Issues regarding patient assessment scores that focus on acid base changes in fracture patients.

To the Editor: We are writing to you today to indicate issues in an article published in your Journal. In the publication, the authors discussed that they have recalculated the recommendations published in 2005 and discarded the meaningfulness of that article. In fact, a group of European orthopedic trauma surgeons published an article on the clinical assessment of the polytraumatized patient in the Journal of Orthopaedic Trauma. Of 156 publications, parameters to assess trauma patients in the early stages of their injuries were summarized. These parameters were incorporated into four different categories, based on the triad of death (shock, coagulopathy, temperature, soft tissue injuries). Parameters indicative of complications were added, which focus on chest trauma, soft tissue injuries, and massive transfusions. For several parameters, the authors purposefully used overlapping numbers or general recommendations. The authors felt that these recommendations should not be used to classify a given patient or for individual scoring. In their 2014 publication in the Journal of Trauma and Acute Care Surgery, Nahm et al. claim to have used a slightly altered version of our recommendation. However, this is not the case. Instead, they have used a substantially different categorization that has little to do with the original suggestion. Because of a lack of availability in their database, limited information was available regarding certain categories described in the publication in 2005. Among these were those regarding coagulatopathy, pulmonary function, and indicators of severe hemorrhage. Other parameters were also omitted. Some of these are important in the assessment and treatment of trauma patients, such as factor II and V, fibrinogen, D-dimer levels, the Advanced Trauma Life Support classification for shock, urinary output values, the PaO2/FIO2 ratio, and the Thoracic Trauma Score. To our mind, this selection byNahmet al. precludes getting a well-rounded view on patient physiology but focuses on certain parameters that are part of their own scoring system. The effects of this selection are best summarized as follows: 1. Upgrade of the weighting of lactate and base deficit, by using preset values. 2. Downgrade of the weighting of thoracic injuries by including patients without chest trauma (Abbreviated Injury Scale [AIS] score, 0), and alteration of the grading of chest trauma by changing the values of AIS for patients in borderline, unstable, and in extremis condition from the original recommendation. Nahm et al. focus only on the patients who are cleared for surgery and select only patients with AIS scores from 0 to 3. 3. Downgrade of the importance of massive transfusion by expanding the time of transfusion toward the entire first day after trauma rather than the first hours.