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ORIGINAL ARTICLE
Year : 2019  |  Volume : 32  |  Issue : 2  |  Page : 511-516

Trauma-injury severity score versus acute physiology and chronic health evaluation IV score in predicting mortality


Department of General Surgery, Emergency Medicine Unit, Faculty of Medicine, Menoufia University, Shibin El-Kom, Menoufia Governorate, Egypt

Date of Submission16-Nov-2017
Date of Acceptance09-Jan-2018
Date of Web Publication25-Jun-2019

Correspondence Address:
Mona KM Mesrega
Shibin El-Kom, Menoufia Governorate
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_783_17

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  Abstract 


Objective
The objective of this study was to compare the performances of Trauma-Injury Severity Score (TRISS) and Acute Physiology and Chronic Health Evaluation (APACHE) IV in predicting mortality of seriously injured patients with polytrauma.
Background
Several scoring systems have been developed to evaluate trauma outcomes. The TRISS and APACHE IV are commonly used to predict injury severity and the risk of mortality.
Patients and methods
The study was conducted on 100 of seriously injured patients with polytrauma attending the Emergency Department of the Menoufia University Hospital from 2016 to 2017. The required variables for calculating the two scores were recorded. The accuracy of the two models in predicting mortality was compared using area under the receiver operating characteristic curve.
Results
The mean TRISS-estimated mortality rate was 17.41 ± 25.03, whereas the mean APACHE IV Score was 18.87 ± 19.89. There was a statistically significant difference between survived and dead patients regarding the two scores (P = 0.001). The best cutoff value of TRISS and APACHE IV for prediction of mortality among studied patients was 32.5 and 32, respectively, with sensitivity of 96 and 84%, respectively; specificity of 98 and 96%, respectively; and accuracy of 97 and 93%, respectively.
Conclusion
Both scores can be used in predicting mortality of seriously injured patients with polytrauma but TRISS model is better and more applicable than APACHE IV.

Keywords: acute Physiology and Chronic Health Evaluation Score, Injury Severity Score, mortality, trauma


How to cite this article:
Albatanony AA, Abd Elshaheed MA, Nassar MN, Mesrega MK. Trauma-injury severity score versus acute physiology and chronic health evaluation IV score in predicting mortality. Menoufia Med J 2019;32:511-6

How to cite this URL:
Albatanony AA, Abd Elshaheed MA, Nassar MN, Mesrega MK. Trauma-injury severity score versus acute physiology and chronic health evaluation IV score in predicting mortality. Menoufia Med J [serial online] 2019 [cited 2019 Sep 20];32:511-6. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/511/260922




  Introduction Top


It is a well-known fact that trauma is a serious public health problem and the leading cause of morbidity and mortality all over the world[1].

Several scoring systems have been developed and validated for use to predict trauma outcome, improve resource allocation, and assist in clinical decision making[2].

There are three main groups of scoring systems that can be used for risk prediction in patients with trauma: anatomical scores, physiological scores, and combined scores[3].

The necessity to improve the quality of trauma care has led researchers to develop more accurate grading systems that allow physicians to predict the outcomes of injured patients such as Glasgow Coma Scale (GCS), Injury Severity Score (ISS), New Injury Severity Score, Trauma-Injury Severity Score (TRISS), and Acute Physiology and Chronic Health Evaluation (APACHE) Score[4].

TRISS, the most widely used combined system, provided improvements in the ability to predict outcome after trauma. It was developed by the American College of Surgeons, based on a study started in 1982 and published in 1990[5].

TRISS is based on a combination of the physiologic Revised Trauma Score, anatomic ISS as well as patient's age to predict post-trauma survival[6].

The APACHE scoring system is a logistic regression model including physiologic and laboratory parameters[7].

The original APACHE Score was proposed in the year 1981 and was surprisingly accurate in mortality prediction of patients in a variety of ICUs[8].

