The age change tendency of trauma patients
The analysis of NTDB showed the proportion of geriatric trauma increased from 18% to 30% from 2005 to 2015. Meanwhile, the proportion of trauma patients aged less than 65 declined during the same period (Figure 1a). The death rate of geriatric trauma patients was significantly higher than that of their younger counterparts. In addition, the mortality of male geriatric trauma patients was higher than that of their female younger counterparts (Figure 1b). Eighty nine thousand patients with ISS (injury severity score) ≥9 in the DGU® was analyzed. The mean age rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥60 rose from 16.5% to 37.5% from 1993 to 2013(Figure 1c, 1d). In China, major trauma accounts for more than 60 million visits annually to Chinese hospitals, and is related to 700 000 to 800 000 deaths [18]. According to the National Bureau of Statistics of the People’s Republic of China (http://www.stats.gov.cn/), the proportion of population aged ≥65 increased from 7.7% to 10.1% between 2005 and 2014 Figure 1e.
Comparison of different scoring tools in prediction of mortality in geriatric trauma
A total of 311 patients aged more than 65 years were extracted from the study by Lorenz [16, 17], of which 59.00% were male. One hundred and sixty-four (52.73%) patients died in the hospital. Table 1 shows the detailed characteristics of included patients. There was no significantly statistical difference between the survival group and death group in trauma mechanism, base excess, body mass index, leucocytes, thrombocytes, prothrombin, systolic blood pressure, mean artery pressure, and temperature. The median age in the death group was older than that in the survival group. The Glasgow coma Scale (GCS) scores and hemoglobin level were lower in the death group than that in in the survival group. The median lactate level was higher in the death group than that in the survival group. Patients in the death group had a shorter length of intensive care unit (ICU) stay and hospital stay compared with the survival group
Table 1 Characteristics of included patients
|
|
Survival
|
Death
|
P value
|
Number of patient
|
147
|
164
|
|
Trauma mechanism
|
|
|
|
Blunt
|
144(48.30%)
|
154(51.70%)
|
0.07
|
Penetrating
|
3(23.10%)
|
10(76.90%)
|
GCS
|
|
|
|
3-8
|
47(27.30%)
|
125(72.7-%)
|
<0.01
|
9-12
|
22(61.10%)
|
14(38.90%)
|
13-15
|
78(75.70%)
|
25(24.30%)
|
Age
|
74.00 (68.25 to 80.00)
|
78.00(72.00 to 83.00)
|
<0.01
|
Base excess [mEq/L]
|
-2.80 (-5.50 to -0.80)
|
-3.25(-7.80 to -0.55)
|
0.32
|
Body mass index
|
25.95 (22.89 to 28.40)
|
25.90(22.04 to 29.16)
|
0.74
|
Hemoglobin [g/L]
|
11.80 (9.90 to 13.10)
|
10.60(8.10 to 12.20)
|
<0.01
|
Lactate [mmol/L]
|
1.90 (1.15 to 2.80)
|
2.10(1.40 to 3.40)
|
0.03
|
Los of hospital [days]
|
16.50 (9.00 to 25.00)
|
1.50(1.00 to 3.00)
|
<0.01
|
Leucocytes [10^9/L]
|
10.49 (7.33 to 13.96)
|
11.12(6.96 to 14.24)
|
0.86
|
Thrombocytes [10^9/L]
|
190.50(152.00 to 239.50)
|
174.00(132.00 to 230.00)
|
0.07
|
Prothrombin [% normal]
|
80.00 (59.00 to 95.00)
|
74.00(52.00 to 89.25)
|
0.08
|
Systolic pressure mmHg]
|
142.50 (115.00 to 160.000)
|
125.00(110.00 to 158.75)
|
0.09
|
Mean artery pressure [mmHg]
|
100.00 (82.00 to 112.75)
|
92.00(76.50 to 113.50)
|
0.22
|
Temperature
|
35.40(34.50 to 36.20)
|
35.25(34.10 to 36.00)
|
0.31
|
Los of ICU [days]
|
5.00 (2.00 to 12.00)
|
1.00(0.50 to 2.00)
|
<0.01
|
Los of MV [days]
|
1.00(0.00 to 6.25)
|
1.00(0.25 to 2.00)
|
0.04
|
GCS, Glasgow score; Los, length of stay; ICU, Intensive care unit; MV, mechanical ventilation.
