e-ISSN: 2722-3558 Sriwijaya Journal of Surgery [SJS] https://sriwijayasurgery.
A Preliminary Retrospective Analysis of the Blunt Abdominal Trauma Scoring System (BATSS) in a High-Prevalence Cohort: A Single-Center Indonesian Experience Akbar Rizky Wicaksana1*.
Alsen Arlan2.
Theodorus3 1Specialized Residency Training Program.
Department of Surgery.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 2Division of Digestive Surgery.
Medical Staff Group/Department of Surgery.
Dr.
Mohammad Hoesin General Hospital.
Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia 3Faculty of Medicine.
Universitas Sriwijaya.
Palembang.
Indonesia
ARTICLE
INFO
Keywords:
BATSS
Blunt abdominal trauma Diagnostic accuracy Scoring system Triage *Corresponding author:
Akbar Rizky Wicaksana E-mail address:
rizkyw@gmail.
All authors have reviewed and approved the Anal version of the manuscript.
https://doi.
org/10.
37275/sjs.
ABSTRACT
Introduction: The triage of blunt abdominal trauma (BAT) is a critical challenge, and the utility of clinical scoring systems like the blunt abdominal trauma scoring system (BATSS) requires validation in diverse clinical This study aimed to provide a preliminary, critical appraisal of the BATSS's diagnostic performance and the behavior of its individual components in a unique, high-risk cohort at a tertiary Indonesian trauma Methods: A retrospective analysis was conducted on 37 BAT patients who underwent definitive diagnostic evaluation (CT scan or laparotom.
between July 2021 and July 2025 in Palembang.
Indonesia.
The cohort was noted to have a significant selection bias, with an intra-abdominal injury (IAI) prevalence of 91.
9% .
injured, 3 uninjure.
A component-level analysis of the seven BATSS variables was performed alongside a standard diagnostic accuracy assessment using an ROC curve to determine the optimal cut-off.
Results: The cohort was predominantly young males injured in traffic accidents.
The ROC analysis demonstrated poor discriminatory power (AUC = 0.
At an optimal cut-off of 8.
BATSS showed a sensitivity 4% and a statistically unstable specificity of 33.
3% .
% CI: 0.
8% to 6%).
The PPV was 93.
3%, while the NPV was critically low at 14.
Component analysis revealed that sensitivity was primarily driven by highpoint variables like a positive FAST scan, while low specificity was associated with non-specific signs like abdominal tenderness.
Conclusion: In this highprevalence, pre-selected cohort.
BATSS failed to perform as a reliable triage Its poor specificity and dangerously low NPV render it unsuitable and unsafe for ruling out IAI.
The score's apparent sensitivity was driven by variables that already indicate a high-risk patient, suggesting the score adds little value to standard clinical assessment.
This preliminary study highlights the critical need for robust, large-scale validation before clinical adoption and suggests BATSS may be inappropriate for settings with a high pre-test probability of injury.
Introduction particularly perilous entity, constituting up to 75% of Trauma persists as a formidable global health all significant blunt injuries.
The modern world, crisis, representing a primary cause of death and defined by high-speed transportation and industrial disability, particularly among younger populations.
1 It activity, creates an environment where the forces is not a singular disease but a spectrum of complex imparted during collisions, falls, and accidents can far pathologies initiated by the transfer of kinetic energy exceed the structural tolerance of the human torso.
to the human body.
Within this spectrum, blunt The abdomen, a compliant cavity housing a dense abdominal trauma (BAT) represents a frequent and array of vital organs without the rigid protection of the thorax, is exquisitely susceptible to these forces.
The Sonography for Trauma (FAST).
The FAST exam is a consequences are diverse and severe, ranging from rapid, non-invasive bedside tool that has become an immediate exsanguination from solid organ rupture to essential component of the primary trauma survey, delayed sepsis from hollow viscus perforation.
3 The pathophysiology of intra-abdominal injury (IAI) in BAT sonographic signature of intra-abdominal bleeding.
is a direct function of the mechanism and magnitude a hemodynamically unstable patient, a positive FAST of the force applied.