Further work by APACHE's designers resulted in the introduction of APACHE II in 1985, which incorporated a number of changes from the original APACHE, and then the release of APACHE III in 1991[9].

Most recently, APACHE IV was developed by remodeling APACHE III with the same physiological variables and weights but different predictor variables and refined statistical methods[10].

The calculated APACHE IV Score is a successful scoring system that can be used to estimate the risk of mortality and length of ICU stay[11].

Our study aimed to evaluate and compare the performances of TRISS and APACHE IV in mortality prediction of seriously injured patients with polytrauma.


  Patients and Methods Top


Patients

The study was conducted on 100 of seriously injured patients with polytrauma attending the Emergency Department of the Menoufia University Hospital, Egypt, from 2016 to 2017.

Patients included in this study were chosen according to these criteria.

Inclusion criteria

Adult patients (≥18 years old), patients with injury to several physical regions or organ systems where at least one injury or the combination of several injuries are life-threatening and need ICU admission, and patients of both sex were included in the study.

Exclusion criteria

Patients transferred from other hospitals after undergoing any medical or surgical procedure and patients with burns were excluded from the study.

Methods

All patients were subjected to the following:

Primary survey

Primary survey (ABCDE) protocol included the following: Airway and cervical spine control, Breathing, Circulation and hemorrhage control, Disability, and Exposure.

Secondary survey

It included information about Allergy, Medication, Past illness/Pregnancy, Last meal and Events/Environment related to injury (AMPLE) history, and general and local examination.

Investigations

Radiological: Radiological examination included radiography (chest and pelvis), abdominal ultrasound, and other additional radiological investigations as needed.

Laboratory: complete blood count, arterial blood gas, urea, creatinine, albumin, bilirubin, serum sodium, and blood glucose level were estimated.

TRISS was calculated by the TRISS calculator, which consists of the following: revised trauma score, which is calculated by a combination of results from three categories (GCS, systolic blood pressure, and respiratory rate); an ISS, which is calculated by abbreviated injury score, which is an anatomically based system of grading injuries on an ordinal scale ranging from 1 (minor injury) to 6 (lethal injury); and patient age. Then the estimated mortality rate was calculated: (100 − probability of survival).

Calculating APACHE IV Score-estimated mortality rate, which consists of age, temperature, mean arterial blood pressure, heart rate, respiratory rate, serum parameters (sodium, creatinine, urea, blood sugar, albumin, and bilirubin), hematocrit, white blood cells, GCS, if mechanically ventilated or not, fractional inspired oxygen concentration, partial pressure of oxygen, partial pressure of carbon dioxide, arterial hydrogen ion concentration (pH), urine output, chronic health condition admission information, and admission diagnosis.

Both scores were recorded at the same setting with no time interval during the first 24 h after resuscitation and ICU admission.

The outcome of each patient with trauma was recorded and the relation between TRISS and APACHE IV scores and the outcome was studied.

The study received an approval from Ethical Committee of Menoufia Faculty of Medicine University and was performed after obtaining the informed consent from the first-degree relative of all patients.

Statistical analysis

Data were collected and coded and then entered into a spreadsheet using Microsoft Excel for Windows Office 2010 (Microsoft company, Redmond, Washington, USA). Data were statistically analyzed using statistical package of social science software, version 16 (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean ± SD whereas qualitative data were expressed as frequency and percentages. Qualitative categorical variables were compared using a χ2-test. Quantitative continuous data were compared using the Mann–Whitney test. The area under the receiver operating characteristic curve for each scale was used to compare the accuracy of the studied models. A P value less than 0.05 was considered statistically significant.


  Results Top


A total of 100 seriously injured patients with polytrauma were studied. Most of our patients were male (74%) and 26% were female, with mean age of 37.9 ± 5.9 years [Table 1].
Table 1: Study population characteristics

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The most common cause of injury was road traffic accidents (71%). Others were falling from height (16%) and violence (13%) [Table 1].

