Animal Trauma Triage Score, Modified Glasgow Coma Scale, age, and weight were associated with outcome in feline bite wounds (1,065 cases): a VetCOT registry study

Ashlei T. Tinsley Ryan Veterinary Hospital, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA

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Mark A. Oyama Ryan Veterinary Hospital, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA

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Erica L. Reineke Ryan Veterinary Hospital, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA

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Abstract

OBJECTIVE

To identify associations between admission variables, Animal Trauma Triage (ATT) score, and Modified Glasgow Coma Scale (MGCS) score with need for transfusion or surgical interventions and survival to discharge in cats with bite wounds.

ANIMALS

1,065 cats with bite wounds.

PROCEDURES

Records of cats with bite wounds were obtained from the VetCOT registry from April 2017 to June 2021. Variables included point of care laboratory values, signalment, weight, illness severity scores, and surgical intervention. Associations between admission parameters, terciles of MGCS, quantiles of ATT scores, and death or euthanasia were assessed using univariable and multivariable logistic regression analysis.

RESULTS

872 cats (82%) survived to discharge, while 170 (88%) were euthanized and 23(12%) died. In the multivariable model, age, weight, surgical treatment, ATT and MGCS scores were associated with nonsurvival. For every 1 year of age, odds of nonsurvival increased by 7% (P = .003) and for every 1 kg of body weight, odds of nonsurvival decreased by 14% (P = .005). Odds of dying increased with lower MGCS and higher ATT scores (MGCS: 104% [95% CI, 116% to 267%; P < .001]; ATT: 351% [95% CI, 321% to 632%; P < .001). Odds of dying decreased by 84% (P < .001) in cats that underwent surgery versus those that did not.

CLINICAL RELEVANCE

This multicenter study indicated association of higher ATT and lower MGCS with worse outcome. Older age increased the odds of nonsurvival, while each kilogram increase in bodyweight decreased odds of nonsurvival. To our knowledge, this study is the first to describe associations of age and weight with outcome in feline trauma patients.

Abstract

OBJECTIVE

To identify associations between admission variables, Animal Trauma Triage (ATT) score, and Modified Glasgow Coma Scale (MGCS) score with need for transfusion or surgical interventions and survival to discharge in cats with bite wounds.

ANIMALS

1,065 cats with bite wounds.

PROCEDURES

Records of cats with bite wounds were obtained from the VetCOT registry from April 2017 to June 2021. Variables included point of care laboratory values, signalment, weight, illness severity scores, and surgical intervention. Associations between admission parameters, terciles of MGCS, quantiles of ATT scores, and death or euthanasia were assessed using univariable and multivariable logistic regression analysis.

RESULTS

872 cats (82%) survived to discharge, while 170 (88%) were euthanized and 23(12%) died. In the multivariable model, age, weight, surgical treatment, ATT and MGCS scores were associated with nonsurvival. For every 1 year of age, odds of nonsurvival increased by 7% (P = .003) and for every 1 kg of body weight, odds of nonsurvival decreased by 14% (P = .005). Odds of dying increased with lower MGCS and higher ATT scores (MGCS: 104% [95% CI, 116% to 267%; P < .001]; ATT: 351% [95% CI, 321% to 632%; P < .001). Odds of dying decreased by 84% (P < .001) in cats that underwent surgery versus those that did not.

CLINICAL RELEVANCE

This multicenter study indicated association of higher ATT and lower MGCS with worse outcome. Older age increased the odds of nonsurvival, while each kilogram increase in bodyweight decreased odds of nonsurvival. To our knowledge, this study is the first to describe associations of age and weight with outcome in feline trauma patients.

Introduction

Currently there is a paucity of information in the veterinary literature on feline bite wounds and large multicenter studies in this patient population are lacking. Information from small retrospective studies suggest that bite wounds are the second most common cause of trauma in cats accounting for 15% of trauma.13 Motor vehicle accidents have been found to be the most common cause of trauma in cats.4 Bite wounds can result in blunt traumatic injuries, penetrating traumatic injuries, or a combination of both.

