Trauma Revisado (RTS) em 200 vítimas de trauma com mecanismos diferentes Analysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms

Objective : to analyze the epidemiological profile and mortality associated with the Revised Trauma Score (RTS) in trauma victims treated at a university hospital. Methods : we conducted a descriptive, cross-sectional study of trauma protocols (prospectively collected) from December 2013 to February 2014, including trauma victims admitted in the emergency room of the Cajuru University Hospital. We set up three groups: (G1) penetrating trauma to the abdomen and chest, (G2) blunt trauma to the abdomen and chest, and (G3) traumatic brain injury. The variables we analyzed were: gender, age, day of week, mechanism of injury, type of transportation, RTS, hospitalization time and mortality. Results : we analyzed 200 patients, with a mean age of 36.42 ± 17.63 years, and 73.5% were male. The mean age was significantly lower in G1 than in the other groups (p <0.001). Most (40%) of the visits occurred on weekends and the most com-mon pre-hospital transport service (58%) was the SIATE (Emergency Trauma Care Integrated Service). The hospital stay was significantly higher in G1 compared with the other groups (p <0.01). Regarding mortality, there were 12%, 1.35% and 3.95% of deaths in G1, G2 and G3, respectively. The median RTS among the deaths was 5.49, 7.84 and 1.16, respectively, for the three groups. Conclusion : the majority of patients were young men. RTS was effective in predicting mortality in traumatic brain injury, however failing to predict it in patients suffering from blunt and penetrating trauma.


Alvarez
Analysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms injured, especially in the pre hospital environment and initial treatment in the emergency room 5,8,9 .
There are several trauma scores, with different levels of complexity for practical implementation.The Revised Trauma Score (RTS) is widely used by emergency services around the world.It is classified as physiological, since it takes into account parameters of the patient's vital functions.This is an improvement of Trauma Score (TS), created in 1981, but without the assessment of capillary refill and respiratory effort, difficult variables to be analyzed in practice 10 .RTS assesses three parameters: neurological evaluation by the Glasgow Coma Scale (GCS); hemodynamic evaluation by systolic blood pressure (SBP); and respiratory rate (RR) 8 .Depending on the each parameter's outcome, there is a corresponding value in the RTS scale, able to evaluate the morbidity and mortality of the polytrauma patient and, depending on the severity, indicate the recruitment of more specialized teams, to improve the approach to this type of patient.
The values of variables must be weighted and summed by the formula: RTS = 0.9368 x GCS v + 0.7326 x SBP v + 0.2908 x RR v , where v is the value (0-4) corresponding to the variables at the patient's admission.Thus, the RTS may vary from 0 to about 8, allowing fractions.The higher the final value, the better the prognosis, the survival probability being possibly known 8 (Table 1).
On the RTS calculation formula, the greater constant multiplies the Glasgow Coma Scale, the SBP   We randomly selected the first 200 records that had the trauma mechanisms specific of the research.We divided patients into three groups according to their mechanism of injury: Group 1 -penetrating trauma to the chest and abdomen; Group 2 -blunt trauma to the chest and abdomen; and Group 3 -blunt trauma to the brain.
The group of variables consists of four parameters, trauma mechanism, Glasgow coma scale, systolic blood pressure and respiratory rate, besides epidemiological data, such as gender, age, day of the week, type of transportation, hospitalization time and patients who died.
After tabulating the results of quantitative variables, we described them by means and standard deviations or medians and quartiles.We described qualitative variables as frequencies and percentages.
To compare the types of trauma (penetrating, blunt or brain) in relation to age, we used the analysis of variance (ANOVA) with one factor or the nonparametric Kruskal-Wallis test.For comparison regarding death, we used the Fisher's exact test.We considered p values <0.05 as statistically significant.We analyzed data with the software SPSS Statistics v.20.0.
Table 2 shows the distribution of RTS parameters in each study group.
The mean RTS value for the total sample was 7.53.In G1, the average was 7.29 and median 7.84 with 1 st and 3 rd quartile = 7.84.In G2, the RTS average was 7.79 and median 7.84 with 1 st and 3 rd quartiles with the same value.In G3, the average was 7.44 with a median of 7.84 and 1 st and 3 rd quartile = 7.84.We found statistically significant (p =0.003) when comparing the medians between the groups G1 and G2, but not when assessing G1 versus G3 (p =0.207) and G2 versus G3 (p =0.052).
The data regarding the length of stay are shown in Table 3, the overall average being 12.76 ± 32.29 days.
Of the 200 evaluated patients, ten (5%) died, six as a result of penetrating trauma, three due to brain trauma and one victim by blunt trauma.Mortality and comparison between groups are presented in Table 4.
All G1 deaths were male and the median age was 25.5 years, with the 1 st quartile 22.25, and 3 rd , 31.The Glasgow Coma Scale presented a median of six, with 1 st quartile three, and 3 rd , 13.5.The median length of stay was 0.5 days, with 1 st quartile in zero and 3 rd quartile of 2.5 days.In G2, there was one death of a 78 year old woman, GCS 15, RTS 7.84 and two days of hospitalization.In G3, two (66.6%) were male, the median age was 81 years, with the 1 st quartile 64 and 3 rd, 82; median GCS was three, with 1 st quartile 3 and 3 rd quartile, seven; for RTS the median was 1.16, with 1 st quartile 0.58 and 3 rd , 2.62; and a median hospitalization time of six days, with 1 st quartile six and 3 rd quartile 12.

