|Year : 2013 | Volume
| Issue : 1 | Page : 3-7
Assessing the severity of injury using the revised trauma score in a tertiary institution in North-Central Nigeria
Usman Adamu Gwaram1, Chikwe Henry Ihezue2, Icha Inalegwu Onche2
1 Department of Surgery, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Surgery, Jos University Teaching Hospital, Jos, Nigeria
|Date of Web Publication||29-Aug-2013|
Usman Adamu Gwaram
Department of Surgery, Aminu Kano Teaching Hospital, Kano, PMB 3452
Source of Support: None, Conflict of Interest: None
Background: Current trauma management advocates inclusion of a measure of severity of the injury during evaluation. Aims: To evaluate the validity of the Revised Trauma Score (RTS) in assessment of trauma patients in accident and emergency unit of a tertiary hospital in Nigeria. Materials and Methods: Two hundred and fifty-two consecutive patients 18 years and above with injuries were recruited for the study. Written informed consent was obtained from each of the patients or their relations if unconscious. Each patient was registered according to the guidelines of International Categorization of External Causes of Injuries. The severity of injury was calculated using the RTS and the patients were followed-up, and their condition at discharge was documented. Results: Two hundred and fifty-two patients above the age of 18 years were studied. Mean age of patients' was 32.9 years with the oldest being 72 years. There were 192 male and 60 female with a male to female ratio of 3.2:1. Most of the injuries were following road traffic accidents. Among the patients with minor injuries from the RTS, 71% made full recovery, 25% were handicapped, and 4% died, while 22% of the patients with severe injuries made full recovery, 11% were handicapped, and 67% died. Conclusion: There was a statistically significant relationship between the RTS and outcome (P < 0.05) from the study, and the RTS could be used as a standard physiological trauma scoring system in prediction of outcome in our trauma population.
Keywords: Injury severity, injury outcome, revised trauma score, RTA
|How to cite this article:|
Gwaram UA, Ihezue CH, Onche II. Assessing the severity of injury using the revised trauma score in a tertiary institution in North-Central Nigeria. Niger J Basic Clin Sci 2013;10:3-7
|How to cite this URL:|
Gwaram UA, Ihezue CH, Onche II. Assessing the severity of injury using the revised trauma score in a tertiary institution in North-Central Nigeria. Niger J Basic Clin Sci [serial online] 2013 [cited 2021 Dec 2];10:3-7. Available from: https://www.njbcs.net/text.asp?2013/10/1/3/117230
| Introduction|| |
The Revised Trauma Score (RTS) was introduced by Champion et al.,  .It uses blood pressure, Glasgow Coma Scale (GCS), and respiratory rate to quantify the degree of physiological derangement to arrive at scores that correlate with clinical outcomes.
The RTS system is designed to facilitate prehospital triage, identify trauma patients suitable for quality assurance audit, allow accurate comparison of different trauma populations, and organize and improve trauma systems. 
It has become standard in all forms of trauma research to include an injury severity score in the data collection. The objective of this study was to evaluate the utility of the RTS in the assessment of injured patients in a tertiary institution in Nigeria.
| Materials and Methods|| |
The study involved all adult trauma patients who presented to the Accident and Emergency Unit of Jos University Teaching Hospital less than 24 h after injury, from 1 st July to 31 st December 2009, who consented to participate in the study or their relation if unconscious or severely injured.
Sociodemographic data were obtained as regards age, sex, marital status, occupation, and residential address, which were recorded. Note was also made of who conveyed the patient from the scene of injury to the hospital. Detailed history of the event was taken. The time and place of the incident, time interval before presentation to hospital, and cause of injury were recorded. For road traffic accidents (RTAs), in addition, use of vehicular safety elements and alcohol or psychoactive substance use was also recorded.
The vital signs taken at the beginning of resuscitation and the GCS were used for the assessment of RTS. The respiratory rate was counted for 1 min after exposing the chest and the first Korotkoff's sound of a snugly fitting cuff of adult size sphygmomanometer was recorded as the systolic blood pressure. The GCS was assessed. These were all recorded in the proforma. Patients with a total RTS score of 12 were categorized as minor injuries, 11 moderate, and 10-3 severe.