The severity of injuries resulting from bite wounds can range from minor to life threatening and complex. On cursory examination, the severity of these wounds can be misleading because the inherent elasticity of the skin provides some resistance to traumatic forces.2 Small external punctures and lacerations may not be indicative of the injuries to the subcutaneous tissues, muscles, and intrathoracic or intrabdominal compartments. Damage to these deeper tissues and body compartments results from contact of the teeth to body surfaces leading to compression, tearing, and shearing injuries.2,5 These injuries can compromise blood supply, create regions of dead space, and become a source of bacterial infection.6 Treatment can range from irrigation, bandaging, and empiric antibiotic therapy to surgical debridement and exploratory thoracic or abdominal surgery.2,7

Scoring systems play an important role in the assessment of trauma patients and can be beneficial in triage, tracking patients over time, and in clinical research. The Modified Glasgow Coma Scale (MGCS) is a veterinary illness severity score modified from the human Glasgow coma scale. This scale system had shown prognostic ability in veterinary head trauma cases.6,810 Three parts of neurologic function are evaluated and scored from 1 to 6: brain stem reflexes, motor activity, and level of consciousness. A total score is calculated ranging from 3 to 18 with a lower score indicating greater severity of trauma. The Animal Trauma Triage Score (ATT) is a veterinary illness severity score used to classify degree of trauma.11 This scoring system has 6 categories: perfusion, cardiac, respiratory, eye/muscle/integument, skeletal, and neurological. Each category is given a score of 0 to 3 and total score is calculated ranging from 0 to 18.12 A higher score indicates greater severity of injury.

A retrospective VetCOT registry study evaluating the ATT and MGCS scores as predictors of mortality in a large number of injured cats showed the ATT score was an excellent predictor of survival. Of the 6 categories, perfusion, neurologic, and respiratory subcategories were the best predictors.13 The MGCS was evaluated to be a fair predictor of mortality in cats with the motor subscore being the most predictive component.13 A different retrospective study of 43 client owned cats that underwent bite wound trauma found an association between elevated plasma lactate, low ionized calcium, and low venous pH with higher ATT scores.3 Similarly in this study, increased ATT scores were associated with nonsurvival.

The aims of this study were to explore associations between admission parameters, ATT and MGCS score, need for transfusion or surgical interventions, and survival to discharge in a large multicenter international population of feline bite wound patients using the VetCOT database registry. We hypothesized that a higher ATT score and lower MGCS would be associated with a worse outcome. We also hypothesized that a higher ATT score would be associated with the need for transfusion and surgical intervention. Additionally, we hypothesized increased admission lactate, low base excess, low PCV, and low TS would be associated with a worse outcome.

Materials and Methods

The American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma (ACVECC–VetCOT) database registry access was obtained following proposal submission. The VetCOT Trauma Registry was established in 2013 to improve patient care and outcomes, expand knowledge, and advance research on canine and feline trauma patients. Veterinary trauma centers (VTCs) enter data on all patients presenting for trauma using a web-based application for research tool, the Research Electronic Data Capture (REDCap) tool.14 The admission data (collected within the first 6 hours of presentation) and outcome data (collected throughout the patients stay) are included. The VTCs are veterinary hospitals that provide high level comprehensive care and resources for trauma patients. These hospitals are verified by the ACVECC–VetCOT members.14

Patient information from 39 level 1 and level 2 trauma centers which include both academic veterinary teaching hospitals and private referral practices located in the USA, UK, Canada, and Australia was obtained. Feline bite wound trauma patients were selected from the VetCOT registry from April 2017 to June 2021. The registry database search was used to identify trauma patients using the key terms feline, bite penetrating trauma, and non-penetrating bite wound. Animal variables included age, sex, and weight. Additional variables included type of trauma (blunt, penetrating, both), administration of prehospital care (bandage placement, oxygen supplementation, wound care and antibiotics, chest compression), illness severity score (ATT, MGCS), presence of head or spinal injury, surgical procedure, point of care ultrasound results, point of care laboratory values (base excess, blood lactate concentration, ionized calcium [iCa], PCV, total solids [TS], and blood glucose), and administration of blood products. Blood products administered included packed red cells, whole blood, fresh frozen plasma, and human serum albumin. Variables recorded included survival to discharge, euthanasia, and death. The reason for euthanasia was recorded when present. In the study, death, as the primary outcome, was defined as euthanasia or dying in the hospital.