4 Deceleration injuries, the is a clear mandate for immediate surgical exploration.
hallmark of motor vehicle collisions, cause differential Yet, the FAST exam has well-defined limitations.
it is movement of internal structures, leading to shearing insensitive to retroperitoneal hemorrhage, contained forces at points of anatomical fixation.
This can result solid organ hematomas, diaphragmatic ruptures, and in devastating vascular avulsions at the hilum of the the vast majority of bowel and mesenteric injuries.
For spleen or liver, or transection of the small bowel at the the larger cohort of hemodynamically stable patients, ligament of Treitz.
Direct compressive forces, such as a blow from a steering wheel, can crush organs against tomography (CT) has become the undisputed gold CT provides unparalleled anatomical detail, fractures in the liver, spleen, or pancreas, and "burst" allowing not only for the diagnosis of injury but also injuries in hollow organs when intraluminal pressure for its precise grading, a critical factor that has Understanding these enabled the widespread and successful adoption of mechanisms is fundamental to appreciating the non-operative management (NOM) for many solid organ injuries.
spikes within a closed complex, and clinically silent in the initial post-injury contrast-enhanced Despite its diagnostic power, the indiscriminate use of CT is neither feasible nor desirable.
CT scanning The emergency management of BAT is a race against time, governed by the principle of the "golden transporting a potentially unstable patient away from hour," during which rapid and accurate diagnosis is the resuscitation area.
It involves substantial costs, a paramount to survival.
6 However, the initial clinical critical consideration in all healthcare systems, and assessment is notoriously fallible.
The classic signs of exposes patients to a significant dose of ionizing peritonitis or hemorrhagic shock are often late radiation, a concern particularly in young patients and for whom repeat scans may be necessary.
In many physiological insult has occurred.
The clinical picture parts of the world, including parts of Indonesia, is frequently obscured by confounding factors.
immediate 24/7 access to a high-quality CT scanner mental status from a concomitant traumatic brain injury or intoxication can render a patient unable to guaranteed, creating a diagnostic gap that needs to be localize pain, while the intense pain from a femur or This gap has led to the development of clinical pelvic fracture can easily distract both the patient and scoring systems, which aim to standardize risk stratification by combining objective clinical findings This into a predictive score.
The blunt abdominal trauma examination places a heavy burden on adjunctive scoring system (BATSS) is one such tool, developed to diagnostic tools to unmask the occult injury.
The predict the probability of IAI needing intervention.
diagnostic algorithm for BAT has been revolutionized integrates seven variablesAihypotension, tachycardia, over the past three decades.
The invasive and often abdominal pain, abdominal tenderness, lower chest non-specific diagnostic peritoneal lavage (DPL) has wall signs, pelvic fracture, and a positive FAST resultAi been largely replaced by the Focused Assessment with into a weighted 24-point scale.
9 Each variable was chosen for its statistical association with significant for retrospective designs.
The study was conducted in Hypotension and a positive FAST carry the full accordance with the ethical principles outlined in most weight, reflecting their strong correlation with the Declaration of Helsinki.
The complete research major hemorrhage.
The theoretical appeal of BATSS is protocol was submitted to the institutional review its potential to serve as a rapid, evidence-based tool at board, the Ethics Committee of Dr.
Mohammad Hoesin the bedside, helping clinicians to make more rational General Hospital Palembang, and was granted a decisions about resource allocation and to expedite the care of the most severely injured patients.
10 However, (No.
DP.
03/D.
XVi.
08/ETIK/202/2.
As the the promise of any scoring system is contingent on its study relied exclusively on the retrospective review of performance in the real world, outside of the controlled de-identified data from existing medical records, the environment of its developmental study.
The trauma committee waived the need for individual patient community remains divided on whether these scores informed consent.
Strict protocols were enforced to offer a tangible benefit over the "clinical gestalt" of an maintain data anonymity and patient confidentiality experienced surgeon.
throughout the research process.
The study was The translation of a clinical scoring system into a it is an act of validation.
