Evaluation of ISS, RTS, CASS and TRISS scoring systems
for predicting outcomes of blunt trauma abdomen
Ewaluacja skal ISS, RTS, CASS i TRISS w ocenie rokowania u pacjentów
po urazie tępym jamy brzusznej
Arshad Alam, Arun Kumar Gupta, Nikhil Gupta, Raghav Yelamanchi, Lalit Kumar Bansal, C K Durga
Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India Article history: Received: 05.10.2020 Accepted: 10.02.2021 Published: 11.02.2021
ABSTRACT: Introduction: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation.
Aim: The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen.
Materials and methods: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality.
Results: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality.
Conclusions: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other could not be proved.
KEYWORDS: blunt trauma abdomen, Clinical Abdominal Scoring System, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score
STRESZCZENIE: Wstęp: Urazy pozostają główną przyczyną zgonów u osób poniżej 45. r.ż. Jedną czwartą wszystkich urazów stanowią urazy jamy brzusznej. Skale kliniczne stosowane w urazach są niezbędne dla oceny ich ciężkości i wcześniejszego zorganizowania środków w oczekiwaniu na przyjazd chorego.
Cel: Celem badania była ocena zastosowania skal RTS, ISS, CASS i TRISS w urazach tępych jamy brzusznej.
Materiały i metody: Przeprowadzono prospektywne jednoośrodkowe badanie kliniczne na 43 pacjentach z urazem tępym jamy brzusznej. Obliczono wyniki w: skali oceny ciężkości urazów (RTS), skali oceny ciężkości mnogich obrażeń ciała (ISS), klinicznej skali oceny jamy brzusznej (CASS) oraz w skali ciężkości urazu i obrażeń (TRISS), a także porównano je z punktami końcowymi, takimi jak: potrzeba leczenia zabiegowego, powikłania pooperacyjne i zgon.
Wyniki: W niniejszym badaniu większość stanowili mężczyźni (83,7%). Uraz jamy brzusznej był głównie wynikiem wypadku komunikacyjnego (72,1%). Najczęściej dochodziło do urazu śledziony. Wyniki CASS i TRISS były istotne w przewidywaniu potrzeby interwencji zabiegowej. Jedynie dla ISS wykazano istotność w przewidywaniu powikłań pooperacyjnych. Wszystkie skale, z wyjątkiem CASS, istotnie przewidywały ryzyko zgonu.
Wnioski: Spośród przeanalizowanych skal, CASS i TRISS przewidywały konieczność interwencji zabiegowej z dobrą dokładnością. W przypadku ryzyka powikłań pooperacyjnych jedynie wynik w skali ISS wykazywał istotność statystyczną.
Skale ISS, RTS i TRISS przewidywały zgon z dużą dokładnością, bez przewagi jednej ze skal nad pozostałymi.
SŁOWA KLUCZOWE: Clinical Abdominal Scoring System, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, uraz tępy jamy brzusznej
CECT – contrast enhanced computerized tomography FAST – Focused Assessment with Sonography for Trauma GCS – Glasgow Coma Scale
ISS – Injury Severity Score
ROC – eceiver operating characteristic RTS – Revised Trauma Score
TRISS – Trauma And Injury Severity Score
ABBREVIATIONS
AAST – American Association for the Surgery of Trauma AIS – Abbreviated Injury Scale
ATLS – Advanced Trauma Life Support AUC – area under the ROC curve
CASS – Clinical Abdominal Scoring System
INTRODUCTION
Trauma is the leading cause of mortality in people below the age of 45 years who constitute the most productive population of so- ciety [1]. Apart from mortality, trauma will be the leading cause of years of productive life lost by the end of this decade as per the World Health Organization estimates [2]. Abdominal trauma constitutes one-fourth of the trauma burden and blunt trauma to the abdomen is the most common mechanism of injury [2, 3].
Blunt trauma most commonly leads to solid organ injury rather than hollow viscus injury. All trauma patients should undergo re- suscitation as per a standardized protocol as it has been shown to reduce mortality by 15% in patients with severe trauma [4, 5].
Advanced Trauma Life Support (ATLS) is one of the most com- monly followed trauma systems worldwide designed initially by dr.
James Styner after the tragic private jet crash involving his family [6]. Apart from trauma management systems, many scoring sys- tems have been designed for trauma for prediction of outcomes.