Normality of data was tested using the D’Agostino-Pearson omnibus test. Descriptive data was tabulated and presented as mean (SD [SD]), median (IQR), or count (proportion). Cats were divided into 3 or 4 groups based on MGCS and ATT scores to account for the uneven distribution of animals within the MGCS and ATT scoring system. Cats were divided into terciles of MGCS subcategory scores (ie, subcategory scores of 6, 5, and ≤ 4) as well as terciles of total MGCS score wherein terciles 1-3 contained cats with scores of 18, 17, and ≤ 16, respectively. Cats were divided into terciles of ATT subcategory scores (ie, ATT subcategory 0, 1, and ≥ 2) as well as quantiles of total ATT score quantiles 1 to 4 contained cats with scores of 0, 1, 2, and ≥ 3, respectively. Correlation between patient variables was examined using Spearman rank or Pearson correlation coefficients. Predictors of the primary outcome (death or euthanasia while in hospital) were assessed using univariable and multivariable logistic regression analysis with listwise deletion. The associations between predictor variables and outcome were calculated as odds ratios (OR), which describe the odds associated with each unit change of a continuous variable (ie, an OR = 3 for body weight indicates that for every 1 kg increase in body weight, the odds of the outcome increase by 3 times). In the setting of binary predictor variables, the OR is the ratio of odds of 1 condition over the other (ie, an OR = 2 associated with presence of spinal injury indicates that the odds of a patient with spinal injury experiencing the outcome of interest are 2 times the odds of patient without spinal injury). The potential effects of collinearity and outliers on model building was assessed by calculation of variance inflation factors and Dfbeta values, respectively. Assumption of linear association between outcome and explanatory variables was tested using the Box-Tidwell test. Model fit was assessed by the Hosmer-Lemeshow test and comparison of Akaike information criterion values. Predictors of secondary outcomes, including need for blood products or surgical treatment were also explored using logistic regression. Variables with P < .2 in the univariate analyses were used in a multivariate model with backward selection. The authors did not correct for multiple comparisons. A value of P < .05 was significant.

Results

The VetCOT data set used included a total of 1,065 cats. Of these cats, 435/1,065 (40.8%) were female and 620/1065 (58.2%) were male. The sex was unknown in 10/1065 (0.94%) cats. The median total ATT score was 3 (0 to 15) and the median total MGCS was 18 (0 to 6, 8 to 18). The mean weight was 4.7 kg (range, 3.7 to 5.7 kg) and the mean age was 5 years (2 to 10 years). Descriptive data is presented in Table 1.

Table 1

Patient descriptive data of cats sustaining bite wound trauma from the American College of Veterinary Emergency and Critical Care Veterinary Committee on Trauma Registry 2017 to 2021.

Data variable Median IQR Number
Age (y) 5 2 to 10 1,060
Weight (kg) 4.7 3.7 to 5.7 1,049
Lactate (mmol/L) 2.1 1.3 to 3.8 264
Base excess (mmol/L) -6.7 -9.4 to -5.0 208
Ionized calcium (mmol/L) 1.3 1.2 to 1.3 227
PCV (%) 38 32 to 43 341
Total solids (g/dL) 7 6.3 to 7.6 325
Blood glucose (mg/dL) 173 132 to 212 362