DISCUSSION
One of the problems of the trauma victims approach is that the profile of the people cared differ as to the nature and severity of injuries.The heterogeneity and difficulty in adjusting these variations have stimulated scientific research 8 .In the present study there was a predominance of injuries in males (73.5% of the sample), in the age range considered economically active, ie young adults, as observed in the literature 2,[4][5][6]8,11 . Penerating injuries were the ones affecting younger patients, with a mean age of 27.1 years.The highest overall prevalence of injuries occurred on weekends, 40% of cases.
Regarding the type of transportation to the emergency room, there was a predominance of SIATE -193 -in all groups, and SAMU -192 -in blunt and head injuries, 22% of patients suffering from penetrating wounds having been admitted after arriving through direct search, the second most prevalent type of transportation in the group.
The most prevalent mechanism in the penetrating trauma group was gunshot wound, while in blunt trauma and brain injury groups it was accidents caused by motor vehicles.According to studies by the National Department of Highways (DNER), the average cost per injured person is US$ 13,360.00,this value comprising medical expenses, property damage (vehicles and highways) and the victim's loss of income during the period of inactivity 16 .This confirms the important role of trauma prevention in improving the economy and reducing public spending, which has been shown by several studies [11][12][13] .
Regarding RTS variables, we found that patients who suffered penetrating and blunt trauma presented, within the physiological parameters, with lower values of respiratory rate, while the systolic blood pressure values did not show significant variations.On the other hand, patients suffering from blunt injury had higher Glasgow Coma Scale values compared with the other groups.RTS values were higher among victims of blunt injury compared with victims of penetrating injury.However, when analyzing the power in predicting mortality, the three groups had similar RTS mean values.
The length of stay proved to be significantly different when comparing the three groups.The victims of penetrating trauma required more in-hospital period, becoming more costly cases to the public health system, a fact corroborated by the literature, showing that individuals victims of gunshot wounds (penetrating) have an average of 7.7 days of hospitalization, with an average cost of US$ 692.95 to the hospital 4 .Another problem related to long hospital stay of trauma patients is that they contribute to overcrowding, since the lack of beds is a common health problem in the Brazilian system 4 .
Most patients were admitted with RTS values above seven, predicting good chance of survival.Even with average RTS values similar to other groups, victims of penetrating wounds had a mortality of 12%.Among the cases of blunt trauma, mortality was 1.35%, and in victims of traumatic brain injury, 3.95%.We can therefore see that even being a universally accepted trauma score, RTS is faulty when analyzing patients in groups individualized by trauma mechanism, since it does not account for this variable.
The deficiency observed in the RTS computation between groups can be explained by the fact that the variable Glasgow Coma Scale (GCS) displays and RR being multiplied by lower constants.From this, victims of neurological trauma, whose GCS values are smaller, will have a lower final RTS result and be classified as potentially more severe.In contrast, patients with thoracic or abdominal trauma, which at first may not display changes in level of consciousness, may result in an overestimated RTS value, apparently not predicting gravity.This failure in the evaluation of such patients may not correlate well with the actual clinical situation and case seriousness, often not demanding more specialized staff, which may impair the patient's progress.This study aims to analyze the epidemiological profile and mortality associated with the Revised Trauma Score (RTS) in trauma victims treated at a trauma reference university hospital.METHODS This study was approved by the Ethics in Research Committee of the Pontifical Catholic University of Paraná (number 480483 of 04.12.2013).We prospective collected data from trauma protocols of all trauma victims seen at the Emergency Room of the Cajuru University Hospital (HUC) between December 7, 2013 and February 1, 2014 for a period of 24 hours a day including holidays.For data collection, we used the help of the Medical School undergraduates of the Cajuru University Hospital Trauma League (LATHUC).The researchers trained 35 students, accounting for a total of four hours of training, explaining the research's importance and the proper way of filling the form.This is a descriptive, cross-sectional study of trauma protocols (prospectively collected) held in Curiti- ba, a city of great size of the State of Paraná.The survey took place through the data collection of 825 records of trauma patients seen in the HUC emergency room.

Table 1 . RTS Parameters and survival rate.
AlvarezAnalysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms GCS: Glasgow coma scale, v: value, SBP: systolic blood pressure, RR: respiratory rate, RTS: revised trauma score

Table 2 . Distribution of the RTS parameters by groups.
SBP: systolic blood pressure, mmHg: millimeters of mercury, RR: respiratory rate, irpm: respiratory incursions per minute, GCS: Glasgow coma scale.