Performance hospital and designated trauma center for the province can be dramatically altered by local factors, including of South Sumatra.
Patient data were identified and extracted from the hospital's comprehensive medical healthcare system processes.
While BATSS has been records archive.
The study period included all eligible patients admitted from July 1st, 2021, to July 31st, epidemiological landscape of Southeast Asia remains The source population comprised all patients largely unknown.
This study, therefore, was conceived aged 17 years and older who presented to the not as a definitive validation but as a preliminary, emergency department with a primary diagnosis of blunt abdominal trauma.
Inclusion in the final analytical cohort was contingent upon patients having volume Indonesian trauma center.
The primary aim undergone a definitive investigation to either confirm was twofold: first, to assess the overall diagnostic or exclude the presence of IAI.
This was defined as the accuracy metrics of the BATSS in our unique, high- completion of a contrast-enhanced CT scan of the prevalence cohort.
and second, to move beyond this abdomen and pelvis or an exploratory laparotomy.
Patients component-level performance of BATSS in the specific context of a high- performed at Dr.
Mohammad Hoesin General Hospital in Palembang.
Indonesia, the primary tertiary referral precluded the calculation of a full BATSS or the behavioral characteristics of the score's constituent ascertainment of the final diagnosis were excluded.
Additionally, patients with penetrating trauma or those under the age of 17 were excluded.
It is critical Methods to acknowledge that these inclusion criteria create a This study was conducted as a retrospective, single-center significant and inherent selection bias.
The resulting The primary objective was to evaluate the undifferentiated population of BAT patients who performance of the BATSS against a definitive present to the emergency department.
Instead, it reference standard for the diagnosis of IAI.
The study represents a highly filtered subgroup of patients in adhered to the Standards for Reporting of Diagnostic whom the pre-test probability of significant injury was Accuracy Studies (STARD) guidelines where applicable already deemed high enough by the treating clinicians to warrant advanced imaging or surgical intervention.
The optimal cut-off value was determined from This selection bias leads to a cohort with a very high the Youden's index on the ROC curve to maximize prevalence of IAI, a factor that is known to profoundly sensitivity for screening.
Using this cut-off, a 2x2 contingency table was used to calculate the sensitivity, particularly positive and negative predictive values.
(PPV),
This study, therefore, evaluates the performance of negative predictive value (NPV), along with their 95% BATSS within a high-risk population, not as a general CIs.
To address the study's exploratory aims, two screening tool for a low-risk population.
secondary analyses were conducted.
A component- A standardized data extraction form was developed level analysis was performed to describe the frequency to ensure systematic and consistent data collection.
of each of the seven positive BATSS variables within single investigator reviewed the medical records to the overall cohort.
These frequencies were then minimize inter-rater variability.
The following data compared between the IAI-positive and IAI-negative points were meticulously extracted for each patient:
groups using Fisher's exact test, given the small Demographic and Trauma Data: Age, gender, and sample size.
A stratified analysis was conducted to mechanism of injury.
BATSS Component Variables:
evaluate the performance of the BATSS using the Each of the seven variables required for the BATSS originally published risk strata: Low Risk (<.
, calculation was extracted from the initial clinical Moderate Risk .
, and High Risk (Ou.
The assessment documented in the emergency department diagnostic metrics were calculated using cut-offs of Ou8 These included: Hemodynamic Status: First and Ou12 to allow for direct comparison with the recorded heart rate and systolic blood pressure, foundational literature on the BATSS.
Physical Examination:
Documented tenderness, guarding, or rigidity.
Associated Injuries:
Evidence Results Figure 1 provides a comprehensive and multi- .
ruising, faceted schematic overview of the demographic and tenderness, or fractures of ribs 6-.
and radiological trauma-related characteristics of the 37-patient cohort confirmation of a pelvic fracture.
FAST Result: The documented result of the initial FAST examination.
overwhelmingly composed of males, who represent Reference Standard Outcome: The definitive diagnosis of the presence or absence of IAI was determined from predominance is a consistent finding in trauma the official, final reports of abdominal CT scans or the detailed findings documented in the operative notes differences in risk-taking behaviors, occupational from exploratory laparotomy.
exposures, and involvement in high-velocity activities.