The injuries were characterized as penetrating trauma, blunt trauma, or both. One hundred twenty cats (120/1065; 11.3%) had blunt wounds, 790 cats (790/1065; 74.2%) had penetrating wounds, and 155 cats (155/1065; 14.5%) had both blunt and penetrating injuries. The absence or presence of a head or spinal injury was documented in 1,061 cats and this data was missing in 4 cats. Of those cats, 194/1061 (18.3%) had a head injury and 73/1061 (6.9%) had a spinal injury. Two hundred and forty-nine cats (23.4%) had thoracic point of care ultrasound results and abdominal point of care ultrasound was performed in 277 cats (26%). Pleural effusion was present in 15 cats (15/248; 6%) and a glide (the normal motion of the lung sliding along the thoracic wall)15 was present in 224 cats (224/248; 90%). Administration of prehospital care treatment by a nonveterinarian before presentation to the hospital occurred in 35 cats (35/1065; 3.3%). One hundred sixty cats (160/1065; 15%) were treated by a veterinarian prior to presentation to the trauma center. Point of care laboratory values were available in only 31% of cats (325/1,065). Surgical intervention was performed in 345 (345/1,065; 32%) cats. Nineteen cats (19/1065; 1.8%) received blood products. Of those transfused, 3 (15.8%) cats received plasma transfusions, 2 (10.5%) were given whole blood, and 7 (36.8%) were given packed red cells. Six (31.6%) cats received a combination of plasma and packed red blood cell transfusions, and one of these cats was given a packed red cell xenotransfusion. One (5.3%) cat received whole blood, packed red cells, and human serum albumin.

In total, 872/1,065 (82%) cats survived to discharge, and 193/1,065 (18%) cats did not survive to discharge. Of the nonsurvivors, 170 (170/193; 88%) were euthanized and 23 (23/193; 11.9%) died naturally. The reason for euthanasia was reported in 168 cats. Reasons for euthanasia were due to grave prognosis in 79 cats (47.02%), financial limitations in 26 cats (15.48%), due to both finances and grave prognosis in 59 cats (35.12%), and not applicable in 4 cats (2.38%).

Univariate logistic regression analysis evaluated factors associated with nonsurvival (death or euthanasia). It revealed that older age, lower weight, the presence of a head or spinal injury, pleural effusion, lower base excess, lower packed cell volume (%), lower ionized calcium, and lower total solids were associated with higher odds of mortality. For example, head or spinal injury was associated with a 2.65 (95% CI, 1.85 to 3.78; P < .001) and 9.42 (95% CI, 5.69 to 15.59; P < .001) increased odds of mortality as compared to cats without these injuries. The loss of a glide sign on point of care ultrasound was associated with an increased odds of nonsurvival (P < .001). Surgical intervention decreased the odds of death or euthanasia (P < .001).

The odds of death or euthanasia increased with worsening severity illness score. For each quantile increase of ATT neurologic score, the odds of nonsurvival increased by 8.22 (95% CI, 6.01 to 11.26; P < .001). For each quantile increase of total ATT score, the odds of death or euthanasia increased by 4.63 (95% CI, 3.66 to 5.87; P < .001). For each tercile increase in the MGCS consciousness score the odds of nonsurvival increased by 7.61 (95% CI, 5.45 to 10.64, P < .001). For each tercile increase in the MGCS motor and brain score, the odds of nonsurvival increased by 5.40 times (95% CI, 4.07 to 7.17; P < 0.001) and 4.85 times (95% CI, 3.50 to 6.72, P < .001) respectively.

The univariate model revealed that surgical intervention decreased the odds of death or euthanasia by 0.17 (95% CI, 0.10 to 0.28, P < .001).

Blood product administration was also associated with nonsurvival. The mean PCV of cats receiving blood products was 27% (range, PCV 9% to 47%). The odds of dying for a cat that received blood products were 3.39 (95% CI, 1.34 to 8.53; P = .01) times higher when compared to cats that did not receive blood products. Data regarding the univariate analysis is presented in Table 2.

Table 2

Univariate analysis. OR associated with death or euthanasia. OR > 1 indicates that the variable increased odds of dying in hospital and not being discharged whereas OR < 1 indicates that the variable decreased odds of dying in hospital and not being discharged.