Laboratory and radiological investigations done were reviewed and diagnoses recorded in the proforma. The patients were followed-up to the definitive management with other comanaging teams and clinical progress was monitored.
At discharge, patients that returned to preinjury state and those patients with no bone pain or mobility at fracture site and evidence of strong callus formation from X-ray were regarded as fully recovered, while patients with head injury with a Glasgow Outcome Score less than five and those with gross deformities were regarded as handicapped. All patients that died and those patients that request discharge against medical advice were recorded.
The individual filled proforma for each of the patients was entered into EpiInfo computer software version 3.2.2. Results were expressed as mean/standard deviation and/or median with ranges. Chi-square test was used to check for association where appropriate. A 'P' δ 0.05 was considered significant.
The ethical committee of the hospital approved the study, after review of the proposal. Written informed consent was obtained from each patient and/or relations if unconscious.
| Results|| |
Three hundred and sixty-eight patients were seen during the period of study, out of which 252 (68%) met the inclusion criteria. None of the recruited patients refused to consent for participation in the study, nor the relations of patients that were unconscious. The age distribution ranged from 18 to 72 years with a mean of 32.9 ± 11.9 years.
There were 192 (76.2%) male and 60 (23.8%) female, with a male to female ratio of 3.2:1. One hundred and twenty-six (50%) patients were single, while married patients constituted 110 (43.7%) patients. Four (1.6%) patients were widowed and 12 (4.7%) patients were divorced. Eighty-nine (35.3%) were students, 46 (18.3%) traders and 45 (17.9%) civil servants. There were 61 (20.2%) farmers, while the clergy, unemployed, and pensioners together accounted for eleven (4.4%) in the series.
Cause of injury
One hundred and seventy-eight (70.6%) were transport-related incidents, 25 (9.9%) patients suffered assault, and gunshot wounds accounted for injuries in 13 (5.2%) patients, while eight (3.2%) patients sustained burns. Motorcycle was responsible for 91 (36.3%) patients, 56 (22.2%) patients were pedestrian struck, while passengers and drivers of motor vehicles (car, bus, and truck) accounted for 105 (41.6%) of the patients. None of the injuries was because of bicycle injuries.
Out of the patients that were involved in car or bus incidents. Only two (3.2%) used seat belt; none of the patients involved in motorcycle accidents used a crash helmet and 16 (8.7%) patients were under the influence of alcohol or psychoactive substance at the time of accident.
Following the incidents, 126 (50%) patients were brought to hospital by their relations, 80 (31.7%) patients by the Police/Federal Road Safety Corps and 24 (9.5%) patients by good Samaritans; 7.5% came to hospital on their own after injury. One hundred and seventy-eight (70.6%) of the injuries were transport-related and occurred on the road, 34 (13.5%) cases were unintentional injuries that occurred at work (occupational injuries), only four of which were sustained while operating machineries in industries. Thirty-two (12.7%) patients were injured at home, while four victims were injured during sport.
One hundred and eighty (71.4%) of the incidents occurred during the daytime between the hours of 7 am and 6 pm, while 62 (24.6%) occurred between 7 pm and 12 am, only 10 (4%) occurred between 1 am and 6 am. Twenty-eight (11.1%) patients presented to the hospital within 1 h, 118 (46.8%) presented 1-2 hours after the event and 60 (23.8%) patients presented more than 4 h after the event.
RTS, diagnosis, and outcome
[Table 1] shows the diagnoses and the injury severity from RTS and group mean RTS. While [Table 2] shows the outcome for different severity groups from the RTS.
There was a statistically significant relationship between the RTS and outcome [Table 3], the time interval between injury to presentation and outcome, while there was no statistically significant relationship in the severity of injury between the elderly (≥65 years) and patients between 18 and 64 years.
| Discussion|| |
This study has found a significant relationship between outcome and severity of injury from the RTS calculated in the accident and emergency, as opposed to similar studies were the RTS was evaluated at the site of accident. ,, The study also evaluated handicap as an outcome measure in addition, which is advancement on studies that focused on survival and injury severity from the RTS. ,,
Most of the victims of trauma from this study were young men similar to other studies from tertiary institutions in Nigeria, ,,,,, Africa, ,, and a community survey from USA. 