Revised Trauma Score (RTS) is a physiological scoring system and is based on Glasgow Coma Scale (GCS), systolic blood pressure and respiratory rate [7, 8]. RTS ranges from 0 to 7.8408. Injury Severity Score (ISS) is an anatomical scoring system based on the degree of injuries in six different body regions. Each region is assigned an Abbreviated Injury Scale (AIS). The AIS of the three most severely injured body regions is squared and added to derive the score [7].
Clinical Abdominal Scoring System (CASS) was initially designed as a predictor of the need for laparotomy in blunt trauma abdo- men patients [9]. The various parameters considered in CASS are the time of presentation after trauma, pulse rate, systolic blood pressure, GCS and abdominal clinical findings [9]. Trauma And Injury Severity Score (TRISS) is based on ISS and RTS along with the inclusion of age as a parameter [7, 10]. It estimates the prob- ability of survival of a trauma patient. It is hypothesized as a bet- ter scoring system as it includes an anatomical score as well as a physiological score.
Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. Scor- ing systems can also be used to objectively convey the prognosis to the patients’ relatives. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen.
Authors hypothesized that the above scoring systems significant- ly predicted the outcomes of patients of blunt trauma abdomen.
MATERIALS AND METHODS
Institutional ethics committee approval was taken prior to the com- mencement of the study. All patients were enrolled in the study after taking written informed consent.
STUDY DESIGN AND POPULATION
A prospective single-center study was conducted in our institu- tion which is a tertiary care and academic center located in India from November 2017 to March 2019. Forty-three patients of blunt trauma abdomen were included in the study on accrual. All adult patients who were diagnosed with blunt trauma abdomen in the
surgical department of our hospital during the study period, sat- isfying the inclusion and exclusion criteria, were included in the study (consecutive sampling). All patients belonged to a single cohort as per the protocol and were followed up prospectively till discharge or death.
INCLUSION CRITERIA
All adult patients of blunt trauma abdomen who presented to the surgical department of our hospital during the study period were included in the study.
GENDER PROPORTION
Male 83.7%
Female 16.3%
AGE GROUP (years)
≤ 20 27.9%
21–30 27.9%
31 27.9%
40 9.3%
51–60 2.3%
61–70 4.6%
ETIOLOGY
Road traffic accident 72.1%
Fall from height 18.6%
Fall of heavy object 4.64%
Physical assault 2.32%
Railway accident 2.32%
ORGAN FREQUENCY PROPORTION
Spleen 9 20.95%
Liver 14 32.56%
Kidney 3 6.98%
Pancreas 1 2.32%
Bladder 2 4.64%
Mesentery and gastrointestinal tract 6 13.95%
Multiple organ injuries 8 18.6%
OUTCOMES
Uneventful conservative
management 20 46.5%
Operative management
without complications 13 30.2%
Operative management with
complications 8 18.6%
Death 2 4.7%
Tab. I. Demographic details of the population and the etiologies of blunt trauma abdomen.
Tab. II. Organs injured and outcomes.
Statistics, International Business Machines Corporation, New York). Data was not normally distributed. Hence, non-parametric test such as the Wilcoxon-Mann-Whitney U Test was used to test statistical significance. Association between the scores and the out- comes was tested using receiver operating characteristic (ROC) curves and the cut-off values were calculated. The area under the ROC curve (AUC) of scores was compared using the De Long’s test.
RESULTS
The majority of the study subjects were males (83.7%). Females ac- counted for only 16.3% of patients (Tab. I.). The mean ± standard deviation of age of the population was 31.18 ± 12.564 years. The age distribution of patients is shown in Tab. I. The most common etiology for blunt trauma abdomen as per this study was road traf- fic accident (72.1%) followed by fall from height (18.6%) (Tab. I.).
Other etiologies included fall of heavy objects (4.64%), physical assault (2.32%) and railway accidents (2.32%) (Tab. I.).
Solid organs were more commonly injured when compared to hol- low viscus (Tab. II.). The distribution of injuries of various organs is shown in Tab. II. Multiple organ injuries occurred in 13.95% of cases (Tab. II.). Conservative management was carried out in 21 cases and operative intervention was performed in 22 patients.
Post-operative complications occurred in 8 patients. The mortal- ity rate as per this study was 4.7% (Tab. II.).