Discharge variable OR Standard error P value 95% CI Number
Age (y) 1.02 0.02 .14 0.99–1.06 1,060
Weight (kg) 0.77 0.04 < .001 0.70–0.85 1,048
Male 0.61 0.10 .002 0.44–0.84 1,054
Head injury (yes vs no) 2.65 0.48 < .001 1.85–3.78 1,061
Spinal injury (yes vs no) 9.42 2.42 < .001 5.69–15.59 1,061
Blood product (yes vs no) 3.39 1.60 .010 1.34–8.53 1,065
Surgery (yes vs no) 0.17 0.04 < .001 0.10–0.28 1,065
Pleural effusion (yes vs no) 2.61 0.48 .62 0.20–2.64 248
Loss of glide (yes vs no) 5.00 2.22 < .001 2.09–11.95 248
Lactate (mmol/L) 1.12 0.03 < .001 1.06–1.18 264
BE (mmol/L) 0.89 0.03 < .001 0.84–0.95 208
iCa (mmol/L) 1.12 0.16 .44 0.84–1.49 227
PCV (%) 0.96 0.02 .02 0.93–0.99 341
TS (g/dL) 0.57 0.08 < .001 0.43–0.76 362
Total MGCS tercile 4.45 0.49 < .001 3.59–5.53 1,047
Total ATT quantile 4.63 0.56 < .001 3.66–5.87 1,065

ATT = Animal Trauma Triage. BE = Base excess. iCa = Ionized calcium. MGCS = Modified Glasgow Coma Scale. TS = Total solids.

Trauma scores were associated with the decision to perform surgery. Each quantile increases in total ATT score increased the odds of surgical intervention by 1.19 (95% CI, 1.06 to 1.35; P = .004). Each tercile increase in total MGCS decreased the odds of surgical intervention by 0.58 (95% CI, 0.46 to 0.73; P < .001). The presence of a spinal injury also decreased odds of surgical intervention by 0.39 (95% CI, 0.21 to 0.73; P = .003).

In the multivariable model only age, weight, surgical intervention, total ATT score, and total MGCS score were found to be significantly associated with survival (Table 3). Admission point of care blood and biochemical variables were not included in multivariable modeling due to the low numbers of cats.

Table 3

Multivariate model. OR associated with death or euthanasia. OR > 1 indicates that the variable increased odds of dying in hospital and not being discharged whereas OR < 1 indicates that the variable decreased odds of dying in hospital and not being discharged.

Discharge variable OR Standard error P value 95% CI Number
Age (1 y) 1.07 0.02 .003 1.02–1.12 1,032
Weight (1 kg) 0.86 0.06 .005 0.73–0.95 1,032
Surgery (yes vs no) 0.16 0.04 < .001 0.09–0.28 1,032
Total MGCS tercile 2.04 0.28 < .001 1.16–2.67 1,032
Total ATT quantile 4.51 0.78 < .001 3.21–6.32 1,032

See Table 2 for key.

Older age had a negative impact on survival; for every 1 year of age, odds of nonsurvival increased by 7% (95% CI, 2% to 12%; P = .003). Conversely, weight was shown to be protective; for every 1 kg of body weight, the odds of nonsurvival in hospital decreased by 14% (95% CI, 5% to 7%; P = .005). The odds of nonsurvival in hospital for cats who underwent surgical intervention decreased by 84% (95% CI, 72% to 91%; P < .001). The odds of nonsurvival increased with lower MGCS and higher ATT scores (MGCS: 104% [95% CI, 116% to 267%; P < .001]; ATT: 351% [95% CI, 321% to 632%; P < .001).

Discussion

This study is the largest multicenter study to date investigating patient variables and illness severity scores in cats with bite wound injuries. The veterinary hospital population consisted of academic and private practices in rural and urban areas allowing for a multicenter study. Multicenter studies compared to single center studies allow for enhancement of reproducibility and generalizability. In addition, the accessibility of the parameters and scoring systems for the ATT and MGCS severity illness scores allow for use of these indices by veterinary general practitioners presented with trauma cases. This study demonstrated that age, body weight, surgical intervention, and illness severity scores (ATT, MGCS) were significantly associated with odds of dying in the multivariable model. Sex was not associated with survival in this study, although males had a decreased odds of euthanasia or dying in hospital in the univariate model.

Previous cat trauma studies have also investigated ATT score as a predictor of mortality in cat trauma patients.11,13 These studies have shown that for each ATT score point increase, there was an increase in mortality odds.11,13 In the study by Lapsley et al13 that investigated ATT score in all causes of trauma, it was found that each point increase in ATT score was associated with an increase in mortality odds of 1.78 (P < .001) and an ATT score of greater than or equal to 5 was found to significantly decrease survival. Like these studies, we also found that a higher ATT score was associated with a worse outcome. Specifically in our cat population, each quantile increase in total ATT score increased the odds of death or euthanasia by 4.51 (95% CI, 3.21 to 6.32; P < 0.001).