|
The ISS (34.00 vs 24.00, P<0.01), NISS (50.00 vs 27.00, P<0.01), APACHE Ⅱ (23.00 vs 15.00, P<0.01), and SAPS Ⅱ (55.00 vs 34.00, P<0.01) in the death group were significantly higher than that in the survival group. The median TRISS was significantly lower in the death group than that in the survival group (0.51 vs 0.96, P<0.01). It is important to note that TRISS calculates the survival probability (Table 2 and Figure 2).
Table 2 Comparison of different scoring tools between two groups
|
Survival
|
Death
|
P value
|
ISS
|
24.00 (14.50 to 29.00)
|
34.00(25.00 to 75.00)
|
<0.01
|
NISS
|
27.00 (22.00 to 38.00)
|
50.00(34.00 to 75.00)
|
<0.01
|
TRISS
|
0.96(0.78 to 0.99)
|
0.51(0.11 to 0.82)
|
<0.01
|
APACHE Ⅱ
|
15.00 (10.00 to 22.00)
|
23.00(19.00 to 29.00)
|
<0.01
|
SPAS Ⅱ
|
34.00 (27.00 to 55.00)
|
55.00(34.75 to 61.00)
|
<0.01
|
SPAS Ⅱ, simplified acute physiology score Ⅱ; APACHE Ⅱ, Acute Physiology and Chronic Health Evaluation Ⅱ; ISS, injury severity score; NISS, new injury severity score; TRISS, Trauma and Injury Severity Score.
The AUC was calculated to assess the predictive performance of different scoring tools in prediction of in-hospital mortality in case of geriatric trauma. Table 3 and Figure 3 shows the AUC of ISS was 0.807, NISS was 0.850, TRISS was 0.828, APACHE Ⅱ was 0.715, and SPAS Ⅱ was 0.725.
Table 3 Diagnostic value of different scoring tool in predicting in-hospital mortality
|
|
AUC
|
95% CI of AUC
|
APACHE Ⅱ
|
0.715
|
0.644 to 0.778
|
ISS
|
0.807
|
0.743 to 0.861
|
NISS
|
0.850
|
0.790 to 0.898
|
SPAS Ⅱ
|
0.725
|
0.655 to 0.788
|
TRISS
|
0.828
|
0.766 to 0.880
|
SPAS Ⅱ, simplified acute physiology score Ⅱ; APACHE Ⅱ, Acute Physiology and Chronic Health Evaluation Ⅱ; ISS, injury severity score; NISS, new injury severity score; TRISS, Trauma and Injury Severity Score; AUC, area under the receiver operating characteristic curve.
Table 4 shows the difference of AUC between the above scoring tools. Compared with APACHE Ⅱ and SAPS Ⅱ, the ISS, NISS, and TRISS appear to be better predictors of in-hospital mortality in elderly trauma patients. Especially the AUCs of NISS and TRISS were statistically significant higher than that of the APACHE Ⅱ and SPAS Ⅱ (P<0.01).
Table 4 The matrix of AUC comparison between different scoring tool using P value
|
|
SPAS Ⅱ
|
APACHE Ⅱ
|
ISS
|
NISS
|
TRISS
|
SPAS Ⅱ
|
|
0.61
|
0.07
|
<0.01
|
<0.01
|
APACHE Ⅱ
|
0.61
|
|
0.03
|
<0.01
|
<0.01
|
ISS
|
0.07
|
0.03
|
|
0.02
|
0.34
|
NISS
|
<0.01
|
<0.01
|
0.02
|
|
0.37
|
TRISS
|
<0.01
|
<0.01
|
0.34
|
0.37
|
|
SPAS Ⅱ, simplified acute physiology score Ⅱ; APACHE Ⅱ, Acute Physiology and Chronic Health Evaluation Ⅱ; ISS, injury severity score; NISS, new injury severity score; TRISS, Trauma and Injury Severity Score; AUC, area under the receiver operating characteristic curve.