The mean TRISS-estimated mortality rate was 17.41 ± 25.03, whereas the mean APACHE IV Score was 18.87 ± 19.89 [Table 1].

There was a statistically significant difference between survived and dead patients regarding TRISS and APACHE IV scores (P = 0.001) [Table 2].
Table 2: Comparison between Trauma-Injury Severity Score and Acute Physiology and Chronic Health Evaluation IV Score in predicting mortality

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The best cutoff value of TRISS for prediction of mortality among studied patients was 32.5, with sensitivity of 96%, specificity of 98%, positive predictive value of 92%, negative predictive value of 99%, and accuracy of 97% [Table 2] and [Figure 1].
Figure 1: Receiver operating characteristic (ROC) curve of Trauma-Injury Severity Score for prediction of mortality among studied patients.

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The best cutoff value of APACHE IV Score for prediction of mortality among studied patients is 32, with sensitivity of 84%, specificity of 96%, positive predictive value of 87%, negative predictive value of 95%, and accuracy of 93% [Table 2] and [Figure 2].
Figure 2: Receiver operating characteristic (ROC) curve of Acute Physiology and Chronic Health Evaluation IV Score for prediction of mortality among studied patients.

Click here to view



  Discussion Top


Trauma commonly affects young individuals and it is considered the leading cause of death in the first four decades of life[1].

More than 50 scoring systems have been published for classification and assessment of polytrauma patients in the field, emergency room, and intensive care settings[2].

TRISS provided improvements in the ability to predict outcome after traumatic injury[12].

APACHE is one of the most commonly used scoring system to measure the severity and the prognosis of critically ill diseases for adult patients admitted to ICUs[13].

Although APACHE IV Score is complicated and time consuming, APACHE IV Score seems to be a good predictor of mortality and for risk stratification[14].

In the present study, most patients were male (74%) and 26% were female, with mean age of 37.9 ± 5.9 years.

These findings can be explained by the fact that frequency of trauma is more among young age group. As this age group is the most active group in the society, and male individual are more marked affected by trauma in all communities of the world, because of conditions in the workplace and for behavioral reasons. For example, male drivers are more often engaged in dangerous driving in comparison with female drivers.

These results were near to those reported by Yadav and Agarwal[1] who found that most of the studied patients were men (88%) and only 12% were female, with most patients in the young population (20–50 years old). These results also near to those reported by Mazandarani et al.[2] who found that most of the studied patients were male (78.94%) and only 21.05% were female, with mean age of 37.09 ± 14.60 years.

In the present study, road traffic accident was responsible for most of the cases (71%).

This explained as most studies done on the epidemiology of trauma found that the majority of cases are due to road traffic accidents. The most commonly affected road users, such as pedestrians, motorcyclists, and drivers, are involved in most of the deaths and disabilities owing to lack of safety measures in our roads and ignorance of safety instruction.

This result nears to those reported by Mazandarani et al.[2] who found that the most common cause of trauma was traffic accidents (78.7%). Similarly, a study done by Singh et al.[15] also had found that road traffic collisions were the most common cause of trauma (72%).

On the basis of the results of the present study, the mean TRISS for prediction of mortality rate was 17.41 ± 25.03, as we calculate the estimated mortality rate not the probability of survival in this study. We also found a statistically significant difference between survived and dead patients regarding TRISS (P = 0.001).

A study done by Saad et al.[16] found that the mean TRISS probability of survival among studied patients was 90.38 ± 18.66, and there was a statistically significant difference between survived and dead patients regarding TRISS (P = 0.001).

Another study done by Orhon et al.[17] found that the mean TRISS probability of survival was (98.02 ± 7.42), and there was a statistically significant difference between survivors and dead patients regarding TRISS (P = 0.001).

The present results found that the best cutoff value of TRISS for prediction of mortality was 32.5, with sensitivity of 96%, specificity of 98%, positive predictive value of 92%, negative predictive value of 99%, and accuracy of 97%.