In the study reported here, a higher ATT score was also associated with surgery and each quantile increase in total ATT score increased the odds of surgical intervention by 1.19 (P = .004). Additionally, ATT provides a better assessment of global patient injury in cases of trauma and is a better predictor for surgery as compared to the MGCS. The degree of injury is used to determine the proper course of action, such as surgical intervention. Although there is no standard protocol for treatment of bite wounds,16 the finding that more severely injured cats required surgery is consistent with expert recommendations that puncture wounds should be sterilely lavaged and debrided. In the case of penetrating or crushing abdominal injuries surgical intervention is also recommended once the patient has been stabilized. However, the recommendation for treatment of thoracic bite wounds has been debated with some authors recommending thoracotomy for wound exploration whereas others suggest some thoracic bite wounds may be managed medically if there is no physical or radiographic evidence of penetrating injury.7 In a retrospective study evaluating thoracic dog bite wounds in cats, the presence of 3 or more radiographic lesions such as pneumothorax, rib or sternal fractures/luxation, pleural effusion, or pulmonary contusions was associated with a penetrating wound and need for thoracic exploration.2 Another retrospective study evaluating thoracic bite wounds in dogs and cats found that the presence of a penetrating injury, more than 3 radiographic lesions, or a combination of both was indicative of a need for thoracotomy.1 In our study, surgery was also associated with a mortality benefit on univariate and multivariate analysis. The odds of nonsurvival decreased by 84% in cats who underwent surgery (P > .001).

Both a lower MGCS score and the presence of a head or spinal injury was associated with nonsurvival on univariable analysis, only MGCS remained significantly associated with survival on multivariable analysis. Modified Glasgow coma scale is a better predictor of outcome due to its global assessment of injuries resulting in neurologic signs such as decreased consciousness or absent motor ability rather than just evidence of trauma to either the skull or spine of the cat. For example, a cat may suffer a bite wound injury to the skull but have a normal MGCS. This finding that MGCS is associated with survival is consistent with previous studies in both dogs and cats.12,17 In dogs with traumatic brain injury, a significant association was found between admission MGCS and survival to 48 hours. A MGCS score of 8 was associated with a 50% probability of survival to 48 hours.17 In a study of traumatized cats, a 1 point decrease in MGCS was associated with an increase in mortality odds of 2.06 (P < .001).13 Similarly, for each tercile increase of total MGCS in the multivariable analysis, the odds of death or euthanasia in hospital increased by 2.04 (95% CI, 1.16 to 2.67; P < .001).

In addition to MGCS and ATT, age was associated with outcome in cats suffering from bite wounds; for each additional year of age, the odds of dying increased by 7% (P = .003). The association of age with a more severe outcome is similar to what has been previously identified in both dogs and people. In a VetCOT registry study evaluating over 6,000 moderately to severely traumatized dogs (ATT ≥ 3, MGCS ≤ 14), geriatric status (defined according to body weight) was significantly associated with an increased risk of mortality (Hazard risk = 1.48, P < .0001) despite interventions or euthanasia due to grave prognosis.18 The authors of this study hypothesize that age was associated with increased mortality due to the presence of comorbidities and reduced physiologic reserves. In people, increased age is a risk factor for mortality in geriatric trauma patients. In 1 study, mortality rates in trauma patients aged 65 years or older were significantly higher than in patients aged 18 to 64 years.19 In a separate study evaluating geriatric trauma, it was found that each year increase in age was associated with an increase in mortality risk by 6.8% (95% CI, 6.1 to 7.5).20 Similar to what is hypothesized in dogs, the reason for this finding is likely multifactorial and include preexisting conditions, immunocompromised state, higher complication rates, and changes in physiology. Similar factors could also be contributing to the association of age with a worse outcome in cats with bite wounds, however, additional prospective studies are needed. There is also the possibility given that most of the cats that did not survive to discharge were euthanized in our study, that the age of the cat factored into the decision to not pursue treatment by the pet owner.