EXCLUSION CRITERIA
Patients of blunt trauma abdomen with other significant comor- bidities which may adversely affect outcomes such as uncontrolled diabetes mellitus, coronary artery disease with cardiac dysfunc- tion, uncontrolled hypertension, etc. were excluded from the study.
MANAGEMENT
All patients with a history of blunt trauma abdomen who present- ed to the emergency initially underwent a primary survey as per the ATLS protocol. The vital parameters of patients were moni- tored continuously. RTS, ISS, CASS and TRIS scores were calcu- lated for all patients.
All patients underwent Focused Assessment with Sonography for Trauma (FAST). All hemodynamically stable patients with positive FAST underwent contrast enhanced computerized tomography (CECT) of the abdomen for further assessment of the injury. Pa- tients also underwent other investigations like non-contrast com- puterized tomography of the head and relevant X-rays based on the clinical history and examination findings. Based on the clinical and radiological findings further management of the patient was decided by the trauma team. The indications for operative inter- vention in a case of blunt trauma abdomen were:
•
blunt trauma abdomen with hemodynamic instability with positive FAST,•
free intraperitoneal air or retroperitoneal air on imaging,•
abdominal CECT suggestive of perforated gastrointestinal tract, intraperitoneal bladder rupture, renal pedicle injury or severe solid organ injury as per the American Association for the Surgery of Trauma (AAST) grading,•
clinical features suggestive of peritonitis.Patients with the above indications were shifted to the operation the- atre and underwent all necessary procedures. Bleeding from solid organs was controlled by pressure, packing and by applying local haemostatic agents. Splenectomy was required in 2 cases in view of severe splenic injury in our study. Mesenteric and bowel injuries were repaired primarily if the vascularity of the bowel was preserved.
If the vascularity of the bowel was not maintained, resection and anastomosis was performed. Urinary bladder injury was repaired primarily. In the post-operative period patients received routine post-operative care and were closely monitored for any complica- tions such as wound infection, wound dehiscence, intraabdominal collections, respiratory complications, sepsis, etc. The scores calcu- lated were evaluated for predicting the following outcomes:
•
need for surgical intervention,•
post-operative complications,•
mortality.STATISTICAL ANALYSIS
The sample size was 43 patients on accrual. The data acquired was coded and recorded in the MS Excel spreadsheet (Microsoft Of- fice, Microsoft, Washington). Data was analyzed using Statistical Package for Social Sciences (SPSS) version 23.0 (IBM SPSS
MANAGEMENT
Scores
Conservative
(n = 21) Surgical
(n = 22) P-value
RTS 7.78 ± 0.89 7.56 ± 0.62 0.3051
ISS 19.95 ± 9.32 24.50 ± 6.75 0.051
CASS* 9.29 ± 1.68 11.36 ± 1.09 <0.0011 TRISS* 95.31 ± 12.03 94.70 ± 9.53 0.0101
POST-OPERATIVE COMPLICATIONS
Scores
Present
(n = 9) Absent
(n = 14) P-value
RTS 7.41 ± 0.88 7.83 ± 0.70 0.5961
ISS* 27.78 ± 6.48 21.36 ± 6.78 0.0381
CASS 11.56 ± 1.13 11.07 ± 1.21 0.3181
TRISS 91.69 ± 14.60 96.96 ± 2.30 0.2691
MORTALITY
Scores
Present
(n = 2) Absent
(n = 41) P-value
RTS* 5.44 ± 1.32 7.78 ± 0.55 0.0011
ISS* 37.50 ± 4.95 21.54 ± 7.76 0.0321
CASS 12.50 ± 2.12 10.24 ± 1.68 0.1341
TRISS* 48.65 ± 6.29 97.26 ± 2.56 0.0191
*Significant at P < 0.05, 1: Wilcoxon-Mann-Whitney U Test Tab. III. Summary of significance of scores in predicting outcomes.
(De Long's Test P = 0.178). There was no significant difference in the diagnostic performance of TRISS and CASS (De Long's Test P = 0.889). There was no significant difference in the diagnostic performance of TRISS and RTS (De Long's Test P = 0.384). There was no significant difference in the diagnostic performance of CASS and RTS (De Long's Test P = 0.629) (Tab. IV.).