Saad et al.[16] found in their study that the best cutoff value of TRISS for prediction of mortality among patients was 90, with sensitivity of 77%, specificity of 89%, positive predictive value of 52.6% and negative predictive value of 96%.

A study done by Yousefzadeh-Chabok et al.[18] found that the best cutoff point of TRISS for predicting mortality in elderly patients was less than or equal to 2 with 95% sensitivity and 72% specificity.

Another study done by Mazandarani et al.[2] found that the best cutoff points for TRISS mortality prediction was 13.2, with sensitivity of 76.52% and specificity of 95.65%.

Another research done by Eeyilmaz et al.[19] who compared different trauma scores for adults who fell from height as survival predictors found that the most satisfactory cutoff point for TRISS was 73.5%, with sensitivity of 88.9%, specificity of 98.7%, positive predictive value of 88.9%, and negative predictive value of 98.0%.

From the present result, the mean APACHE IV Score-estimated mortality rate was 18.87 ± 19.89, and there was a statistically significant difference between survived and dead patients regarding APACHE IV Score (P = 0.001). We also found that the best cutoff value of APACHE IV Score for prediction of mortality among the studied patients was 32, with sensitivity of 84%, specificity of 96%, positive predictive value of 87%, negative predictive value of 95%, and accuracy of 93%.

A study done by Abolghasemi et al.[20] found that the mean score of APACHE IV in studied patients was 44.5 ± 17.7, and there was a statistically significant difference between survived and dead patients regarding APACHE IV Score. They also found that the cutoff point of APACHE Score was 47.5, with a sensitivity equivalent to 84.9% and specificity equivalent to 64.4%.

The study done by Saad et al.[16] found that APACHE IV demonstrated 67% sensitivity and 95% specificity at a cutoff point of 99.

Another research by Faizal et al.[14] showed that APACHE IV was the best predictor of mortality with an area under the curve value of 0.792. The best cutoff was 67.5, with sensitivity of 75% and specificity of 67% in predicting mortality with a statistical significant difference between survived and dead patient.

Another study done by Shrope-Mok et al.[21] in Jackson Park Hospital Department, USA, found that APACHE IV demonstrated 84.6% sensitivity, 96.0% specificity, 64.7% positive predictive value, and 98.6% negative predictive value.

According to results of this study, both TRISS and APACHE IV models were approximately equal in predicting mortality of patients with trauma, but TRISS had higher sensitivity, specificity, and accuracy.

A study done by Chico-Fernández et al.[22] found that TRISS methodology in the evaluation of severe trauma in Spanish ICUs showed good discrimination.

Mazandarani et al.[2] also found that TRISS and APACHE models have the same accuracy in predicting mortality of patients with trauma, but it seems that TRISS model is more applicable in this regard.

Another study done by Singh et al.[15] stated that TRISS has a better combination of high specificity and better sensitivity.


  Conclusion Top


Both TRISS and APACHE IV scores can accurately predict the mortality of patients with polytrauma but TRISS model is more better and more applicable than APACHE IV owing to simplicity of its calculation, independency of patient care value, and consideration of trauma features and severity.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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2.
Mazandarani PD, Heydari K, Hatamabadi H, Kashani P, Jamali Danesh Y. Acute Physiology and Chronic Health Evaluation (APACHE) III score compared to Trauma-Injury Severity Score (TRISS) in predicting mortality of trauma patients. Emerg (Tehran) 2016; 4:88–91.  Back to cited text no. 2
    
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Saad S, Mohamed N, Moghazy A, Ellabban G, El-Kamash S. Venous glucose, serum lactate and base deficit as biochemical predictors of mortality in patients with polytrauma. Ulus Travma Acil Cerrahi Derg 2016; 22:29–33.  Back to cited text no. 16
    
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    Tables

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