Prehospital care, transport, and early intervention are established methods of reducing trauma-related morbidity and mortality. ,,,, None of the patients from the study was brought to hospital with an ambulance. This may have contributed to the mean hospital presentation time of 77 min from the study, which is higher than the 30 min recorded by Wolde et al.,  in Addis Ababa, perhaps because of availability of ambulance services around the city. This study identified a statistically significant relationship between the time interval between injury and presentation to hospital and outcome similar to the finding of Litchveld et al.,  which showed that deteriorating RTS between first assessment and arrival to hospital was a strong independent predictor of mortality.
RTA accounted for the highest cause of injury, which is in keeping with other studies in Nigeria, ,,,, except in Port Harcourt  where domestic accidents were the commonest followed by criminally motivated injuries and RTA ranked third. Variations have also been documented in USA,  where falls accounted for the highest cause of presentation to the emergency room. In Puerto-Rico, Brazil, and Columbia, firearms was found to be the leading cause of injury,  which is probably due to easy access of civilians to firearms and drug-related violence.
Among the motor vehicular causes of injury, motorcycle injuries ranked highest from the finding of this study. Earlier studies from Nigeria  reflect a much lower contribution by motorcycles, even though in a recent community based survey by Labinjo et al.,  motorcycle crashes accounted for 54% of injuries. This may be because of increasing use of motorcycles as a mode of transport in Nigeria. None of the victims from motorcycle injuries (46 drivers and 18 passengers) wore a crash helmet, which is similar to the finding of Solagberu et al.,  in 2006. However, Asogwa  reported 34% of patients wore a crash helmet from his series in 1980.
Mean RTS is a measure of group injury severity for comparison between trauma populations. The mean RTS from the study is 11.6. This is higher than 7.0 reported from Lagos by Onwudike et al.,  of the weighted version of RTS (upper limit 7.8) and Solagberu et al.,  found a mean RTS of 5.2 in their retrospective studies of the pattern and distribution of trauma deaths. Patients with head injury and the multiply injured had the lowest group mean RTS, indicating increased severity. This may be because of the contribution of GCS in both cases, being the least likely variable of the RTS to be compensated in the physiological response to trauma. Injury severity match by assessment of mean RTS is inferior to the "W" statistics of the Trauma and Injury Severity Score (TRISS) methodology; in which mean RTS as a measure of physiological disturbance, Injury Severity Score (ISS) for anatomical injury severity is combined with age to predict probability of survival. ,, Outcome prediction analyses were not done because there was no measure of anatomical severity from the study.
Twelve patients with minor and moderately severe injuries from the RTS, died. These were the patients with abdominal, chest, and cervical spine injury, which is a recognized weakness of RTS in predicting severe injury involving single anatomical region.  In the study by Gilpin and Nelson  RTS identified 42 of 53 patients with severe injuries, among which, five had penetrating trauma and three had spinal cord injuries. This is a similar weakness of the ISS,  which led to development of the New Injury Severity Score (NISS)  with better discriminatory capacity than the ISS or RTS. There was a statistically significant relationship between injury severity from the RTS and the outcome. This is similar to other studies ,, despite differences in study designs.
A total of 20.6% of the patients were handicapped in this study. This is lower than the findings of Labinjo et al.,  perhaps because the latter is a community-based survey and patients that did not present to hospital were reflected. Patients with extremity injuries accounted for the highest rate of handicap from the study, similar to the finding in Ghana.  Handicap was also recognized not to be an outcome option for patients with chest and abdominal injuries.
Thirty-four (13.5%) patients took discharge against medical advice (DAMA), which is lower than 29% from the study by Lateef and Adedayo. These patients were catered for by a factor of attrition in the sample size calculation for the study, but further research is warranted to identify their reasons and subsequent plight.
