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Abstract

Objectives

The aim of this study was to evaluate possible risk factors for death in traumatized cats based on the clinicoepidemiological profile, the Animal Trauma Triage (ATT) scale score and the Modified Glasgow Coma Scale (MGCS) score at the time of presentation to the hospital.

Methods

This was a cross-sectional study involving cats admitted to the emergency sector (ES) and the surgical clinic sector (SCS) of a veterinary teaching hospital (VTH) in northeastern Brazil over a 12-month period (2018–2019). Probable risk factors associated with non-survival after trauma were analyzed by calculating the prevalence ratio. The prediction of non-survival was evaluated by analyzing the receiver operating characteristic (ROC) curve employing the ATT scale score, MGCS score and rectal temperature.

Results

In 1 year, 89 traumatized cats were admitted to the VTH, of which 90% (n = 80) were young, 54% (n = 48) were male, 79% (n = 70) were intact, 59% (n = 53) were indoor cats and 92% (n = 82) were considered as mixed breed. Blunt trauma was the most prevalent cause of injuries, reported in 76% (n = 68) of the cats. Accidents involving falls (30%; n = 27) that affected the pelvic limbs (50.6%) were the most commonly reported. The prevalence of death among cats admitted to the ES was 9.44 times higher than that of animals treated at the SCS. Trauma as result of being run over and chest trauma were associated with a higher probability of death. Most of the animals that died had a lower rectal temperature than those that survived. The ATT scale score, MGCS score and rectal temperature were predictive of mortality.

Conclusions and relevance

Rectal temperature, ATT scale score and MGCS score were effective predictors of an unfavorable prognosis and point to the need for emergency procedures. Hypothermia, being run over and chest trauma were associated with a higher risk of mortality. Our findings highlight the importance of prompt and effective care for these conditions.

Keywords

Accident MCGS risk factors prognosis ATT

Introduction

Traumatized cats are often seen in veterinary centers,^1–3 and young male cats that have access to the outdoors are the most commonly affected.² Studies in several countries have identified being run over as the main cause of trauma and death, with mortality rates reported to be between 12% and 22%^2–5 in animals with signs of shock, spine injuries, abdominal injuries or multiple injuries.^2,6 Recently, multiple organ dysfunction was identified as a common complication in feline polytrauma, leading to a higher risk of mortality, and hemostatic and respiratory disorders.⁷

The Animal Trauma Triage (ATT) scale and the Modified Glasgow Coma Scale (MGCS) scores are validated severity scoring systems,^8–10 proven to be useful prognostic tools for the evaluation of cats that have experienced trauma. In clinical practice, these screening scores assist in the identification of critical patients and help to manage emergencies, direct treatments and make accurate prognoses.^7,11

Despite the high incidence, studies on trauma in cats are primarily retrospective studies or focus on single trauma mechanisms. The identification of specific characteristics and the rapid determination of clinical severity can help to improve trauma care, with direct repercussions on the prognosis of affected animals. Thus, the aim of this study was to evaluate the possible risk factors based on the clinicoepidemiological profile and on the ATT and MGCS scores at the time of presentation to the hospital, as well as their influence on the prognosis of death in traumatized cats at a veterinary teaching hospital (VTH) in northeastern Brazil.

Materials and methods

This project was approved by the Animal Ethics and Experimentation Committee of the School of Veterinary Medicine and Animal Science at the Federal University of Bahia (protocol number 93/2018).

Data collection

This was a cross-sectional study that involved cats with a known history of, or suspected, traumatic injuries, admitted to the emergency sector (ES) and surgery clinical sector (SCS) of a VTH in Salvador, Bahia, Brazil, between October 2018 and October 2019. Trauma was defined as ‘any tissue injury that occurred suddenly as a result of an external or accidental force’.¹² For this study, we used a convenience sample of all cats with a known history of, or suspected, traumatic injuries. Cats whose guardians did not authorize treatment were excluded from the study. Data were collected from the electronic records of the VTH regarding breed, sex, body weight, age, origin, reproductive profile, pre-existing diseases and reports on previous first aid. First aid was defined as immediate assistance by a veterinary professional, including stabilization of vital parameters when necessary. In addition, the characteristics of the trauma were also registered, such as: nature (blunt or penetrating); type of traumatic event; location of the lesions (head, chest, abdomen and limbs); presence of concomitant injuries; and time between trauma and hospital care. The size of the cats was categorized as small (⩽4.5 kg), medium (>4.5 and <8.0 kg) or large (⩾8 kg). According to age, they were classified as young (⩽3 years), adult (>3 and <8 years), or old (⩾8 years).

