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J Trauma Acute Care Surg. 2019 Sep;87(3):658-665. doi: 10.1097/TA.0000000000002402.

Rethinking the definition of major trauma: The need for trauma intervention outperforms Injury Severity Score and Revised Trauma Score in 38 adult and pediatric trauma centers.

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From the Division of Trauma, Critical Care, & Acute Care Surgery (J.W.R.-F., N.R.R., M.L.F.), Baylor University Medical Center at Dallas, Dallas, Texas; Children's Minnesota Research Institute (A.L.Z.), Children's Minnesota, Minneapolis, Minnesota; Division of Acute Care Surgery (K.W.S., W.C.B.), University of Arkansas for Medical Sciences, Little Rock, Arkansas; Centura Health Trauma System (C.M., R.A.C.), Colorado Springs, Colorado; St. Anthony Hospital (A.R.B.), Lakewood, Colorado; Center for Trauma and Critical Care (J.H., B.S.B.S.), George Washington University, Washington, District of Columbia; Penn State Hershey Children's Hospital (J.C.H.), Hershey. Pennsylvania; Trauma Department, Children's Hospital of Dallas (C.G.), Dallas, Texas; Rhode Island Hospital (C.A.A., S.N.L.); Warren Alpert Medical School of Brown University (C.A.A., S.N.L.), Providence, Rhode Island; Division of Trauma (M.W.), Cook Children's Medical Center, Forth Worth, Texas Clinical Research Institute, Methodist Health System (V.A.); Associates of Surgical Acute Care (J.D.A.), Methodist Dallas Medical Center, Dallas, Texas; University of North Carolina HealthCare (C.F.W.), Chapel Hill, North Carolina; Division of Trauma and Acute Care Surgery (D.J.M.), Medical College of Wisconsin; Froedtert Memorial Luthern Hospital (A.B.), Milwaukee, Wisconsin; University of Colorado Health Medical Center of the Rockies (W.D., M.J.W.), Loveland, Colorado; Department of Surgery (J.C.), Greenville Health System, Greenville, South Carolina; Trauma & Acute Care Services (C.A.L.), John Peter Smith Health Network, Forth Worth, Texas; Division of Trauma & Acute Care Surgery (J.L.R.), Baylor Scott & White Medical Center, Temple, Grapevine, Texas; Regions Hospital (M.D.M.), St. Paul, Minnesota, Pediatric Trauma (S.D.F.), Helen Devos Children's Hospital, Grand Rapids, Michigan; Aspirus Wausau Hospital (S.S.), Wausau, Wisconsin; Children's Hospital of Philadelphia (M.L.N., M.C.), Philadelphia, Pennsylvania; Division of Trauma (B.P., D.S.), Baylor Scott & White Medical Center at Grapevine, Grapevine, Texas; and Department of Surgery (T.J.S.), University of Colorado School of Medicine; Division of Trauma (T.J.S.), University of Colorado Health-Memorial Hospital, Aurora, Colorado.



Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS) <7.84 defines major physiologic derangement, but there is no standard definition for reserve. The Need For Trauma Intervention (NFTI) identifies severely depleted reserves (NFTI+) with emergent interventions and/or early mortality. We hypothesized NFTI would have stronger associations with outcomes and better model fit than ISS and RTS.


Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).


The NFTI had stronger associations with complications and LOS than ISS and RTS (odds ratios [99.5% confidence interval]: NFTI = 9.44 [8.46-10.53]; ISS = 5.94 [5.36-6.60], RTS = 4.79 [4.29-5.34]; LOS incidence rate ratios (99.5% confidence interval): NFTI = 3.15 [3.08-3.22], ISS = 2.87 [2.80-2.94], RTS = 2.37 [2.30-2.45]). NFTI was more strongly associated with continuing care discharge but not significantly more than ISS (relative risk [99.5% confidence interval]: NFTI = 2.59 [2.52-2.66], ISS = 2.51 [2.44-2.59], RTS = 2.37 [2.28-2.46]). Cross-validation revealed that in all cases NFTI's model provided a much better fit than ISS greater than 15 or RTS less than 7.84.


In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.


Prognostic, level IV.

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