Extremity injuries accounted for 10% of all the mortality from the study; this is lower than the finding of Mandong et al.,  of 37% in their study of the epidemiology of trauma deaths in Jos. The mortality (11.9%) rate from the study was high, though similar to other studies from Nigeria , and Africa,  when compared to findings in the USA  where the mortality rate is 0.02%. This clearly shows the gap in terms of outcome with developed communities, which were achieved through development of effective trauma and emergency management services. ,,,
In conclusion, young males are the commonest victims of trauma as shown by the study and mostly from RTAs.
Extremity, head, and multiple injuries were the commonest injuries, with extremity injury accounting for most disabilities and discharges against medical advice, while most of the mortality was from head injury. About two-third of all mortalities were in patients with severe injury and 70% of patients that recovered fully had minor injuries. However, handicap is proportionately higher among patients with moderate injuries from the RTS. The RTS could be used as a standard physiological scoring system for the prediction of survival in our patients. There should be further studies on the RTS and other scoring systems to identify differences and permit comparison with other trauma population.
| References|| |
|1.||Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29:623-9. |
|2.||Timothy HP, Scott HB, Patrick O. Trauma scoring systems. Trauma 2009;5:1-9. |
|3.||Lichtveld RA, Spijkers AT, Hoogendoorn JM, Panhuizen IF, van der Werken C. Triage revised trauma score change between first assessment and arrival at the hospital to predict mortality. Int J Emerg Med 2008;1:21-6. |
|4.||Zafonte RD, Hammond D. Evaluation of revised trauma score: An additive predictor of disability following traumatic brain injury. Am J Phys Med Rehabil 1997;11:403-7. |
|5.||Roorda J, van Beeck EF, Stapert JW, ten Wolde W. Evaluating performance of the revised trauma score as a triage instrument in the pre-hospital setting. Injury 1996;27:163-7. |
|6.||Moore L, Lavoie A, Abdous B, Le Sage N, Liberman M, Bergeron E, et al. Unification of the revised trauma score. J Trauma 2006;61:718-22. |
|7.||Gabbe BJ, Cameron PA, Finch CF. Is the revised trauma score still useful? ANZ J Surg 2003;73:944-8. |
|8.||Gilpin DA, Nelson PG. Revised trauma score: A triage tool in the accident and emergency department. Injury 1991;22:35-7. |
|9.||Manasseh AN, Mohammed AZ, Mandong BM. Epidemiology of trauma deaths in Jos, Nigeria. Niger J Surg Sci 2003;13:10-3. |
|10.||Mandong BM, Madaki JK, Mohammed AZ, Kidmas AT, Echejoh GO. Epidemiology of accident deaths in Jos, Nigeria. Ann Afr Med 2006;59:149-52. |
|11.||Solagberu BA, Adekanye AO, Ofoegbu CP, Udoffa US, Abdur-Rahman LO, Taiwo JO. Epidemiology of trauma deaths. West Afr J Med 2003;22:177-81. |
|12.||Lateef OA, Adedayo TO. Epidemiology of severe injury in a Nigerian Hospital. Niger J Orthop Trauma 2007;6:67-9. |
|13.||Akinpelu OV, Oladele AO, Amusa YB. Pattern and epidemiologic characteristics of trauma admissions to the Obafemi Awolowo Teaching Hospital. East Afr J Surg 2007;12:63-7. |
|14.||Akiode O, Izegbu NC, Agboola AO, Aina OO. Medico-legal deaths from Road Traffic accidents in Shagamu. Niger Med Prac 2004;45:1-2. |
|15.||Geraldine O, Kobusingye O. Trauma registries as a tool for improved clinical assessment of trauma patients in an urban African hospital. East Central Afr J Surg 2001;6:57-63. |
|16.||Twagirayezu E, Teteli R, Bonane A, Rugwizargogo E. Road traffic injuries at kigali central university teaching hospital, Rwanda. East Afr J Surg 2008;13:73-6. |