This The gender-based All statistical analyses were performed using SPSS This is complemented by the age analysis, which software (Version 26.
IBM Corp.
Armonk.
NY).
The shows that the vast majority of patients .
6%) fall cohort was characterized using descriptive statistics.
Continuous variables were reported as mean A demographic concentration highlights that severe standard deviation, while categorical variables were blunt abdominal trauma is predominantly a disease of reported as frequencies and percentages.
A standard young, economically productive adults, amplifying its diagnostic accuracy assessment was performed.
societal impact through loss of life and disability Receiver Operating Characteristic (ROC) curve was during peak working years.
Traffic accidents were generated, and the area under the curve (AUC) with its responsible for an overwhelming 89.
2% of cases, 95% confidence interval (CI) was calculated to assess establishing high-velocity vehicular collisions as the the overall discriminatory ability of the total BATSS principal source of severe abdominal trauma in this 19-to-40-year This population.
The minimal contribution from falls .
patients with blunt abdominal trauma but rather a and other causes .
4%) further emphasizes the individuals in whom the clinical suspicion for severe threatening events.
This finding points directly to the injury was already substantial.
This exceptionally high urgent need for targeted public health interventions pre-test probability of disease is a crucial lens through related to road safety, vehicle standards, and post- which all subsequent diagnostic analyses must be crash care systems.
Finally, and perhaps most viewed, as it profoundly influences the performance critically from a clinical standpoint, the "Overall Injury and interpretation of any predictive tool.
In essence.
Profile" panel reveals a startlingly high prevalence of Figure 1 illustrates that the typical patient in this confirmed Intra-Abdominal Injury (IAI), with 91.
9% of study was a young male, injured in a traffic accident, the cohort .
of 37 patient.
having sustained who presented with a near-certainty of having a This fundamental to understanding the context of the pre-selected high-risk life-threatening abdominal injury.
entire study.
the cohort is not a representation of all Figure 1.
Demographic and trauma characteristics.
Figure 2 offers a granular deconstruction of the cohort demonstrated a predominance of colon injuries, clinical and anatomical characteristics of the high-risk which were identified in 8 patients.
This was followed patient cohort, providing critical context for the by the liver .
and spleen .
, with performance of the blunt abdominal trauma scoring the pancreas and jejunum also showing notable Category This specific injury signature may reflect Distribution" provides the initial and most striking regional patterns in trauma mechanisms or patient evidence of the cohort's high-acuity nature.
The bar transport and underscores the importance of local chart clearly demonstrates that a significant majority epidemiological data.
The high frequency of colonic of the patients, 62.
2%, were stratified into the "High and jejunal injuries, which can be diagnostically Risk" category .
core Ou.
based on the originally challenging in their early stages, further highlights the published BATSS criteria.
This finding is reinforced by need for a highly sensitive and specific triage tool.
(BATSS).
The "BATSS Risk the "Key BATSS Statistic" panel, which reports a mean Figure 3 provides the most critical and revealing BATSS score of 11.
84 (A 4.
for the entire group.
analysis of the manuscript, moving beyond the global mean score bordering on the high-risk threshold performance metrics to dissect the behavior of the indicates that the average patient in this study individual components of the blunt abdominal trauma presented with multiple clinical indicators of severe scoring system (BATSS).
The main grouped bar chart, trauma, such as hemodynamic instability or a positive "Component Frequency by Injury Status," visually tells FAST scan.
This is not a cohort of patients with minor the story.
For the IAI-positive group .
, there is a abdominal contusions.
rather, it is a population wide distribution in the prevalence of the different However, for the IAI-negative group .
, a derangement at the time of their initial evaluation, a stark pattern fact that is central to interpreting the subsequent abdominal pain and tenderness, are present in 100% performance of the scoring system.
Shifting from of these uninjured patients, while the next four, more clinical scoring to anatomical findings, the "Organ Type Hypotension, and Pelvic FractureAiare present in 0%.