In each animal a clinical evaluation based on the current trauma care literature was performed by a trained veterinarian (see Figure S1 in the supplementary material). The clinical and laboratory parameters registered at the time of presentation to the hospital prior to any treatment were heart rate, respiratory rate, mucous membrane color, rectal temperature, packed cell volume, plasma total protein, albumin and globulin. Blood samples were collected by jugular venipuncture. For cats attended to in the ES, the ATT scoring system¹⁰ and the MGCS scoring system⁹ were applied.

Severity parameters included clinical variables indicative of hypovolemic shock (rectal temperature and mucous membrane color), and regions affected by the trauma (head, chest, abdomen and limbs). Outcomes of traumatized cats were obtained during hospitalization, recording survival or death for each patient. The time from presentation to the hospital until death was recorded and categorized as <6 h, 6 to <12 h, 12 to <24 h, 24–72 h or >72 h. Non-survival was classified as death during hospitalization, non-hospitalization and death, or euthanasia owing to a lack of financial resources or because of a poor prognosis.

Statistical analysis

The incidence of feline trauma was calculated as the ratio of the number of traumatized cats and the total number of cats admitted to the VTH for any reason during the study. The frequency of epidemiological data extracted from records were described. The assumption of normality of quantitative variables was assessed by the Shapiro–Wilk test. Depending on the distribution of data, the Student’s t-test or the Wilcoxon Mann–Whitney test was used to assess the difference in the mean or median of clinical and laboratory variables and ATT and MGCS injury severity scores between non-surviving and surviving cats. The Mann–Whitney U-test was also used to assess the difference in the median ATT score between cats that received and did not receive first aid before admission to the VTH. Associations between qualitative variables were analyzed by calculating the prevalence ratio (PR), with a 95% confidence interval (CI). Depending on sample size and category frequencies, Fisher’s test or the χ² test was used to assess the statistical significance of the qualitative clinical variables. The exact Fisher’s or χ² tests were used to assess the differences in the proportion of cats that received first aid before admission to the VTH between the different sectors (ES and SCS), as well as to compare the severity of the cases attended. The receiver operating characteristic (ROC) curve analysis was performed to assess the accuracy of the rectal temperature, and the ATT and MGCS scoring systems in predicting mortality. Rectal temperature was assessed in all 89 cats, while ATT and MGCS scores were assesses only from cats admitted to the ES. The accuracy of each parameter was measured as the area under the curve (AUC), and we also assessed sensitivity and specificity in discriminating between survivor and non-survivor cats.

All analyses were performed using Epi Info version 7 (Centers for Disease Control) and GraphPad Prism. Data were considered to be statistically significant at P <0.05.

Results

Characteristics of patients with trauma

The incidence of feline trauma patients at the VTH between October 2018 and October 2019 was 13.6% (n = 89/654). Of the traumatized cats, 31.5% (n = 28) were treated at the ES and 68.5% (n = 61) at the SCS. The characteristics of cats with traumatic accidents at presentation to the hospital are described in Table 1. There was a predominance of male (54%), intact (78%), young (90%), indoor (59%) and mixed-breed (92 %) cats.

Table 1

Distribution of cats included in the study

Characteristics of the cats (n = 89)		n	%
Sex	Female	41	46
	Male	48	54
Reproductive profile	Intact male	42	47.2
	Castrated male	6	6.7
	Intact female	28	31.5
	Spayed female	13	14.6
Age	Young	80	90
	Adult	8	9
	Old	1	1
Size	Small	81	91
	Medium	8	9
Origin	Indoor/outdoor cat	12	13.5
	Indoor cat	53	59.5
	Outdoor cat	24	27
Breed	Mixed breed	82	92.1
	Angora	2	2.2
	Persian	2	2.2
	Siamese	3	3.4
Pre-existing diseases	Hematological	7	7.9
	Genitourinary	6	6.7
	Gastrointestinal	5	5.6
	Ocular	1	1.1
	Integumentary	1	1.1
	Healthy	69	77.5

Trauma characteristics

Of the 89 patients treated, 76.4% (n = 68) were victims of blunt trauma and 23.6% (n = 21) suffered penetrating trauma. Falls represented 30% (n = 27) of traumatic events. In most cases, trauma was located in the pelvic limb region (50.6%) with femoral fractures found most commonly (28.1%). Traumatic events and body regions affected by trauma are depicted in Figures 1 and 2, respectively.

