Development and Validation of FOUR Score-Modified Trauma Scoring Systems for Mortality Prediction in Trauma Patients: A Multicenter Prospective Observational Cohort Study

Trauma is the leading cause of death worldwide, particularly in those younger than 35 years of age. Injuries and violence represent a major global public health, according to the World Health Organization (WHO), injuries and violence cause approximately 4.4 million deaths worldwide each year, accounting for nearly 8% of all deaths. Of these, about 3.16 million deaths are attributable to unintentional injuries and 1.25 million to violence-related injuries. Injuries and violence also contribute substantially to disability, with an estimated 10% of all years lived with disability attributed to these conditions.

Trauma severity scoring systems are important adjuncts to trauma care and are used to characterize the nature and extent of injury. They can support triage and assist in assessing and predicting patient outcomes, thereby helping to organize and improve trauma care systems. Trauma scoring systems can be divided into anatomical, physiological, and combined scores each with advantages and disadvantages. Anatomical scores describe the injuries recorded by clinical examination, imaging, surgery, or autopsy. While Physiologic Scores describe changes due to a trauma and translated by changes in vital signs and consciousness. The combination of anatomic scoring system and physiological scoring system is better than single scoring system for death prediction in patients with severe trauma in ICU, and it may be considered to be a new method for early identification of death risk in patients with severe trauma.

The Revised Trauma Score (RTS), a revision of the original Trauma Score developed by Champion et al., in 198, is a commonly used prehospital trauma triage tool. While there has been conceptual evolution of the core concept behind the RTS since its development, including the development of respiratory rate, pulse rate, and motor response (RPM) measure by Sacco et al., which may provide important mitigation of subjectivity of Glasgow Coma Scale (GCS) assessment, the RTS remains most prevalent in the literature. The RTS only requires three metrics to calculate: respiratory rate, systolic blood pressure, and GCS.

First introduced by Champion et al. in 1981, TRISS is a combination of the RTS and ISS with an age component. This system was to assess patients at the time of initial presentation to predict overall prognosis. Earlier studies had issues related to its applicability, but recent studies lend support to TRISS being a better scoring system when compared with others, such as ISS, NISS, and RTS. The past three decades have seen many international studies providing evidentiary support that it is, in fact, an accurate predictor of patient mortality.

More recent scoring systems, such as the Glasgow Coma Scale, Age, and Systolic Blood Pressure (GAP) score, have gained attention due to their simplicity and applicability in the field. The GAP score is especially relevant for traffic accident triage, as it can be quickly implemented at the scene, allowing for more efficient patient stratification and resource allocation. The New Trauma Score (NTS), which replaces the Respiratory Rate (RR) with arterial blood oxygen saturation percentage (SpO2), has shown improved performance over RTS in predicting mortality for trauma patients, including those from traffic accidents.