|17.||Wolde A, Abdella K, Ahmed E. Pattern of injuries in addis ababa, Ethiopia: A one year descriptive study. East Central Afr J Surg 2008;13:14-22. |
|18.||Injury in the United States: 2007 Chart book. U.S. Department of Health and Human Services. CDC. National Center for Health Statistics. USA. 2007. p. 43-4. |
|19.||Shackford SR. The evolution of modern trauma care. Surg Clin North Am 1995;75:147-56. |
|20.||Cales RH. Trauma mortality in orange country: The effect of implementation of a regional trauma system. Ann Emerg Med 1984;13:1-10. |
|21.||Shackford SR, Mackersie RC, Hoyt DB, Baxt WG, Eastman AB, Hammill FN, et al. Impact of a trauma system on outcome of severely injured patients. Arch Surg 1987;122:523-7. |
|22.||West JG, Trunkey DD, Lim RC. Systems of trauma care. A study of two countries. Arch Surg 1979;114:455-60. |
|23.||West JG, Williams MJ, Trunkey DD, Wolferth CC Jr. Trauma systems. Current status-future challenges. JAMA 1988;259:3597-600. |
|24.||Elechi EN, Etawo SU. Pilot study of injured seen in the University of Port Harcourt Teaching Hospital, Nigeria. Injury 1991;20:234-8. |
|25.||Lois AF. International collaborative effort (ICE) on injury statistics 2005. Cuervanaca, Mexico. Available at: www.cdc.gov/nchs/advice.htm. |
|26.||Aganga AO, Umoh JU, Abechi SA. Epidemiology of road traffic accidents in Zaria, Nigeria. J R Soc Health 1983;103:123-6. |
|27.||Labinjo M, Juillard C, Kobusingye OC, Hyder AA. The burden of road traffic injuries in Nigeria: Results of a population based survey. Inj Prev 2009;15:157-62. |
|28.||Solagberu BA, Ofoegbu CK, Nasir AA, Ogundipe OK, Adekanye AO, Abdur-Rahman LO. Motorcycle injuries in a developing country and the vulnerability of riders, passengers and pedestrians. Inj Prev 2006;12:266-8. |
|29.||Asogwa SE. Some characteristics of drivers and riders involved in road traffic accidents in Nigeria. East Afr Med J 1980;57:399-404. |
|30.||Onwudike M, Olaloye OA, Oni OO. Teaching hospital perspective of the quality of trauma care in Lagos, Nigeria. World J Surg 2001;25:112-5. |
|31.||Ahmed HN. Evaluation of revised trauma score in polytraumatized patients. J Coll Physicians Surg Pak 2004;14:286-9. |
|32.||Talwar S, Jain S, Porwal R, Laddha BL, Prasad P. Trauma scoring in a developing country. Singapore Med J 1999;40:386-8. |
|33.||Tamim H, El-Chemaly S, Jaana M, Musharrafieh U, Jamali F, Taha AM. Trauma epidemiology and outcome in a developing country: Perspectives from a university teaching hospital in Beirut. Int J Inj Contr Saf Promot 2006;13:245-9. |
|34.||Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96. |
|35.||Champion HR, Copes WS, Sacco WJ, Lawnick MM, Bain LW, Gann DS, A new characterization of injury severity. J Trauma 1990;30:539-45. |
|36.||Bouillon B, Krämer M, Tiling T, Neugebauer E. Trauma Score Systems as instruments in quality control. A prospective study on validation of 7 trauma score systems. Unfallchirurg 1993;96:55-61. |
|37.||Mcleod JB, Kobusingye O, Frost C. A comparison of the Kampala Trauma Score (KTS) with the Revised Trauma Score (RTS), ISS and TRISS method in Ugandan Trauma Registry; is equal performance achieved with fewer resources? Eur J Trauma 2003;29:392-8. |
|38.||Kuhls DA, Malone DL, McCarter RJ, Napolitano LM. Predictors of mortality in adult trauma patients: The physiologic trauma is equivalent to the trauma and injury severity score. J Am Coll Surg 2002;194:695-704. |
|39.||Mock CN, Boland E, Acheampong F, Adjei S. Long-term injury related disability in Ghana. Disabil Rehabil 2003;25:732-41. |
|40.||Odero W, Garner P, Zwi A. Road traffic injuries in developing countries: A comprehensive review of epidemiological studies. Trop Med Int Health 1997;2:445-60. |
[Table 1], [Table 2], [Table 3]