Figure 1

Frequency of the main traumatic events that occurred in cats admitted to a veterinary teaching hospital in Brazil over a 12-month period

Figure 2

Frequencies of the involvement of body regions (head, chest, abdomen and limbs) and the main characteristics of traumas by body region in cats admitted to a veterinary teaching hospital in Brazil over a 12-month period

Trauma outcome

Of the 89 cats, 82% (n = 73) survived until hospital discharge and 18% (n = 16) did not survive. Of the registered deaths, 43.8% (n = 7) of cats died during hospitalization, 18.7% (n = 3) died at home after their guardians refused to hospitalize them and 37.5% (n = 6) were euthanized (83.3% [n = 5] owing to financial limitations and 16.6% [n = 1] owing to severe prognosis) (Table 2).

Table 2

Distribution of cats according to the type of death and the time elapsed between presentation to the hospital and death

Type of death	Time elapsed between presentation to the hospital and death (h)
Type of death	<6	12–24	24–72	>72
Death during hospitalization	4 (57)	0	1 (14.4)	2 (28.6)
Non-hospitalization and death	1 (33.3)	1 (33.3)	0	1 (33.3)
Euthanasia	4 (66.6)	1 (16.6)	1 (16.6)	0

Data are n (%)

Factors associated with death

The main factors that were significantly associated with death are described in Table 3. Patients who did not receive first aid were 2.8 (95% CI 1.06–7.44) times more likely to die than those who received first aid. Of the 28 cats admitted in the ES, 17.9% (n = 5) received first aid, while 82.1% (n = 23) were admitted for the first time at the VTH. Of the 61 cats attended to at the SCS, 73.8% (n = 45) received first aid, while 26.2% (n = 16) were treated for the first time at the VTH. Statistical analysis showed a significant difference (P <0.0001) between the number of cats that received first aid admitted by the two sectors.

Table 3

Factors associated with death in traumatized cats

Factors associated with death	Traumatized cats		PR	95% CI	P value*
Factors associated with death	Non-survivors	Survivors	PR	95% CI	P value*
Sector of admission
ES SCS	13 (46.4)3 (4.9)	15 (53.6)58 (95)	9.44	2.92–30.50	0.00
Run over
Yes No	9 (45)7 (10)	11 (55)62 (90)	4.43	1.8–10.4	0.001
Chest injury
Yes No	6 (50)10 (13)	6 (50)67 (87)	3.8	1.7–8.6	0.006
First aid
Yes No	5 (10)11 (28)	45 (90)28 (72)	2.8	1.06–7.44	0.036

Data are n (%) unless otherwise indicated

Fisher’s exact test

PR = prevalence ratio; CI = confidence interval; ES = emergency sector; SCS = surgical clinic sector

There was a higher prevalence of death among cats admitted to the ES (PR 9.44; 95% CI 2.92–30.50), cats that were run over (PR 4.43; 95% CI 1.8–10.4) and cats with thoracic trauma (PR 3.8; 95% CI 1.7–8.6) than cats which experienced other traumatic events involving other body regions.

Characteristics such as sex, reproductive profile, age, size, origin, pre-existing diseases and nature of trauma (blunt or penetrating) were not significantly associated with death.

There was a statistical difference between the median temperature (36°C) of non-survivors (interquartile range [IQR] 3.2) and the median temperature (38°C) of survivors (IQR 1) (P = 0.0002). The other clinical and laboratory variables assessed were not different between the groups (see Table 1 in the supplementary material).

Some clinical parameters indicative of hypovolemic shock (rectal temperature and pale mucous membranes) were more evident in animals treated in the ES (Table 4).

Table 4

Clinical parameters of patients treated in the emergency sector (ES) and the surgical clinic sector (SCS)

Clinical parameters	Cats	Hospital care		P value*
Clinical parameters	Cats	ES	SCS	P value*
Mucous membrane color
Normal	54 (73)	16 (29.63)	38 (70.37)	0.0400
Pale	19 (25.7)	11 (57.89)	8 (42.11)
Congested	1 (1.3)	1 (100)	0
Body region affected
Head	14 (15.7)	11 (78.6)	3 (21.4)	<0.0001
Abdomen	15 (16.85)	11(73.3)	4 (26.67)	0.0003
Clinical parameters		Median (IQR) hospital sector		P value^†
		ES	SCS
Temperature (°C)		36.8 (3.1)	38 (0.4)	<0.0001