Injured" emerges: the first variablesAiPositive FAST.
The donut chart illustrates a near-even understanding the score's paradoxical performance.
split between injuries to solid organs .
2%) and The "High-Impact Variables ('Action Drivers')" panel highlights the components that were exclusively proportion having mixed injuries .
1%).
This finding present in patients with confirmed IAI.
These are not is clinically significant because solid organ injuries, subtle diagnostic clues.
they are definitive markers of which typically lead to hemorrhage, and hollow viscus severe physiological derangement or high-energy injuries, which lead to peritonitis, often have different Hypotension, tachycardia, a positive FAST clinical presentations and temporal profiles.
The scan, and a pelvic fracture are each, in their own right, balanced distribution suggests that any diagnostic tool major red flags in a trauma assessment.
Their applied to this population must be capable of detecting complete absence in the uninjured group confirms both of these distinct pathophysiological processes their high specificity for significant injury.
The BATSS with equal efficacy.
Finally, the "Most Frequently derives nearly all of its ability to correctly identify Injured Organs" panel provides specific anatomical severely injured patients from these powerful, albeit detail that challenges some conventional expectations often late-stage, indicators.
Conversely, the "Low- in blunt trauma.
While the liver and spleen are often Specificity Variables ('Clinical Noise')" panel exposes cited as the most commonly injured organs, this the score's fundamental weakness.
5%),
Tachycardia.
This powerful somewhat unexpected balance in the types of injuries Figure 2.
Injury profile and BATSS distribution.
Abdominal tenderness and pain were ubiquitous, scientifically elegant dashboard summarizing the primary diagnostic accuracy of the blunt abdominal significant blunt force to the abdomen will cause pain trauma scoring system (BATSS) as determined in this and tenderness from the abdominal wall contusion This multi-paneled figure synthesizes the core itself, irrespective of deeper injury.
These signs offer no statistical findings, allowing for an immediate and discriminatory value in this cohort.
More strikingly, holistic understanding of the score's performance at chest wall injury was actually more prevalent in the the statistically optimized cut-off of Ou8.
The top-left uninjured group than the injured group .
3% vs panel displays the receiver operating characteristic 8%).
By incorporating these non-specific and (ROC) curve, a fundamental graphical representation BATSS of a diagnostic test's performance.
The blue line, introduces significant "noise" into its calculation, representing the BATSS, plots the true positive rate which is the primary driver of its high false-positive (Sensitivit.
rate and consequently poor overall specificity.
Specificit.
across all possible score thresholds.
Pathophysiologically.
Figure .
- Figure 3.
Component-level analysis of BATSS.
Its proximity to the dashed red "Line of No- existent cohort of uninjured patients, making any Discrimination" .
hich represents the performance of conclusions about the score's performance in ruling random chanc.
is a stark visual indicator of the out injury statistically fragile.
Finally, the bottom-right score's limited ability to distinguish between injured panel translates the raw data from the contingency table into the four key clinical metrics that are most confirmed in the top-right panel, which highlights the relevant to a practicing surgeon.
As shown in Figure 4.
Area Under the Curve (AUC).
The reported AUC of the BATSS achieves a high sensitivity .
4%) and a 525 is profoundly low, indicating that the overall correspondingly high positive predictive value (PPV) discriminatory power of the BATSS in this specific .
3%).
These metrics suggest that a positive test is cohort is only marginally better than a coin flip.
The likely to be correct in identifying an injured patient.
bottom-left panel presents the 2x2 Contingency Table.
However, which is the foundational data for all subsequent undermined by the critically poor performance in the It clearly shows the distribution of the 37 other two metrics.
The specificity is exceptionally low patients: 28 true positives, 6 false negatives, 2 false 3%, with a wide confidence interval indicating positives, and only 1 true negative.
This table is crucial profound statistical uncertainty.
Most alarmingly, the as it visually demonstrates the severe class imbalance negative predictive value (NPV) is a mere 14.
that underpins the study's findings, with a nearly non- rendering the score clinically dangerous and entirely This unreliable for excluding the presence of an intra- the surface but ultimately fails as a reliable triage instrument due to its inability to correctly classify Figure narratively encapsulates the central paradox of the uninjured patients.
study: the BATSS is a tool that appears sensitive on Figure 4.