The ROC curve between the scores and the prediction of mortal- ity revealed that TRISS has greater AUC and diagnostic accuracy than other scores (Fig. 1C.). There was no significant difference in the diagnostic performance of TRISS and RTS (De Long's Test P = 0.480). There was no significant difference in the diagnostic performance of TRISS and ISS (De Long's Test P = 0.371). There was no significant difference in the diagnostic performance of TRISS and CASS (DeLong's Test p = 0.261). There was no signifi- cant difference in the diagnostic performance of RTS and ISS (De Long's Test P = 0.439). There was no significant difference in the diagnostic performance of RTS and CASS (De Long's Test P = 0.255). There was no significant difference in the diagnostic per- formance of ISS and CASS (De Long's Test P = 0.251) (Tab. IV.).
DISCUSSION
Males constituted the majority of trauma victims in this study as in many other previous studies [2, 7, 11]. Road traffic accident was the most common cause of blunt trauma abdomen as per this study and also in previous studies [2, 3, 7, 9]. Solid organs were more commonly injured when compared to hollow viscus in this study. Spleen was the most commonly injured organ followed by the liver as in previous studies [2].
Among the scoring systems, the need for surgical intervention was predicted by CASS and TRISS. The AUC and diagnostic accuracy On calculating the significance of the scores in predicting the need
for operative intervention in patients of blunt trauma abdomen, only CASS and TRISS scores had significant P-values. The P-values of RTS and ISS scores did not reach significance (Tab. III.). On cal- culating the significance of the scores in predicting post-operative complications only the ISS score had a significant P-value while the P-values of RTS, CASS and TRISS scores were not significant (Tab. III.). On calculating the significance of the scores in predict- ing mortality, all scores except CASS significantly predicted mor- tality as evident by P-values of less than 0.05 (Tab. III.).
The scores were compared with the outcome parameters by ROC analysis. The ROC curve between the scores and prediction of the need for surgical intervention revealed CASS to have greater AUC than other scores (Fig. 1A.). There was no significant difference in the diagnostic performance of CASS and TRISS (De Long's Test P
= 0.086). The diagnostic performance of CASS (AUC = 0.877) was significantly better than that of ISS (AUC = 0.675) (De Long's Test P = 0.027). The diagnostic performance of CASS (AUC = 0.877) was significantly better than that of RTS (AUC = 0.566) (De Long's Test P =< 0.001). There was no significant difference in the diag- nostic performance of TRISS and ISS (De Long's Test P = 0.218).
There was no significant difference in the diagnostic performance of TRISS and RTS (De Long's Test P = 0.060). There was no sig- nificant difference in the diagnostic performance of ISS and RTS (De Long's Test P = 0.280) (Tab. IV.).
The ROC curve between the scores and the prediction of post-op- erative complications revealed ISS to have greater AUC than other scores (Fig. 1B.). There was no significant difference in the diag- nostic performance of ISS and TRISS (De Long's Test P = 0.370).
There was no significant difference in the diagnostic performance of ISS and CASS (De Long's Test P = 0.318). There was no sig- nificant difference in the diagnostic performance of ISS and RTS
PREDICTOR CUT-OFF AUROC 95% CI P-VALUE SN SP PPV NPV DA
SURGICAL INTERVENTION
RTS 7.108 0.566 0.443–0.689 0.305 23% 95% 83% 54% 58%
ISS 16 0.675 0.507–0.844 0.049 100% 43% 65% 100% 72%
CASS 11 0.877 0.759–0.994 < 0.001 82% 86% 86% 82% 84%
TRISS 99% 0.729 0.571–0.887 0.010 100% 43% 65% 100% 72%
POST-OPERATIVE COMPLICATIONS
RTS 6.37 0.556 0.358–0.753 0.596 22% 100% 100% 67% 70%
ISS 19 0.762 0.558–0.966 0.038 89% 57% 57% 89% 70%
CASS 11 0.623 0.398–0.848 0.318 89% 29% 44% 80% 52%
TRISS 97% 0.643 0.402–0.884 0.269 67% 64% 54% 75% 65%
MORTALITY
RTS 6.37 0.988 0.954–1 0.001 100% 98% 67% 100% 98%
ISS 34 0.957 0.864–1 0.032 100% 90% 33% 100% 91%
CASS 11 0.817 0.498–1 0.134 100% 54% 10% 100% 56%
TRISS 53.1% 1.000 1–1 0.019 100% 100% 100% 100% 100%
AUROC – Area under ROC curve; CI – Confidence interval – Sn – Sensitivity; Sp – Specificity; PPV – Positive predictive value; NPV – Negative predictive value; DA – Diagnostic accuracy
Tab. IV. Comparison of the diagnostic performance of various scores in predicting the need for surgical intervention, post-operative complications and mortality.
