ORIGINAL ARTICLE

EVALUATION OF THORACIC TRAUMA

SEVERITY SCORE IN PREDICTING THE OUTCOME OF
ISOLATED BLUNT CHEST TRAUMA PATIENTS
∗ ∗ ∗ ∗∗
Adel Elbaih ,1 , Islam Elshaboury , Nancy Kalil and Hamdy El-Aouty
∗ ∗∗
Department of Emergency, Faculty of Medicine, Suez Canal University, Ismailia, Egypt., Cardiothoracic Surgery DDepartment, Faculty of Medicine, Suez
Canal University, Ismailia, Egypt.

ABSTRACT
Background: Chest trauma is a significant cause of mortality and morbidity, especially in the younger population.
Injuries to the thorax are the third most common injuries in trauma patients, next to injuries to the head and extremities.
Outcome and prognosis for the vast majority of patients with chest trauma are excellent. There are many predictors of
mortality in chest trauma patients. However, the present standards for assessing thoracic trauma vary widely. For this in
2000 Pape et al. developed the Thoracic Trauma Severity Score (TTSS), which combines the patient’s age, resuscitation
parameters, and radiological assessment of the thorax. The aim of this study: was to assess the validity if any of the
Thorax Trauma Severity Score and its ability to predict mortality in blunt chest trauma patients. Methodology: It was
a cross-sectional study included 30 patients. Results: It (TTSS) was found to be a good predictor of mortality among
the studied patients on initial evaluation, with a score larger than 7. The score is 100% sensitive and 100% specific
for prediction of poor outcome (Death and ICU admission) versus good outcome (Discharge from ER and inpatient
admission) with 100% positive predictive value and 100% negative predictive value. Conclusion: This study supports
the use of the TTSS for predicting mortality in thoracic injury patients, as higher scores associated with higher mortality
and morbidity.
KEYWORDS: thorax trauma scoring, mortality, thoracic injuries

Introduction

Chest trauma is a significant cause of death and morbidity, es-

pecially in the younger population. [1] Injuries to the thorax
are the third most common injuries in trauma patients, next
to injuries to the head and extremities. Thoracic trauma has
an overall fatality rate of 15–25%. Furthermore, the presence
Copyright © 2016 by the Bulgarian Association of Young Surgeons of thoracic injuries in the setting of multi-systemic trauma can
DOI:10.5455/ijsm.chesttrauma significantly increase patient mortality. [2, 3] Chest trauma may
First Received: February 27, 2016 be due to penetrating or blunt trauma. [4] Road traffic crashes
Accepted: March 29, 2016
(RTCs) are the commonest cause of blunt chest injuries in private
Manuscript Associate Editor: George Baitchev (BG)
Editor-in Chief: Ivan Inkov (BG) practice accounting for up to 70% in some series. Blunt trauma
Reviewers: Stefan Schulz-Drost (DE); Mehmet Ali Karaca (TR); Deyan Yordanov is more common than penetrating chest injury, accounting for
(BG); Hatice Eryigit (TR) more than 90% of thoracic injuries. [5] Outcome and prognosis
1
Adel Hamed Elbaih Department of Emergency, Faculty of Medicine, Suez Canal for a vast majority of patients with chest trauma are excellent.
University, Ismailia, Egypt,
Most (>80%) require either non-invasive therapy or at most a
E-mail: elbaihzico@yahoo.com
thoracostomy tube. The most important determinant of outcome

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
is the presence or absence of significant associated injuries.[6]
The present standards for assessing thoracic trauma vary
widely. A scoring system that can predict complications in tho-
racic trauma patients needed. For this in 2000 Pape et al. devel-
oped the Thoracic Trauma Severity Score, the TTSS combines
the patient’s age, resuscitation parameters, and radiological as-
sessment of the thorax. (Table 1) [7] So, the aim of this study
was to assess the validity if any; of the Thorax trauma severity
score and its ability to predict mortality in blunt chest trauma
patients, this requires follow-up of the cases in this study to as-
sess its prognostic capability in correlation with other included
parameters of severity.
Patient and Methods
The study included 30 patients with inclusion criteria of (above
the age of 18 years old, both sexes) attending emergency depart-
ment presenting with isolated blunt chest trauma. The exclusion
criteria included Penetrating chest trauma, blunt trauma asso-
ciated with healthy ones, a patient’s with burn, any respiratory
disease that affects pulmonary functions, pregnancy,
malignancy, and end organ failure. The patient was clinically
assessed and managed as per the ABC protocol just on arrival
to Emergency Department; Blood samples drew; CBC and
arterial blood gasses analyzed. Chest X-ray, chest computed
topography, electrocar- diogram, or echocardiography to
assess cardiac injury if any. Outcomes were then recorded
along with the patient’s data and applied to the scoring
system to fulfill all the parameters included in the score.
Results
The study revealed that (40%) of the patients were less than 30
years old and that (76.7%) were males. Regarding the mecha-
nism of injury, the motor car accident was the most common
assault; (76.7%) while other trauma mechanisms accounted only
for (23.3%) of injuries.
Upon view of the primary survey of the studied patients, on
a presentation, the majority (60%) had a heart rate of 100-120
beats/minute. As regard to systolic blood pressure; 24 patients
(80%) was equal to or above 100mmHg. Moreover, finally, a
respiratory rate which had a significant statistical difference in
the outcome of the patients; as all fatalities were in the range of
20-29 while all early discharged patients were of 12-20 breath
per minute.(Table 2)
Regarding the trauma findings; the PaO2/FiO2 ratio was
ranging from 150-200 in eight patients (26.6%), followed by
range of 201-300 in (23.3%), then ≤ 150 in six patients (20%),
more than 400 in (16.7%), and finally with range of 301-400 in
(13.4%).
Statistical analysis showed that a ratio <150 was related to
mortality with a p-value (0.004), as the mean ratio in early death
cases was (102.5) and was (429.5) in cases discharged early from
the ER. Regarding the PaO2/FiO2 ratio, it was noticed to have a
statistical significance regarding outcome as shown in this table.
(Table 3)
Thoracic bony injuries were mostly in the form of fractured
1-<3 ribs (53.3%) that is not forming a segment, followed by flail
chest in ten patients (33.3%); lateral flail (right side) in six pa-
tients and sternal flail in four patients. Fracture of >3-6 ribs (not
Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
forming a segment) addressed in two patients (6.7%); one right
and one left, also the fracture of more than three ribs bilateral
(not forming a segment) found in two other patients (6.7%).
Upon lung contusions; we discovered that twelve patients
(40%) had <2 contused lobes ipsilaterally. No evidence (either
on chest radiograph or CT chest) of lung contusion observed
in (26.6%), involvement of one lobe unilaterally in (20%), one
lobe bilateral in (6.7%), less than two lobes bilateral in (6.7%),
while none presented with more than two lobes on each side.
We also found that twelve patients (40%) had pneumothorax;
ten unilateral and two bilateral.
Unilateral hemothorax or hemopneumothorax was in (26.7%),
four patients (13.3%) had tension pneumothorax, and another
four (13.3%) was free of any pleural involvement. Only two
patients (6.7%) had bilateral hemothorax or hemopneumothorax.
Our statistical analysis of data showed a meaningful relationship
of mortality in patients with tension pneumothorax (p-value
0.011).
During our study, we noticed that twenty-six patients
(86.7%) were free of mediastinal injuries, while four patients only
(13.3%) had such injuries, and out of those with specific
injuries two patients died (50%). Management of most of the
patients was conservative; twenty-four patients (80%)
including twenty-two patients with chest tube insertion and
two patients discharged with follow-up instructions. Only six
patients (20%) needed open thoracotomy.
Fourteen patients (46.6%) admitted to Cardiothoracic ICU
after initial assessment; twelve patients (40%) admitted to In-
patient Ward, two patients (6.7%) died at ER, and another two
patients (6.7%) were discharged home from the ER.
On application of the thoracic trauma severity score, ten
(33.3%) of the studied patients scored 0-5, eight (26.6%) scored
6-10, six (20%) scored 11-15, four (13.3%) with a score of 16-20,
and only two (6.7%) scored ≥ 21. Higher scores attributed to
high risk of mortality. Out of those who scored 0-5, two was
discharged, and eight admitted to Inpatient Ward, with a score
of 6-10, four admitted to Inpatient Ward and another four to
ICU. All of those who scored 11-20 admitted to ICU, and above
that score (≥ 21-25) the fate was the early death of two patients.
(Table 4)
Discussion
Our study results match a study performed in 2014, in Pakistan,
where the mean age was (44.8±17.1) years, (79.9%) were male
patients. [8] In 2012, in Hannover Germany, a study was con-
ducted on patients with multiple injuries (mean age 42.7±17.0 y)
were included; (73%) were males and (27%) were females. [9]
Old age was associated with high mortality rates in our study
(with the mean age of mortalities 60 y.) even with an absence
of chronic illnesses, as we excluded co-morbidities in our study.
(Table 5) That coincides with what Shahram et al. suggested;
where increasing age has been found to be an independent risk
factor for a poor outcome after isolated thoracic trauma; (defined
as 65 years and older) have up to four-fold greater morbidity and
mortality compared with injury severity score-matched younger
patients, especially due to thoracic injuries. [10]
Regarding the mechanism of damage, the motor car accident
was the most common assault and showed a statistically sig-
nificant difference. It was also documented by Global et al. in
2012, in KSA where road traffic accidents accused of injury in
(81.25%), and other mechanisms accounted for (18.75%). [11]
Table 1 The Thoracic Trauma Severity Score; (TTSS) to predict outcomes in thoracic trauma patients.
Parameter Finding Points
Age <30 years of age 0
30 to 41 years of age 1
42 to 54 years of age 2
55 to 70 years of age 3
>70 years of age 5
PaO2 to FIO2 ratio >400 0
301-400 1
201-300 2
150-200 3
<150 5
Pulmonary contusion None 0
1 lobe, unilateral 1
1 lobe, bilateral 2
2 lobes, unilateral 2
"<2 lobes, bilateral" (see below) 3
≤ 2 lobes, bilateral 5
Pleural involvement None 0
Pneumothorax 1
Unilateral hemothorax or hemopneumothorax 2
Bilateral hemothorax or hemopneumothorax 3
Tension pneumothorax 5
Rib fractures 0 0
1 to 3 1
3 to 6 (will use 4 to 6), unilateral 2
>3, bilateral 3
flail chest 5
Notes: for calculation of the total score, all categories are summed;
a minimum value of 0 points and a maximum value of 25 points can be achieved.

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
Table 2 Distribution of patients’ outcomes according to clinical findings (N=30).
Discharge Mortality Morbidity
Total p-value
n=2 n=2 n = 26
N % N % N %
Heart Rate <100/min 1 25.0% 0 0.0% 3 75.0% 4 0.200
100-120 1 5.5% 0 0.0% 17 94.4% 18
120-140 0 0.0% 2 25.0% 6 75.0% 8
Systolic
≥ 110 2 8.3% 0 0.0% 22 91.6% 24 0.716
Blood Pressure
90-109 0 0.0% 2 0.0% 2 0.0% 4
<90 0 0.0% 0 0.0% 2 100.0% 2
Respiratory
12-20 2 14.2% 0 0.0% 12 85.7% 14 0.012 *
rate
20-29 0 0.0% 2 12.5% 14 87.5% 16
Glasgow
14-15 2 13.3% 2 13.3% 26 73.3% 30 NA
Coma Scale
Hemoglobin ≥ 9.6 2 13.3% 2 13.3% 26 73.3% 30 NA

Table 3 Distribution of patients’ outcomes according to trauma characteristics (N=30).

Discharge n = 2 Mortality n = 2 Morbidity n = 26 Total p-value
N % N % N %
PaO2-FiO2 >400 2 40.0% 0 0.0% 3 60.0% 5
301 – 400 0 0.0% 0 0.0% 4 100.0% 4
201 – 300 0 0.0% 0 0.0% 7 100.0% 7
150 – 200 0 0.0% 0 0.0% 8 100.0% 8
<150 0 0.0% 2 33.3% 4 66.7% 6 0.004*

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
Table 4 Distribution of patients’ outcomes according to their
grade on thoracic trauma severity score (N=30).
Score on TTSS Fate of the patient
0-5 8 In-patient 2 Discharged
6-10 4 In-patient 4 ICU
11-15 6 ICU
16-20 4 ICU
≥ 21-25 2 Died
Table (4) shows
that out of 10 patients who scored (0-5);
8 were admitted to In-patient and 2
were discharged from ER. And
those with score (6-10); 4 were
admitted to In-patient
and another 4 were admitted to ICU,
with score
(11-15) all of the 6 patients were admitted to ICU,
as well as all the 4
patients with score (16-20).
The fate of the 2 patients who scored 21
or
more was associated with early mortality.
Also thoracic bony injuries results were entirely relevant to
what was stated by Shahzad et al; who found that on chest
radiograph of all blunt chest trauma patients; (37.8%) had 3–6
rib fractures, (23.8%) of patients were having 1-<3 rib fractures,
flail chest in (21%) and >3 bilateral rib fractures in (17.4%). (8)
Upon lung contusions, we observed that they associated with
mortality, especially with bilateral involvement. A retrospective
study of blunt chest trauma in Baltimore, Maryland showed that
severe thoracic parenchymal injury can be present even in the
absence of thoracic bony fractures. [12]
Again regarding pleural involvement among the studied
cases; the results quite match what implicated by Shahzad et al.,
where they documented that (33.3%) presented with unilateral
while (9.1%) with bilateral pneumothorax, one-sided hemotho-
rax in (55.5%) while bilateral was in (21%) of cases. [8]
Our statistical analysis of data showed a significant relation-
ship of mortality in patients with tension pneumothorax. Chad
G. et al. evaluated the records of all patients with severe chest
trauma, among patients with blunt injuries; the incidence of
tension pneumothorax was 1.4%. [13] A study of pneumothorax
in severely traumatized patients also showed that the p-value
for mortality in TPT was - 0.63. [14]
During our study, we noticed the mediastinal injuries if
any, and out of those with specific injuries two patients died
(50%). In 2009, Manuel et al. addressed that the mortality rate
was 38%. In patients with the blunt thoracic trauma, that was
diagnosed with pneumomediastinum. [15]
Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
Figure (1) shows that the TTSS; Thoracic trauma severity score
when larger than (7) is 100% sensitive and 100% specific for
prediction of poor outcome (Death and ICU admission) versus
good outcome (Discharge from ER and inpatient admission)
with 100% positive predictive value and 100% negative predic-
tive value.
A retrospective study conducted at the cardiothoracic sur-
gical unit of the University College Hospital, Ibadan. On all
blunt chest injury patients over a 20 years period and concluded
that majority of blunt chest trauma can be managed by simple
procedures with minimal complications; that (72.9%) of cases
had either closed thoracostomy drainage or clinical observation,
(27.1%) had major thoracic surgical intervention [16], that was
also quite relevant to our results.
Also regarding management; we noticed after data analysis
that the need for mechanical ventilation associated with mor-
tality and high morbidity. In 2002 a study was conducted on
patients with blunt chest trauma; endotracheal intubation was
performed at the scene or in transit on (52%) of patients, and
that associated with poor prognosis. [17]
The fate of the studied cases was close enough to what
Shahzad et al. noticed in their study; where (50.3%) admitted
to ICU, (40.6%) were admitted to Inpatient Ward, (6.1%) were
discharged home and only (3%) died. [8]
On application of the studied score, we noticed that higher
scores attributed to high risk of mortality. Out of those who
scored 0-5, two was discharged, and eight admitted to Inpatient
Ward, with a score of 6-10, four admitted to Inpatient Ward
and another four to ICU. All of those who scored 11-20
admitted to
ICU, and above that score (≥ 21-25) the fate was the early death
of two patients that was close enough to what Shahzad et al.
discovered in their study. [8]
Using the ROC curve analysis; it showed that the TTSS above
a score of 7, the score showed 100% sensitivity and also 100%
specificity for predicting the outcome of thoracic trauma patients;
keeping in mind that we are testing the score in patients with
isolated thoracic trauma. That meets with what found in 2014
in Pakistan, where they concluded that there is a significant
relationship between outcome and TTSS. Outcomes worsened
with increased score, using Chi-square test, results showed the
statistically significant association between patient’s outcome
and Thoracic trauma severity score (TTS). [8] (Fig.1)
In 2011 Tjeerd et al., in The Netherland; had a study to demon-
Table 5 Distribution of patients’ outcomes according to their age & sex (N=30).
Discharge Mortality Morbidity
Total p-value
n=2 n=2 n = 26
N % N % N %
Age <30 2 100.0% 0 16.7% 10 83.3% 12 0.011 *
30-41 0 0.0% 0 0.0% 4 100.0% 4
42-54 0 0.0% 0 0.0% 8 100.0% 8
55-70 0 0.0% 2 50.0% 2 50.0% 4
>70 0 0.0% 0 0.0% 2 100.0% 2
Table (5) shows that age showed statistically significant
difference regarding mortality being associated with old age; with p-value 0.011.

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
strate an association between characteristic (ROC) curve” Lung contusions were
the TTSS and thorax-related it could be shown, that with presented mostly as less than 2. Peters S, Nicolas V and
death. The score was a value of 0.924, the TTS is two lobes ipsilateral and that Heyer C. MDCT-
significantly higher in superior to all other bilateral involvement spectrum of the blunt
patients who died of other described scores. The TTS associated with higher chest wall in
complications. Also, the offers a simple, reliable mortality. The majority of polytraumatized
thorax trauma-related solution to the problem of patients had pneumothorax patients. Clin Radiol
complication rate has been initial, CT-independent and ten- sion pneumothorax 2010; 665:333–8.
shown to be high (27%) and judgment of the severity of showed statistically 3. Clark D and Fantus
can be severe. [18] Also, it thoracic trauma. [20] significant difference R.National Trauma Data
showed [18] that the TTSS between good and poor Bank (NTDB),
is significantly greater in C outcomes. American College of
patients who develop ARDS o Only a small percentage Surgeons Annual
after thorax trauma. n of cases had mediastinal Report. Chicago.
In 2012, Philipp M et al. c injuries; that are not a part American College of
suggested a study l of the TTSS parameters; Surgeons 2007; 1-64.
regarding out- comes of however it showed a
u
chest trauma patients significant relation to poor 4. Sawyer M, Sawyer E
s
comparing different outcomes, as half of them and Jablons D. Blunt
i
thoracic trauma scoring died. chest trauma in J
o
systems reviled that among The management plan Trauma 2007; 63: S68–
n
the examined scor- ing was almost always 80.
systems, only the TTS was Most of the patients were conservative ex- cept for
an independent predictor young adults, and more certain cases where 5. Ulshrestha P and
of mortality. Patients with a than half of them were emergent or possible MunshiIand R. Profile
TTS > 9 had a 4-fold risk of males. Motor vehicle surgery per- formed. A of chest trauma in a
death. [9] collisions were responsible significant number of level I trauma center. J
Furthermore, the TTS for most of the cases. patients needed early Trauma. 2004;
showed the best prediction Most of the patients intuba- tion and mechanical 57(3):576-81.
power com- pared with CT- presented with mild ventilation, which also
independent scoring tachycardia and associated with poor
systems (AISchest, PCS) normotensive state. Mild outcomes. Regarding the
and the CT-dependent tachypnea was the only results; the majority of cases
Wagner-score. As the vital signs that showed were ad- mitted either to
diagnostic value of statistically significant ICU or Inpatient ward and
conventional radiography of difference between good only a small fraction were
the chest seems to be not as and poor outcomes. between the two extremes,
limited in their study as Also, it was found that either discharged early or
they described, it is hypoxemia was a significant died immediately at ER.
reasonable that the TTS predictor of mortality. Most This study supports the
combining anatomical and bony injuries were on the use of the TTSS for
physiologic parameters are same site of trauma in the predicting mor- tality in
superior to CT-dependent form of fracture one to three thoracic injury patients, as
and CT-independent ribs. higher scores associated
scoring systems based only with higher mortality and
on fundamental parameters. morbidity.
Primarily, the inclusion of Sex, heart rate, systolic
age as a component of the blood pressure, and some
TTS may contribute to its ribs frac- tured had no
predictive value, coincide statistically significant
with what also difference between good
documented by Lotfipour S and poor outcomes.
et al. in
2009 that age identified as a Authors’ Statements
risk factor for post-
traumatic com- plications Competing Interests
and poor outcome following The authors declare no
conflict of interest.
thoracic trauma. [19]
Previously in 2002,
Frank H et al. addressed References
that as the TTS does not 1. Mirka H, Ferda J and
require chest CT, it is Baxa J. MDCT of blunt
usable in every hospital chest trauma:
and can be calculated indications, technique
quickly. By using the and interpretation. 2012;
“receiver operating 3:433–49.

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106
 6. Mattox K and Wall M. Thoracic trauma, Glenn’s cardiovas-
cular surgery, 6th ed. Prentice Hall International Inc. 1996;
93-112.

7. Pape H, Remmers D, Rice J, et al. Appraisal of early evalua-

tion of blunt chest trauma: development of a standardized
scoring system for initial clinical decision making, J Trauma.
2000; 49(3):496–504.

8. Shahzadi S, Mohammad M, Khan J, et al. Comparison of

outcome between low and high thoracic trauma severity
score in blunt trauma chest patients Med Coll Abbottabad
2014;26(4)474-77.

9. Philipp M, Christian Z, Hagen A. Comparison of different

thoracic trauma scoring systems in regards to prediction of
post-traumatic complications and outcome in blunt chest
trauma. Journal of Surgical Research; 2012:176, 239–247.

10. Shahram L, Shawn K, Federico E, et al. Factors associated

with complications in older adults with isolated blunt chest
trauma. West J Emerg Med. 2009; 10(2): 79–84.

11. Ayman G., Mohamed A. Role of emergency vats in blunt

chest trauma patients. British Journal of Science; 2013, 9 (2)
37-42.

12. Shorr R M, Crittenden M, Indeck M, et al. Blunt thoracic

trauma. Ann Surg. 1987; 206(2): 200–205.

13. Chad G, Amy D, Wyrzykowski, et al. Thoracic needle de-

compression for tension pneumothorax: clinical correlation
with catheter length. Can J Surg. 2010; 53(3): 184–188.

14. Bartolomeo D, Stefano, Sanson, et al. A Population-Based

Study on Pneumothorax in Severely Traumatized Patients,
Journal of Trauma-Injury Infection & Critical Care: 2001; 4
(51) 677-682.

15. Manuel C, Rebecca L, Rosalba M, et al. Secondary Pneumo-

mediastinum: A Retrospective Comparative Analysis. 2009;
187(5) 341-346.

16. Kent J, David R, Jerry L, et al. Management of Flail Chest

Without Mechanical Ventilation. 1975; 19(4) 355–363.

17. Mehmet E, Gürsel O, Ayten K, et al. Emergency Thora-

cotomy for Blunt Thoracic Trauma, analysis of thoracic
trauma. 2002; 3,189-207.

18. Tjeerd S, Ludo F, Falco H, et al. Validation of the Thorax

Trauma Severity Score for mortality and its value for the
development of acute respiratory distress syndrome, Ams-
terdam, Netherlands. 2011; (3)49-53.

19. Lotfipour S, Kaku SK, Vaca FE, et al. Factors associated

with complications in older adults with isolated blunt chest
trauma. West J Emerg Med 2009; 10:79.

20. Frank H, Martijn G, Rajeev G, et al. Diagnostics and Scor-

ing in Blunt Chest Trauma, European Journal of Trauma
2002(3);157-167.

Adel Elbaih et al./ International Journal of Surgery and Medicine (2016) 2(3): 100-106