Primary diagnostic accuracy analysis of BATSS.
Figure 5 presents a critical and highly informative The left panel of Figure 5 details the analysis at a comparative analysis of the blunt abdominal trauma cut-off of Ou8, which corresponds to separating "Low scoring system's (BATSS) performance when evaluated Risk" patients from those at "Moderate or High Risk.
At this threshold, the score functions as an extremely thresholds derived from the original literature: a cut- sensitive net, achieving a sensitivity of 88.
This off of Ou8 and a more stringent cut-off of Ou12.
This side- indicates that it correctly identified 30 out of the 34 by-side visualization is essential for understanding the injured patients, missing only four.
While this high inherent trade-offs between sensitivity and specificity sensitivity is a desirable trait for a screening tool, it is as the diagnostic bar is raised, and it powerfully rendered clinically meaningless by a complete failure illustrates the profound limitations of the score within this high-risk cohort, regardless of the threshold catastrophic result signifies that the score was entirely unable to correctly identify a single uninjured patient.
specificity, which This all three non-injured individuals in the cohort scored able to correctly identify uninjured patients, correctly Ou8, resulting in a 100% false-positive rate for that classifying two out of the three.
However, this The consequence of this is a negative predictive specificity is still modest and, given the small sample value (NPV) of 0.
0%, the most dangerous possible outcome for a triage tool.
This demonstrates that a predictive value (PPV) remains very high at 95.
7%, the "Low clinically crucial NPV shows only a marginal, and still reassurance and was, in fact, always wrong in this entirely unacceptable, improvement to 14.
Figure The right panel of Figure 5 provides a stark 5 masterfully encapsulates the clinical and diagnostic contrast, analyzing the score at the higher cut-off of dilemma presented by the BATSS in this study.
Ou12, which isolates only the "High Risk" patients.
demonstrates that there is no clinically viable balance expected, increasing the threshold dramatically alters to be found by adjusting the score's threshold.
A low the performance characteristics.
Sensitivity drops threshold (Ou.
is sensitive but dangerously non- significantly to 64.
7%, meaning the score now fails to specific and misleading.
A high threshold (Ou.
identify more than a third of patients with confirmed sacrifices too much sensitivity to be safe for screening.
intra-abdominal injuries .
false negative.
This The persistent and critically low NPV across both renders it an inadequate screening tool, as it misses a strata is the key takeaway, proving that regardless of substantial number of significant injuries.
In exchange how it is stratified, the BATSS cannot be used to safely for this loss of sensitivity, the specificity shows some rule out intra-abdominal injury in this patient improvement, rising to 66.
The score is now better Risk" (<.
While Figure 5.
Performance at other risk strata.
Discussion suggests that in a filtered, high-risk population, the The results of this study offer a sobering and highly BATSS loses its ability to effectively rule out injury.
nuanced perspective on the real-world application of Furthermore, the extreme class imbalance .
injured the blunt abdominal trauma scoring system.
While 3 uninjure.
renders the calculation of specificity conceived as a tool to bring objectivity and efficiency statistically fragile and clinically uninterpretable.
The to trauma triage, our analysis within a high-risk point estimate of 33.
3% is based on a single true Indonesian cohort reveals a performance profile that is negative and two false positives.
The 95% confidence not only suboptimal but potentially misleading if interval, spanning nearly the entire possible range interpreted without a deep understanding of its 8% to 90.
6%, transparently communicates this inherent biases and the pathophysiology of trauma The overarching conclusion is not simply that conclusion about the score's true specificity can be the score "works" or "does not work," but rather that drawn from this dataset.
The AUC of 0.
525, indicating its behavior is complex, context-dependent, and driven performance barely distinguishable from chance, is by a fundamental tension between its different the most honest reflection of the score's failure to discriminate between injured and uninjured patients Before interpreting any performance metric, it is imperative to address the profound impact Therefore, within this specific, imbalanced cohort.
of selection bias on this study's findings.