Fig. 1. Receiver operating characteristic (ROC) curves comparing scores with outcome parameters. (A) ROC curves of scores and prediction of operative intervention; (B) ROC curves of scores and prediction of post-operative complications; (C) ROC curves of scores and prediction of mortality.
predict mortality. The significant association of ISS, RTS and TRISS with mortality was also proved in many other studies [7, 15–17].
The diagnostic accuracy of ISS, RTS and TRISS was very close and no statistical difference was observed between the scores in pre- dicting mortality when AUC was compared using the De Long's test. As TRISS consists of both ISS and RTS the calculation is cum- bersome and some retrospective studies have shown that TRISS prediction of mortality was not accurate [14]. Further, compari- son of cut-off values for mortality of this study with other studies can be erroneous as the mortality rate in this study was lower and the population studied was small. The limitations of the study are small sample size and the sample size was not based on any power factor calculation. Further, the study may have a centripetal bias as it was performed in a single tertiary care center.
CONCLUSIONS
Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For pre- diction of post-operative complications, only ISS score showed statistical significance. ISS, RTS and TRISS predicted mortal- ity with good accuracy but the superiority of one score over the other could not be proved. Further studies in this regard need to be performed on a larger population and in multiple centers to validate the results of the study.
of CASS were higher when compared to TRISS but the difference was not statistically significant. The CASS score was originally designed to predict the need for laparotomy in blunt trauma pa- tients. Even though the diagnostic accuracy of the CASS score in this study was lower when compared to the previous study by Erfantalab-Avini P et al. and Afifi RY (94%), it is still the highest among the scores compared [9, 12]. Historically, the decision of laparotomy when based only on clinical findings was associated with an accuracy of only 16–45% [13]. The cut-off value of CASS was ≥ 11 in this study which was close to other studies where a score of > 12 was used as a criterion for laparotomy [12]. CASS has also avoided auxiliary investigations in a significant propor- tion of cases in the study by Afifi RY [12].
Among the scores studied, a significant association was seen only with ISS in predicting post-operative complications. In a system- atic review by Feldhaus I. et al., both ISS and RTS could be used to predict post-operative complications [14]. The feasibility of the ISS score is questionable as in many studies it was underestimated due to the lack of proper adjunct imaging modalities to accurately assess the severity of injury [14]. However, ISS is one of the commonly used scoring systems in low and middle income countries [14].
As per the study, all scores except CASS predicted mortality significantly. This can be explained as CASS was designed for predicting the need for laparotomy in trauma rather than to
A B C
REFERENCES
1. van der Vlies C.H., Olthof D.C., Gaakeer M. et al.: Changing patterns in diagno- stic strategies and the treatment of blunt injury to solid abdominal organs. Int J Emerg Med., 2011; 4: 47. doi: 10.1186/1865-1380-4-47.
2. Mehta N., Babu S., Venugopal K.: An experience with blunt abdominal trau- ma: evaluation, management and outcome. Clin Pract, 2014; 4(2): 599. doi:
10.4081/cp.2014.599.
3. Karamercan A., Yilmaz T.U., Karamercan M.A., Aytaç B.: Blunt abdominal trau- ma: evaluation of diagnostic options and surgical outcomes. Ulus Travma Acil Cerrahi Derg, 2008; 14(3): 205–210.
4. Celso B., Tepas J., Langland-Orban B. et al.: A systematic review and meta-ana- lysis comparing outcome of severely injured patients treated in trauma centers following the establishment of trauma systems. J Trauma, 2006; 60(2): 371–378.
doi: 10.1097/01.ta.0000197916.99629.eb.
5. van Olden G.D., Meeuwis J.D., Bolhuis H.W., Boxma H., Goris R.J.: Advanced trau- ma life support study: quality of diagnostic and therapeutic procedures. J Trauma, 2004; 57(2): 381–384. doi: 10.1097/01.ta.0000096645.13484.e6.