Interestingly, body weight was found to be protective and for every 1 kg increase in body weight the odds of dying in hospital decreased by 14% (P = .005). To our knowledge, this is the first study to document an association of weight with survival in feline trauma patients. Unfortunately, body condition scores were not available to further evaluate whether these cats were over- or underconditioned. However, it is possible that cats with higher body weights may have increased abdominal and thoracic fat deposits which may provide some protection from bites to deeper internal structures. Additionally, cats with a higher body weight may also have increased physiologic reserves allowing for recovery from traumatic injuries as compared to lower body weight cats. In a study in people evaluating body mass index on prognosis in blunt trauma patients with hemorrhagic shock, underweight as well as overweight patients had an increased risk of mortality. Underweight patients were found to have higher lactates, required more transfusions, and were more likely to undergo surgical intervention.21 In a meta-analysis examining the effect of obesity on prognosis in human trauma patients, obese patients had a 1.45 increased risk of death in comparison to nonobese patients.22 Obese trauma patients were found to have an increased risk of complications from trauma such as acute respiratory distress syndrome (ARDS), acute renal failure, and multiple organ failure increasing their odds of mortality. Given their size, these patients often have decreased lung volume and compliance which leads to a hypoxic state. It is thought that these patients also have an increased risk of organ dysfunction post trauma as a pro-inflammatory state is initiated by adipose tissue resulting in elevated circulating levels of inflammatory mediators such as tumor necrosis factor α and interleukin 6.22 Additional prospective studies are needed to further evaluate the effect of weight and body condition score, as well as the presence of concurrent diseases on outcome in feline trauma patients.

Although one of our initial study aims was to assess for admission variables and associations with outcome, point of care laboratory values were available in less than 1/3 of cats. The low number of patients with admission values could be due inability to obtain blood on intake secondary to poor perfusion, patient stability, or patient compliance. Additionally, cats assessed to be stable on intake and those with less severe injury may not have had laboratory values performed. In this study higher lactate and lower PCV were associated with mortality in the univariate analysis but were not included in the multivariable analysis. It is possible clinicopathologic abnormalities such as lactate can be used as prognostic indicators.2325 Future studies are needed to determine the prognostic significance of clinicopathologic changes such as lactate, ionized calcium, base excess, and blood glucose in feline trauma patients.

There were several limitations to this study. All the veterinary hospitals in this study were VTCs and our results may not be applicable to practices without the same resources such as emergency veterinarians and veterinary specialists. While the VetCOT data registry provided a large multicenter data set, several data variables were missing. The location of the bite wounds and the number of injured regions were not documented in each cat. A greater number of injured areas has been previously associated with an increased risk of mortality.6,26 The source of the bite wound (ie, feline inflicted bite wound; canine inflicted bite wound) was unknown which may also affect outcome. A low number of cats received transfusions which could have affected the association between blood transfusion and outcome. Finally, as mentioned, relatively few cats had clinicopathologic data limiting conclusions on the effect of admission clinicopathologic abnormalities on survival. The associations with outcome identified, specifically MGCS, ATT, age, surgical intervention, and weight in this large multicenter population of bite wound cats can be used to design prospective studies. These future studies could be used to evaluate interventions such as timing of surgical intervention and their effect on outcome in cats with bite wounds injuries.

In conclusion, a higher ATT score, lower MGCS score, the presence of neurologic abnormalities, and older age were associated with nonsurvival. Variables associated with survival included surgical intervention and increased body weight. Higher ATT scores were associated with an increased need for surgical intervention. These findings may aid veterinarians in guiding referral decisions or help with discussion with caregivers regarding patient care, cost, and outcome. Additionally, information from this study may help guide future interventional studies evaluating treatments for traumatically injured cats.

Acknowledgments

The research on which this presentation is based used data from the Veterinary Committee on Trauma Registry and we are grateful to the Veterinary Trauma Centers that participated. The Veterinary Committee on Trauma assumes no responsibility for the interpretation of the Registry data. The project described was supported by Award Number UL1TR002494 from the National Center for Advancing Translational Sciences of the NIH. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Center For Research Resources or the NIH. Study data were collected and managed using REDCap electronic data capture tools hosted at the University of Minnesota.

The authors declare that there were no conflicts of interest.

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