiary hospital in a prospective cohort analysis. A total
of 8607 consecutive admissions were submitted to multivariable logistic
regression. The most frequent APACHE II diagnostic categories at the time of
admission were neurological (2052, 24%), trauma (1522, 18%), infection
categories [1328, 15%; including sepsis (357, 4.1%), severe sepsis (249,
2.9%), septic shock (27, 0.3%)], cardiovascular (1022, 12%), gastrointesti-nal
(848, 10%) and respiratory (449, 5%). The predictors of the final model were
age, prolonged capillary refill time, blood pressure, mechanical ventilation,
oxygen saturation index, Glasgow coma score and APACHE II diagnostic
category. The model showed good discriminative ability, with an area under
the receiver operating characteristic curve of 0.92 and good internal validity.
The model performed significantly better than non-systematic triaging of the
patient. The authors concluded that a prediction model can facilitate the
identification of ED patients with higher mortality risk. Also, better than a
non-systematic assessment and may facilitate more rapid identification and
commencement of treatment of patients at risk of an unfavourable outcome
[17].

Scoring systems to predict clinical complications

Many other scores for the clinical scenario also use multiple parameters:
Baek et al. looked at the SIRS score in predicting the mortality of multiple
trauma patients. In a retrospective review, 229 patients with multiple trauma
were scored on their presentation to the emergency room. SIRS scores above
and below 2 points were compared. The SIRS scores, number of
complications, and mortality rate were significantly higher in those with a
SIRS score of two or above (p<0.001). In the multivariate analysis, the

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Editorial / Injury, Int. J. Care Injured 46 (2015) 18751877

SIRS score was the only independent factor related to mortality. The authors
concluded that the SIRS score is easily calculated on admission and may
accurately predict mortality in patients with multiple trauma [18].
Liu and Holcomb recently performed a new approach: They determined
the effectiveness of using traditional and new vital signs (heart rate variability
and complexity [HRV, HRC]) for predicting mortality and the need for lifesaving interventions (LSIs) in prehospital trauma patients. They assumed that
a statistical regression that combine traditional and new vital signs might be
better predictors than standard vital signs. In 108 pre-hospital trauma patients,
these parameters were documented. Among these, eighty-two patients (76%)
received a total of 142 LSIs. They found a better prediction of mortality and
LSI needs when using heart rate and HRC (area under the curve [AUC];
AUCs, 0.86 and 0.86) when compared with the heart rate alone (AUCs, 0.79
and 0.57). Likewise, receiver-operating characteristic curves demonstrated
better prediction using total GCS score and HRC (AUCs, 0.82 and 0.97) than
using total GCS score (AUCs, 0.81 and 0.91) and heart rate and HRV
(AUCs, 0.86 and 0.73). The authors concluded that it may be advantageous to
use traditional and new vital signs (HRV and HRC) simultaneously to
improve prediction of mortality and the need for LSIs in the prehospital
setting [19].

Thus, the discussions about the optimal patient assessment are ongoing in
many areas. These include the definition of polytrauma, the clinical scoring
early after injury, the prediction of complica-tions and scoring during the
hospital course. All of these have in common that they utilise multiple
parameters instead of a single one. Most of the recent studies have supported
the use of multiple parameters and the combination usually was more
beneficial than any of the isolated ones. Hildebrand used a trauma registry
and applied s ROC analysis for multiple parameters. He proved that the
predictive value of the administration of red blood cells was superior to the
use of the acid base status and the ISS (Table 1). The study also supports the
fact that in order to have an adequate predictive value, multiple parameters
have to be combined [22]. The development of scoring systems is ongoing. To
date, various combinations of conventional parameters as used in the 1980s
still appear to be of value.

Financial support
No financial support has been received for the statistical evaluation of this
study.
References

Likewise, Dewar et al. compared to scoring systems (Denver versus SOFS

score) regarding multiple organ failure. In 140 patients, both scores had
similar performance predicting mortality; however, the Day 3 SOFA score
outperforms the Denver score when predicting ICU LOS and ventilator days.
Either score could be superior based on whether one is seeking to optimise
specificity or sensitivity. It is important to note that these findings are in a
non-head-injured population and that there are practical difficulties using the
SOFA in head-injured patients [20].
Xiao et al. compared the predictive value of anatomic scoring system,
physiological scoring system, and the combination of two systems in death
prediction of patients with severe trauma in an intensive care unit (ICU). The
authors performed a retrospective analysis of patients with severe trauma with
and injury severity score (ISS) 16. Data included anatomic scoring system
(including ISS and new injury severity score (NISS), physiological scoring
system, including acute physiology and chronic health evaluation II
(APACHEII)). The authors conclude that the combination of anatomic scoring
system and physiological scoring system is better than single scoring system
for death prediction in patients with severe trauma in ICU, and it may be
considered to be a new method for early identification of death risk in patients
with severe trauma [21].

Table 1
Values of predictive parameters and their odds ratio in a group of 5988 patients (modified
according to [22]). The administration of red blood cells was the strongest single parameter,
followed by changes of the acid base status and an anatomic scale (AIS).
Predictor

Regression
coefficient

Odds
ratio (OR)

95% confidence
interval (95%-CI)

BP 7690 mmHg
BP 75 mmHg
Base deficit 810
Base deficit >10
INR 1.42.0
INR >2.0
NISS 3549
NISS 5075
pRBCs 314
pRBCs 15

0.249
0.642
0.474
1.215
0.160
0.899
0.900
1.188
0.671
1.692

1.283
1.889
1.606
3.371
1.174
2.457
2.460
3.279
1.957
5.430

0.9621.712
1.3982.580
1.1192.304
2.5534.453
0.8971.536
1.7543.442
1.9163.157
2.4874.324
1.5142.529
3.9107.539

Platelets <150,000

0.555

1.743

1.3832.196

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Hans-Christoph Pape*
Department of Trauma and Orthopaedics/Trauma,
Aachen University Medical Center, Germany
Howard R. Champion
Surgery at Uniform Services University of the Health Sciences, 954
Melvin Rd, Annapolis, MD 21403, USA
*Corresponding author at: Department of Orthopaedic Trauma, 30 Pauwels
Street, 52074 Aachen, Germany. Tel.: +49 241 80 36698 E-mail address:
papehc@aol.com (H.-C. Pape).