Our cohort.
The most insightful findings of this study emerge by design, consisted only of patients in whom clinical from the secondary component-level analysis, which suspicion for IAI was already high enough to trigger a allows us to move beyond the flawed global metrics definitive workup with CT or laparotomy.
This resulted and understand the internal mechanics of the score.
in a population with an IAI prevalence of 91.
9%, a The BATSS is not a homogenous tool but a composite figure far higher than the 12-15% typically cited in of two functionally distinct types of variables: high- unselected BAT populations.
This high pre-test yield "Action Drivers" and low-specificity "Clinical probability fundamentally alters the meaning of the Noise.
" The Action Drivers are the objective, high-point predictive values.
The high PPV of 93.
3% is less a variables: a positive FAST .
, hypotension .
testament to the score's accuracy and more a point.
, and tachycardia .
15 Our analysis reflection of the baseline reality that almost every showed that these findings were present exclusively in patient in the sample was injured.
12 In such an patients with confirmed IAI.
These are not merely environment, any positive test is likely to be a correct predictive markers.
they are clear, unambiguous signs of major physiological insultAinamely, significant Conversely, the critically low NPV of 14.
3% is equally a product of this high prevalence.
13 This trauma surgeon seeing a patient with these signs does finding is perhaps the single most important clinical not require a scoring system to identify them as high- message of this paper: in our high-risk cohort, a low these findings are, in themselves, direct triggers BATSS score was virtually useless for providing A negative test result barely decreased diagnostics for a direct trip to the operating room.
The the likelihood of injury.
This starkly contrasts with BATSS's high sensitivity is almost entirely powered by studies in lower-prevalence populations that reported these variables.
In essence, the score is highly more clinically acceptable NPVs.
This discrepancy sensitive because it effectively identifies patients who underscores a crucial principle of diagnostic testing:
are already in, or on the verge of, extremis.
In this predictive values are not intrinsic properties of a test context, the score is not making a subtle diagnosis.
but are highly dependent on the prevalence of the is simply documenting a crisis that is already clinically disease in the population being tested.
Our study The clinical noise is generated by the subjective, low-point variables: abdominal pain .
abdomen and an equivocal mechanism of injury.
This point.
and tenderness .
16 Our analysis is precisely where a clinician needs a tool to help showed these were nearly ubiquitous, present in decide between watchful waiting and a CT scan.
Our almost all patients, including 100% of the small cohort component analysis strongly suggests that the BATSS without IAI.
This demonstrates their complete lack of fails in this critical scenario.
Consider a stable patient The pathophysiology of trauma makes this .
o hypotension/tachycardi.
with a negative FAST 17 Any significant kinetic impact to the and no pelvic fracture, but with a tender abdomen.
torso will cause pain.
This pain can arise from benign This patient would score 3 points for tenderness, sources like abdominal wall contusions, rectus sheath placing them in the "Low Risk" category (<.
However, hematomas, or referred pain from lower rib fractures, our study, with its 0% NPV at this threshold, shows all of which are common in BAT.
These conditions can that this stratification is dangerously unreliable.
This patient could easily be harboring an occult, contained mimicking the peritonism of an IAI.
By assigning a injury that the score is structurally blind to.
The score total of 5 points to these unreliable signs, the BATSS fails because its only inputs for this gray-zone patient are the noisy, non-specific signs of pain over-scores non-IAI injuries, leading to a high false-positive rate and By failing here, the score fails in its destroying its specificity.
These variables do not clarify primary purpose.
It merely confirms the obvious in the critically ill and provides false reassurance in the ambiguity of the post-traumatic abdominal exam.
deceptively stable, making it a poor tool for practical The true value of any clinical decision rule is not in The low NPV is a direct reflection of this identifying the black-and-white casesAithe clearly pathophysiological blind spot.
A low score does not dying or the clearly uninjuredAibut in helping to equate to the absence of injury.
it may simply mean navigate the vast clinical "gray zone.