Data are n (%) unless otherwise indicated

Fisher’s test or χ² test

†

Mann–Whitney test

Parameters with a P value >0.05 were not reported

IQR = interquartile range

The ATT and MGCS scores were obtained at presentation to the hospital for 100% and 85.6% of the animals admitted to the ES (n = 28), respectively. Of the 28 cats with an ATT score admitted to the ES, 17.9% (n = 5) received first aid, while 82.1% (n = 23) were treated for the first time at the VTH. In comparing ATT scores, we did not find any difference between these two groups (P = 0.7336). Cats who received first aid presented a median ATT score of 4 (IQR 5.5), while cats attended to for the first time at the VTH displayed an ATT score median of 7 (IQR 6). These data suggest that the cats had a similar severity of injury.

Regarding the 28 animals admitted to the ES, 15 survived and 13 did not. ATT score and rectal temperature were measured in all 28 cats, and the MGCS scores were obtained from 12 surviving animals and 12 non-survivors. There was a statistical difference between the median ATT score (7; IQR 5) of non-survivors and the median ATT score (4; IQR 5) of surviving cats (P = 0.0218). No statistical difference was found in MGCS scores between survivors and non-survivors.

Based on the ROC curve, an ATT score ⩾6 and a temperature ⩽37.1°C with a sensitivity of 79% (95% CI 66–88) and 73% specificity (95% CI 44–92; AUC 80%) were predictors for an unfavorable prognosis. The ATT score was found to be a better predictor of prognosis, with a sensitivity of 73% (95% CI 45–92) and a specificity of 69% (95% CI 38–90; AUC 73%) vs MGCS score (sensitivity: 67% [95% CI 35–90]; specificity: 50% [95% CI 21–79; AUC 60%]) (Figure 3).

Figure 3

(a) Animal Trauma Triage (ATT) score, (b) Modified Glasgow Coma Scale (MGCS) score and (c) body temperature used to predict death in traumatized cats. Receiver operating characteristic (ROC) curve analyses were performed to estimate, in a quantitative way, the performance of the different scores and body temperature to predict death. AUC = area under the curve; VTH = veterinary teaching hospital; CI = confidence interval

Discussion

This study provides a detailed description of the clinical and epidemiological profiles of traumatized cats admitted to a veterinary teaching hospital in Brazil. It also demonstrates that rectal temperature, and ATT and MGCS scores are advantageous predictors of prognosis in the primary care of emergency patients.

Most trauma patients were young, male, intact and mixed-breed animals, corroborating the findings of international studies that associated these risk factors with behavioral differences, compared with old cats and female cats, which are considered to be more cautious, and purebred cats, which mostly live in indoor residential environments.^6,13

The feline population that experienced blunt trauma (76%) was considerably larger than that reported in a recent retrospective study (56.7%) carried out in countries in North America, Europe and Australia,¹⁴ confirming that this is the major form of trauma in the species. In the present study, most of the traumas were due to falls, unlike most international studies, in which being run over was more prevalent.^3–5 However, it is worth mentioning that approximately 33% of traumatic events were of unknown cause.

Of the factors identified, the prevalence of death was higher in cats that were run over and in those whose traumas involved the thorax. This is in accordance with the findings of studies that reported a high mortality rate among victims that were run over^2–4,6 and cats with respiratory disorders resulting from trauma.⁷

The pelvic limb was the most affected anatomical region, and the traumas mostly resulted in fractures of the femur and tibia. Similarly, other studies have reported that during high-rise syndrome,¹⁵ and among feline victims of car accidents (n = 1407), the highest frequency of injuries occurred in the limbs.⁶

First aid before presentation to the hospital resulted in fewer deaths, which emphasizes the importance of the ‘time factor’ in the treatment of multiple trauma patients. The ‘golden hour’ is the period of time in which damage can be minimized, and basic and advanced life support can be provided, which will directly influence the prognosis.¹⁶ Although this is an interesting finding, the absence of records of cats that were victims of trauma and that were euthanized or died during previous first aid or during transport to the referral center is recognized as a limitation. For this, further studies would be necessary in order to confirm the impact of first aid on an animal’s prognosis. Moreover, we only assessed five cats that received first aid. It possible that the lack of statistical difference between the ATT score of these cats and those who did not received first aid was due to the small sample size.