6. Abu-Zidan F.M.: Advanced trauma life support training: How useful it is? World J Crit Care Med, 2016; 5(1): 12–16. doi: 10.5492/wjccm.v5.i1.12.
7. Javali R.H., Krishnamoorthy, Patil A. et al.: Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian J Crit Care Med, 2019; 23(2): 73–77. doi: 10.5005/jp-journals-10071-23120.
8. Champion H.R., Sacco W.J., Copes W.S. et al.: A revision of the Trauma Score. J Trau- ma, 1989; 29(5): 623–629. doi:10.1097/00005373-198905000-00017.
Sensitivity Sensitivity Sensitivity
1 - Specificity 1 - Specificity 1 - Specificity
RTSISS CASSTRISS
RTSISS CASSTRISS
RTSISS CASSTRISS
9. Erfantalab-Avini P., Hafezi-Nejad N., Chardoli M., Rahimi-Movaghar V.: Eva- luating clinical abdominal scoring system in predicting the necessity of lapa- rotomy in blunt abdominal trauma. Chin J Traumatol, 2011; 14(3): 156–160.
10. Boyd C.R., Tolson M.A., Copes W.S.: Evaluating trauma care: the TRISS method.
Trauma Score and the Injury Severity Score. J Trauma, 1987; 27(4): 370–378.
11. Shojaee M., Faridaalaee G., Yousefifard M. et al.: New scoring system for in- tra-abdominal injury diagnosis after blunt trauma. Chin J Traumatol, 2014;
17(1): 19–24.
12. Afifi R.Y.: Blunt abdominal trauma: back to clinical judgement in the era of mo- dern technology. Int J Surg, 2008; 6(2): 91–95. doi: 10.1016/j.ijsu.2006.09.005.
13. Davis J.J., Cohn I. Jr, Nance F.C.: Diagnosis and management of blunt ab- dominal trauma. Ann Surg, 1976; 183(6): 672–678. doi: 10.1097/00000658- 197606000-00009.
14. Feldhaus I., Carvalho M., Waiz G. et al.: Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries:
a systematic review. Trauma Surg Acute Care Open, 2020; 5(1): e000424. doi:
10.1136/tsaco-2019-000424.
15. Aydin S.A., Bulut M., Ozgüç H. et al.: Should the New Injury Severity Score re- place the Injury Severity Score in the Trauma and Injury Severity Score? Ulus Travma Acil Cerrahi Derg, 2008; 14(4): 308–312.
16. Yousefzadeh-Chabok S., Hosseinpour M., Kouchakinejad-Eramsadati L. et al.:
Comparison of Revised Trauma Score, Injury Severity Score and Trauma and Injury Severity Score for mortality prediction in elderly trauma patients. Ulus Travma Acil Cerrahi Derg, 2016; 22(6): 536–540. doi:10.5505/tjtes.2016.93288.
17. Hariharan S., Chen D., Parker K. et al.: Evaluation of trauma care applying TRISS methodology in a Caribbean developing country. J Emerg Med, 2009;
37(1): 85–90. doi: 10.1016/j.jemermed.2007.09.051.
Word count: 3713 Page count: 6 Table: 4 Figures: 1 References: 17 10.5604/01.3001.0014.7394 Table of content: https://ppch.pl/issue/13669
Some right reserved: Fundacja Polski Przegląd Chirurgiczny. Published by Index Copernicus Sp. z o. o.
The authors declare that they have no competing interests.
The content of the journal „Polish Journal of Surgery” is circulated on the basis of the Open Access which means free and limitless access to scientific data.
This material is available under the Creative Commons – Attribution-NonCommercial 4.0 International (CC BY-NC 4.0).
The full terms of this license are available on: https://creativecommons.org/licenses/by-nc/4.0/legalcode
Dr. Raghav Yelamanchi (ORCID: 0000-0001-6786-8056); Department of Surgery, Ward 17, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital; New Delhi, 110001, India; E-mail: raghavyelamanchi@gmail.com Alam A., Kumar Gupta A., Gupta N., Yelamanchi R., Kumar Bansal L., Durga C.K.: Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting outcomes of blunt trauma abdomen; Pol Przegl Chir 2021: 93 (2): 9-14
DOI:
Copyright:
Competing interests:
Corresponding author:
Cite this article as:
