Modified Revised-Marshal Score
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New Scoring system of TBI, combining anatomic-Physiologic
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Modified Revised-Marshal Score
- 1. Anne Saputra Mahadewa TG, Golden N Department of Surgery, Faculty of Medicine Udayana University Sanglah General Hospital, Bali
- 2. Traumatic Brain Injury (TBI) Severe TBI mortality 50% (Bullock 2011) Indonesia: (RSCM, PERDOSSI 2009) Severe 35-50% Moderate 5-10% RSUP Sanglah, Bali: • > 2000 cases a year • 30% severe TBI DECISION OF SURGERY ? • Do I need to operate? • When should to operate? Prognostic score model ANATOMICAL & PHYSIOLOGICAL
- 4. TBI Anatomy Mechanism RTS Marshall GOS GCS Sistolic Blood Pressure (mmHg) Respiration rate (times/min) Scoring code 13-15 >89 10-29 4 9-12 76-89 >29 3 6-8 50-75 6-9 2 4-5 1-49 1-5 1 3 0 0 0
- 5. Statistic RTSc = 0.9368 GCSc + 0.7326 SBPc + 0.2908 RRc Chawda, M.N. 2004. Predicting Outcome After Multiple Trauma: Which Scoring System? The International Journal of The Care of The Injured; 35: 347-358.
- 6. Statistic Winn, R. 2017. Youmans & Winn Neurological Surgery (7th ed) in Clinical pathophysiology of traumatic brain injury
- 8. Prognosis TBI PHYSIOLOGY: • GCS • Hypotension • Hypoxia ANATOMY: Imaging Brain CT scan RTS Marshall Both have correlation with outcome 1. COMBINATION??? 2. Improved Outcome???
- 9. Prospective observational approved by Committee of ethical study on 181 patients at ER dept in 2017 • Eligible patients of Moderate/Severe TBI • Both Marshall & RTS were recorded in the first 60 min • Exclude: Respiratory, cardiogenic, neoplasma and multiple trauma • Outcome: GOS 6 months Analyzed using SPSS 16.0, p<0.05
- 11. [CELLRANGE ] 13 [CELLRANGE ] 29 [CELLRANGE ] 17 [CELLRANGE ] 122 3 4-5 6-8 9-12 GCS Mean 8.3 ± 2.8 >29 times 20 11% 10-20 times 161 89% Resp Rate [CELLRANGE ] 4 [CELLRANGE ] 3 [CELLRANGE ] 175 50-75 mmHg 76-89 mmHg >89 mmHg Sistolic BP Mean 21.4+ 3.5 Mean 122.3+ 25.1
- 12. [CELLRANGE] 11 [CELLRANGE] 61 [CELLRANGE] 36 [CELLRANGE] 60 [CELLRANGE] 13 0 10 20 30 40 50 60 70 DI IV NON EVACUATED LESION DI IV EVACUATED LESION DI III DI II DI I Marshall CT Scan
- 13. [CELLRANGE] 66 [CELLRANGE] 1 [CELLRANGE] 4 [CELLRANGE] 17 [CELLRANGE] 93 0 20 40 60 80 100 1 DEATH 2 VEGETATIVE STATE 3 SEVERE DISABILITY 4 MODERATE DISABILITY 5 GOOD RECOVERY GOS Good- Moderate 110 61% Severe, Vegetative, Death 71 39% Categorized GOS
- 15. 2.9 64.8 78.2 72.9 3.9 71.8 80.9 77.3 4.5 84.5 64.5 72.4 RR SENSITIVITY SPECIFICITY ACCURATION RTS Marshall Combination
- 17. Modified Revised Trauma-Marshall score = (0.56 x RTS) + (0.6 x Marshall) – 4,1
- 18. END POINT: 1. Combination results in higher sensitivity and proved to increase validity in predicting outcomes 2. Combination has a correlation NEW modified score prognostic
- 19. Used for early detection of unfavourable outcomes RTS 10 dan CT Scan Marshall 2 An easy-to-use modified trauma score on triage setting (accurate, simple, applicable and reliable)
- 20. THANK YOU
Editor's Notes
- TBI is major global public health problem, with high mortality and morbidity incidence a year. TBI associated with long-term physical, cognitive, and psychological disturbances as quality of life. Trauma is a time-sensitive condition Easy-to-use trauma scoring systems inform physicians of the severity of the trauma in patients and help them to decide
- There is prognostic analysis, the modifiedable factors to prevent secondary brain injury. Those are: Physiological factors (SBP, Hipoxia and Hipotermia). Anatomical
- Revised Trauma Score (RTS). It uses three specific physiologic parameters: Glasgow Coma Scale (GCS), blood pressure, and respiration rate.
- RTS telah banyak digunakan pada trauma center, dan diyakini mampu meramalkan probability of survival pada kasus trauma. Dengan semakin tinggi nilai RTS, makan semakin besar probability of survival
- Neuroimaging is essential in defining the anatomical extent and structural damage of intracranial injury and managing patients with acute brain injury.
- Marshall used as International guidelines on prognosis include this classification as a major predictor of outcome
- A single predictor has been widely used in trauma and provides an overview of the patient’s prognosis. There is no single score is perfect, each has its own limitation. Combination is expected to minimize it.
- Based on this ROC (Receiver Operating Characteristic) analysis to assess the ability of the prediction of RTS in predicting outcomes, assessed based on the Area Under the Curve (AUC). a curve is formed below the diagonal line, which means that the lower the value of the parameter then the chances of getting a higher unfavourable outcomes Interpretation of the ROC curve, Formed diagonal line on these curves in the get AUC amounting to 02542, This means that a low RTS has a good ability to predict unfavourable outcomes. The best cut point is determined based on the coordinates of the line furthest from the diagonal and in the get RTS <=10, Marshall <=2
- Hasil Penggabungan: Kemampuan menunjukan secara akurat dicerminkan dengan sensitive-spesif Skrining ideal memiliki sensi – spesi tinggi: VALIDITAS tinggi SENsitifitas: Kemampuan menunjukkan, berapakah yang benar memiliki unfavorable outcome dari seluruh populasi yang unfavourable outcome Spesif : Kemampuan menunjukan FAV pada populasi FAVourable NPP : kemampuan meramalkan , benar2 unfavorable NPN: kemampuan meramalkan, benar2 FAV Suatu skoring memiliki kelebihan dan kekurangan masing-masing Penggabungan akan lebih meningkatkan kemampuan dan memperkecil kekurangan dari sebuah skoring Terbukti pada penelitian ini!
- Pearson’s correlation formula proved that RTS has a positive correlation to Marshall. logistic regression model of RTS and MCTC, a formula can be generated by combining both scores kemampuan prediksi penggabungan memberikan hasil prediksi yang telah terbukti baik, dilanjutkan dengan mencari korelasi atau kekuatan hubungan Arah korelasi dikatakan searah apabila nilai r positif. Korelasi dikatakan bermakna antara kedua variabel yang diuji apabila nilai p<0,05 Koefisien beta menunjukkan seberapa besar outcome bila MODIF meningkat koefisien determinasi menunjukkan seberapa UNFAV dapat diprediksi oleh MODIF y = a + (b1.x1) + (b2.x2) Berdasar kedua hasil Analisa tersebut di dapatkan nilai koefisien determinasi (R2) 0.3345 dirumuskan PROGNOSTIK SKORING BARU modified RTS-Marshall skor sebagai berikut.
- Skrining awal/deteksi dini -> dapat memprediksi hasil akhir, sebelum muncul tanda dan gejala komplikasi. Treatment lebih awal outcome lebih baik. Salah satu syarat tes skrining : Akurat dan Reabilitas Akurat -> menunjukkan sejauh mana hasil skrining sesuai dengan kenyataan Reabilitas -> standarisasi pengujian, jika pengukuran dilakukan berulang kali hasil yang diperoleh tidak jauh berbeda : Sensitif-Spesifi-NPP-NPN Syarat skrining baik: akurat, Simple, applicable, reliable