Comparative performance of CRAMS, RTS, NISS, and ESI scores in predicting 24-hour mortality in adult multi-trauma...

Accurate mortality prediction in trauma patients is essential for guiding clinical decisions and optimizing resource allocation. This study compared the predictive performance of four commonly used trauma assessment tools-CRAMS (Circulation, Respiration, Abdomen, Motor, Speech), Revised Trauma Score (RTS), New Injury Severity Score (NISS), and Emergency Severity Index (ESI)-in predicting 24-hour mortality among adult multi-trauma patients.

This prospective analytical study was conducted at the Emergency Department of Qazvin Trauma Hospital in Qazvin, Iran, from January to June 2025. A total of 265 adult multi-trauma patients were enrolled. Participants were selected via convenience sampling and were required to meet specific inclusion and exclusion criteria. Upon arrival at the hospital, patients were triaged and assessed using four scoring systems: CRAMS, RTS, NISS, and ESI. The primary outcome was 24-hour mortality. To compare the predictive performance of the scoring systems, Receiver Operating Characteristic (ROC) curves and DeLong's test were used.

Among 265 patients (mean age: 38.29 ± 12.99 years; 78.87% male), 16 (6.03%) died within 24 h. All four scoring systems demonstrated significant predictive ability (p < 0.001). The New Injury Severity Score (NISS) showed superior performance, with the highest area under the receiver operating characteristic (ROC) curve (AUC = 0.98, 95% CI: 0.96-1.00), sensitivity of 100%, and specificity of 92.77%. The CRAMS score ranked second, with an AUC of 0.96 (95% CI: 0.92-1.00), sensitivity of 93.75%, and specificity of 93.98%. The Revised Trauma Score (RTS) demonstrated moderate performance, with an AUC of 0.93 (95% CI: 0.84-1.00), sensitivity of 87.5%, and specificity of 97.59%. The Emergency Severity Index (ESI) showed the lowest performance, with an AUC of 0.88 (95% CI: 0.78-0.99), sensitivity of 87.5%, and specificity of 90.76%. Pairwise comparisons indicated that NISS significantly outperformed ESI (p = 0.030), and CRAMS also performed better than ESI (p = 0.018). Although NISS achieved 100% sensitivity in the present cohort, this finding should be interpreted within the context of the study population and warrants further evaluation in larger cohorts.

All four scoring systems demonstrated significant ability to predict 24-hour mortality in multi-trauma patients. Among the evaluated tools, NISS showed the highest discriminatory performance in this cohort, followed by CRAMS and RTS. Trauma-specific scoring systems generally demonstrated better predictive performance than ESI for early mortality assessment. These findings support the use of trauma-specific assessment tools in emergency trauma care. At the same time, further studies in larger and more diverse populations are warranted to confirm their performance and generalizability.

Incorporating trauma-specific scoring systems into early emergency department assessment may improve risk stratification and support timely clinical decision-making in adult multi-trauma patients.