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External validation of the revised lethal triad criteria for appropriate strategic decision making
Keisuke Suzuki1, Akira Endo, Tomohiro Akutsu
1From the Department of Acute Critical Care Medicine (K.S., A.E., T.A., H.H.), Tsuchiura Kyodo General Hospital, Tsuchiura; Trauma and Acute Critical Care Medical Center (K.S., A.E., T.A., H.H., A.S., W.T., K. Morishita), Institute of Science Tokyo, Bunkyo-ku; Advanced Medical Emergency Department and Critical Care Center (T.O.), Saiseikai Utsunomiya Hospital, Utsunomiya; Emergency and Trauma Center (A.S.), Kameda Medical Center, Kamogawa; Division of Emergency and Critical Care Medicine (S.K., M.F.), Tohoku University, Sendai; Department of Surgery (Tasuku M.), Kenwakai Otemachi Hospital, Kitakyushu; Department of Trauma and Emergency Surgery (N.H.), Saiseikai Yokohamashi Tobu Hospital, Yokohama; Department of Critical Care Medicine and Trauma (K.I), National Hospital Organization Disaster Medical Center, Tachikawa; Department of Emergency and Critical Care Medicine (T.H.), St. Luke's International Hospital, Chuo-ku; Advanced Critical Care Center (Takahito M.), Gifu University Hospital, Gifu; Department of Emergency and Critical Care Medicine (A.M.), Saga University Hospital, Saga; Department of Emergency, Critical Care, and Disaster Medicine (H.N.), Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, Okayama; Trauma and Critical Care Center (T.S.), Japanese Red Cross Kumamoto Hospital, Kumamoto; Department of Emergency and Critical Care Medicine (K. Miyazaki), Nara Medical University Hospital, Kashihara; Department of Critical Care and Emergency Medicine (N.U.), Japanese Red Cross Maebashi Hospital, Maebashi; Department of Traumatology and Critical Care Medicine (Y.S.), Osaka Metropolitan University Hospital, Osaka; Emergency Medical Center (K. Kirizume), Kagawa Medical University, Kita-gun; Department of Emergency Medicine (A.I.), Japan Red Cross Okayama Hospital, Okayama; Department of Emergency and Critical Care Medicine (Y.Y.), Hachinohe City Hospital, Hachinohe; Division of Acute and Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine (T.W.), Faculty of Medicine, Hokkaido University, Sapporo; Emergency Department (K. Kato), Obihiro Kosei Hospital, Obihiro; Department of Emergency and Critical Care Medicine (K.S.), Juntendo University Urayasu Hospital, Urayasu; Emergency and Critical Care Medicine (M.H.), Kindai University Faculty of Medicine, Osakasayama; and Emergency and Critical Care Center (T.K.), Mie University Hospital, Tsu, Japan.
Background:
The conventional lethal triad criteria for trauma are too specific for death and, thus, inappropriate as a standard for strategic decisions. Revised lethal triad criteria were previously proposed based on a multicenter study. Positive is defined as meeting one major criterion (fibrin/fibrinogen degradation product >90 μg/mL) or two minor criteria (base excess <-3 mEq/L or temperature <36°C). The aim of this study was to externally validate the revised lethal triad criteria by evaluating their predictive performance for 28-day mortality in severely injured patients.
Methods:
Patients with trauma with an Injury Severity Score of ≥16, admitted to 25 Japanese institutions between April 2018 and March 2019, were included. The proportion of patients for whom the revised criteria could be calculated was assessed. The predictive accuracy of the conventional and revised lethal triad criteria was evaluated using the area under the receiver operating characteristic curve. Calibration plots were created to visually evaluate the agreement between predicted and observed 28-day mortality.
Results:
Among 1,177 patients with severe blunt trauma, 125 (10.6%) died during hospitalization. The revised criteria could be calculated for 770 patients (65.4%). The conventional criteria predicted 28-day mortality with 2.8% sensitivity and 99.8% specificity, whereas the revised criteria showed 80.6% sensitivity and 64.4% specificity. The area under the receiver operating characteristic curves for the conventional and revised criteria were 0.68 and 0.77, respectively. Calibration plots showed high agreement between predicted and observed values for the revised criteria, indicating a well-calibrated model.
Conclusion:
The revised lethal triad criteria demonstrated clinically sufficient sensitivity and appropriate specificity for predicting 28-day mortality in patients with severe trauma, suggesting their utility as indicators for adopting critical therapeutic strategies.
Level Of Evidence:
Diagnostic Test or Criteria; Level IV.
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