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      Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience

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          Abstract

          Background

          Trauma mortality due to exsanguination is the second most common cause of death. The objective of this study is to investigate the predictors for early death from exsanguination.

          Methods

          A prognostic study was done to identify predictors of early mortality due to exsanguination. Data were extracted from our Trauma Surgery Registry database of Sultanah Aminah Hospital, Johor Bahru, Malaysia. All patients who were treated from May 1, 2011 to April 31, 2014 by the trauma team were included. Adult trauma patients included from the Trauma Surgery Registry were divided into two groups for analysis: early death from exsanguination and death from non-exsanguination/survivors. Univariate and multivariate analysis was performed to look for significant predictors of death from exsanguination. Variables analyzed were demography, mechanism of injury, organ injury scale, physiological parameters (systolic blood pressure (SBP), respiratory rate, heart rate, temperature), Glasgow Coma Scale (GCS), Revised Trauma Score (RTS), New Injury Severity Score (NISS), Trauma and Injury Severity Score (TRISS) and cause of death.

          Results

          A total of 2208 patients with an average age of 36 (±16) years were included. Blunt trauma was the majority with 90.5%, followed by penetrating injuries (9.2%). The overall mortality is 239 out of 2208 (10.8%). Seventy-eight patients (32.6%) died due to central nervous system injury, 69 due to sepsis (28.9%) and 58 due to exsanguination (24.3%). After multivariate analysis, age (OR 1.026 (1.009 to 1.044), p=0.002), SBP (OR 0.985 (0.975 to 0.995), p=0.003) and temperature (OR 0.203 (0.076 to 0.543), p=0.001) were found to be the significant physiological parameters. Intra-abdominal injury and NISS were significant anatomic mortality predictors from exsanguination (p<0.001). Patients with intra-abdominal injury had four times higher risk of mortality from exsanguination (OR 3.948 (2.331 to 6.686), p<0.001).

          Discussion

          In a Malaysian trauma center, age, SBP, core body temperature, intra-abdominal injury and NISS were significant predictors of early death from exsanguination.

          Level of evidence

          II.

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          Most cited references17

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          Patterns of mortality and causes of death in polytrauma patients--has anything changed?

          Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed. A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies. Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death. Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.
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            Mechanism, glasgow coma scale, age, and arterial pressure (MGAP): a new simple prehospital triage score to predict mortality in trauma patients.

            Prehospital triage of trauma patients is of paramount importance because adequate trauma center referral improves survival. We developed a simple score that is easy to calculate in the prehospital phase. Multicenter prospective observational study. Prehospital physician-staffed emergency system in university and nonuniversity hospitals. We evaluated 1360 trauma patients receiving care from a prehospital mobile intensive care unit in 22 centers in France during 2002. The association of prehospital variables with in-hospital death was tested using logistic regression, and a simple score (the Mechanism, Glasgow coma scale, Age, and Arterial Pressure [MGAP] score) was created and compared with the triage Revised Trauma Score, Revised Trauma Score, and Trauma Related Injury Severity Score. The model was validated in 1003 patients from 2003 through 2005. Four independent variables were identified, and each was assigned a number of points proportional to its regression coefficient to provide the MGAP score: Glasgow Coma Scale (from 3-15 points), blunt trauma (4 points), systolic arterial blood pressure (>120 mm Hg: 5 points, 60 to 120 mm Hg: 3 points), and age 0.95 (undertriage of 0.05), the MGAP score was more specific and accurate than triage Revised Trauma Score and Revised Trauma Score, approaching those of Trauma Related Injury Severity Score. We defined three risk groups: low (23-29 points), intermediate (18-22 points), and high risk (<18 points). In the derivation cohort, the mortality was 2.8%, 15%, and 48%, respectively. Comparable characteristics of the MGAP score were observed in the validation cohort. The MGAP score can accurately predict in-hospital death in trauma patients.
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              Predicting early death in patients with traumatic bleeding: development and validation of prognostic model

              Objective To develop and validate a prognostic model for early death in patients with traumatic bleeding. Design Multivariable logistic regression of a large international cohort of trauma patients. Setting 274 hospitals in 40 high, medium, and low income countries Participants Prognostic model development: 20 127 trauma patients with, or at risk of, significant bleeding, within 8 hours of injury in the Clinical Randomisation of an Antifibrinolytic in Significant Haemorrhage (CRASH-2) trial. External validation: 14 220 selected trauma patients from the Trauma Audit and Research Network (TARN), which included mainly patients from the UK. Outcomes In-hospital death within 4 weeks of injury. Results 3076 (15%) patients died in the CRASH-2 trial and 1765 (12%) in the TARN dataset. Glasgow coma score, age, and systolic blood pressure were the strongest predictors of mortality. Other predictors included in the final model were geographical region (low, middle, or high income country), heart rate, time since injury, and type of injury. Discrimination and calibration were satisfactory, with C statistics above 0.80 in both CRASH-2 and TARN. A simple chart was constructed to readily provide the probability of death at the point of care, and a web based calculator is available for a more detailed risk assessment (http://crash2.lshtm.ac.uk). Conclusions This prognostic model can be used to obtain valid predictions of mortality in patients with traumatic bleeding, assisting in triage and potentially shortening the time to diagnostic and lifesaving procedures (such as imaging, surgery, and tranexamic acid). Age is an important prognostic factor, and this is of particular relevance in high income countries with an aging trauma population.
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                Author and article information

                Journal
                Trauma Surg Acute Care Open
                Trauma Surg Acute Care Open
                tsaco
                tsaco
                Trauma Surgery & Acute Care Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2397-5776
                2017
                31 May 2017
                : 2
                : 1
                : e000070
                Affiliations
                [1 ]departmentDepartment of General Surgery , Hospital Sultanah Aminah , Johor Bahru, Johor, Malaysia
                [2 ]Pusat Perubatan Universiti Kebangsaan Malaysia , Cheras, Malaysia
                [3 ]departmentClinical Research Centre , Hospital Sultan Ismail , Johor Bahru, Malaysia
                Author notes
                [Correspondence to ] Dr Tan Jih Huei; huei_87@ 123456hotmail.com
                Article
                tsaco-2016-000070
                10.1136/tsaco-2016-000070
                5877896
                29766083
                87b08654-6d7e-44d4-bb72-cbaea5297b36
                © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 1 December 2016
                : 21 March 2017
                : 21 March 2017
                Categories
                Outcomes
                1506
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                mortality predictors,exsanguination,adult trauma,malaysia

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