" This zone is the absence of overt, decompensated injury at a single occupied by the most common trauma patient: the one point in time.
who is hemodynamically stable but has a tender Figure 6.
Pathophysiological interpretation of BATSS performance.
A central finding of this investigation is the the visceral pain of true peritonitis.
20 This somatic paradoxical performance of the BATSS, which behaves pain triggers the low-point, subjective components of as a tool of two extremes: high sensitivity undermined the BATSS, namely abdominal tenderness and pain.
by poor specificity.
19 To elucidate the underlying As these signs are common in trauma patients both reasons for this dichotomy, a conceptual model was with and without IAI, they introduce significant developed, as depicted in Figure 6.
This schematic statistical "noise" and diagnostic ambiguity.
This visually deconstructs the BATSS into two distinct pathway explains the score's poor specificity, as it systematically misclassifies patients without IAI as different class of clinical variables.
The model posits being at risk based on these unreliable.
that the score's overall performance is not monolithic In a resource-rich environment, the low specificity but is rather the net result of a high-certainty pathway of BATSS might lead to acceptable costs, namely an ("Action Drivers") functioning in parallel with a low- increase in negative CT scans.
However, in a resource- limited setting like many Indonesian hospitals, the illustrates Pathway 1, termed "Action Drivers," which implications are more severe.
A tool with a high false- represents the high-specificity, reliable component of positive rate, if adopted as a primary screening the score.
This cascade begins with a high-energy instrument, would likely lead to a significant increase trauma event, which provides the necessary kinetic in the utilization of a scarce and expensive resource force to cause a major internal injury, such as a solid (CT scanner.
By flagging numerous patients with organ rupture or a significant vascular tear.
The direct only abdominal wall injuries as needing further and immediate pathophysiological consequence of imaging, the system could become overwhelmed, such an injury is internal hemorrhage, leading to the potentially delaying the scan for a patient with a more clinically detectable states of hemoperitoneum and, if subtle but critical injury.
The tool, therefore, risks severe enough, hemorrhagic shock.
These states becoming counterproductive to its goal of rationalizing manifest as objective, high-yield clinical signs that resource use.
Based on our findings, the pragmatic correspond to the most heavily weighted components clinical role for BATSS in our institution would be of the BATSS: a positive FAST scan and hypotension.
extremely limited.
It cannot be used to rule out injury.
Because these signs are direct and unambiguous Its only potential use is as an objective communication markers of severe internal bleeding, they act as tool to document the severity of patients who are powerful and reliable drivers of a high score.
This already identified as high-risk by their primary clinical pathway demonstrates why the BATSS retains high For instance, stating a patient has a "BATSS of it is structurally biased to correctly identify 17" might be a concise way to communicate to a patients who are already in a state of physiological consultant that the patient is hypotensive with a crisis, thus leading to a definitive "true positive" positive FAST, but it adds no new diagnostic diagnostic conclusion.
Conversely.
Pathway 2, termed "Clinical Noise," ("Clinical Noise").
Figure low-specificity, unreliable component of the score.
This pathway can Conclusion be initiated by a blunt trauma event of any energy This preliminary, retrospective analysis of the level, often one insufficient to cause IAI but capable of blunt abdominal trauma scoring system in a high-risk producing superficial or referred injuries, such as an Indonesian cohort reveals a tool with a deeply abdominal wall contusion, a rectus sheath hematoma, paradoxical and ultimately flawed performance profile.
or lower rib fractures.
The pathophysiological result is The study, while limited by its sample size and the generation of somatic pain, which, while intense, inherent selection bias, provides a critical insight: the is a non-specific clinical sign that frequently mimics BATSS, in this context, fails as a balanced and reliable triage instrument.
Its high sensitivity is an artifact of patient in Australia: a case report.
J Trauma its ability to detect overt hemorrhagic shock, a task for Inj.
: 310Ae4.
which a scoring system is largely superfluous.
This is paid for with a profoundly ynzpek A.
Yldrak MK.
Ezberci F.
Hollow viscus injury due to blunt abdominal trauma:
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References