Cats that had lower temperatures (⩽37.1°C) at the time of presentation suffered higher death rates. The characteristics of feline species, such as their low blood volume per body mass ratio and their high surface area to body mass ratio, make them more sensitive to hypothermia and reduced peripheral blood flow.¹⁷ Under normal conditions, rectal temperature ranges from 37.8°C to 39.4°C.¹⁸ Trauma results in hypothermia due to hemorrhagic shock, environmental exposure and treatments (eg, anesthetic drugs and intravenous fluids).¹⁹ In addition to the deleterious effects of excessive thermal loss, which increases the risk of mortality, one must consider pharmacokinetic changes in the drugs, dysfunction of organic systems, increased susceptibility to infections, reduced healing ability, immune response and altered coagulation.²⁰

In the present study, among animals admitted to the ES, the accuracies of the ATT (AUC 0.74) and MGCS (AUC 0.60) scores in predicting the prognosis was confirmed, as high ATT scores and low MGCS scores were predictive of death. Our results corroborate those of Lapsley et al.⁸ According to our findings, cats with an ATT score ⩽6 are more likely to survive trauma. However, an MCGS score ⩽15 suggests the likelihood of an unfavorable prognosis and alert for specialized neurological approach.

Finally, it is also worth mentioning that euthanasia due to lack of financial resources was performed in only five cats, all with poor prognoses and in need of prolonged intensive care. We believe that even with proper care the chance of survival would have been minimal. The main limitation of this study is the fact that we could not obtain additional laboratory and physiological data (eg, blood glucose or blood pressure) for all patients, mainly owing to the financial limitations of the cats’ guardians. Despite our findings, further studies involving traumatized feline patients are needed to improve our understanding of the risk factors and their implications for the prognosis, in order to reduce the mortality rate in the species.

Conclusions

Even though falling from a height is the most frequent traumatic event, being run over, as well as chest trauma, are associated with a higher risk of mortality in cats. A low rectal temperature at presentation to the hospital, and the ATT and MGCS scores in emergency patients were useful in determining the severity of the injuries sustained by the patient.

Supplemental Material

Supplementary Table 1

Clinical and laboratory variables obtained in the initial evaluation of cats that were victims of trauma associated with or without death

Supplemental Material

Supplementary Figure 1

Identification of traumatized patient

Research Data

sj-png-1-jfm-10.1177_1098612X211028027 – for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil

sj-png-1-jfm-10.1177_1098612X211028027 for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil by Débora C Nascimento, João M Costa Neto, Manuela S Solcà, Alessandra Estrela-Lima and Vivian F Barbosa in Journal of Feline Medicine and Surgery

This article is distributed under the terms of the Creative Commons Attribution 4.0 License (http://www.creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).

Research Data

sj-png-2-jfm-10.1177_1098612X211028027 – for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil

sj-png-2-jfm-10.1177_1098612X211028027 for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil by Débora C Nascimento, João M Costa Neto, Manuela S Solcà, Alessandra Estrela-Lima and Vivian F Barbosa in Journal of Feline Medicine and Surgery

Research Data

sj-png-3-jfm-10.1177_1098612X211028027 – for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil

sj-png-3-jfm-10.1177_1098612X211028027 for Clinicoepidemiological profile and risk factors associated with mortality in traumatized cats admitted to a veterinary teaching hospital in Brazil by Débora C Nascimento, João M Costa Neto, Manuela S Solcà, Alessandra Estrela-Lima and Vivian F Barbosa in Journal of Feline Medicine and Surgery

Footnotes

Accepted: 6 June 2021

Supplementary material

The following files are available online:

Table 1: Clinical and laboratory variables obtained in the initial evaluation of cats that were victims of trauma associated with or without death.

Figure 1: Identification of traumatized patient.

Conflict of interest

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was funded, in part, by the Coordination for the Improvement of Higher Education Personnel – Brazil (CAPES) – financing code 001.

Ethical approval

The work described in this manuscript involved the use of non-experimental (owned or unowned) animals. Established internationally recognized high standards (‘best practice’) of veterinary clinical care for the individual patient were always followed and/or this work involved the use of cadavers. Ethical approval from a committee was therefore not specifically required for publication in JFMS. Although not required, where ethical approval was still obtained, it is stated in the manuscript.

Informed consent

Informed consent (verbal or written) was obtained from the owner or legal custodian of all animal(s) described in this work (experimental or non-experimental animals, including cadavers) for all procedure(s) undertaken (prospective or retrospective studies). No animals or people are identifiable within this publication, and therefore additional informed consent for publication was not required.

ORCID iD

Vivian F Barbosa

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Supplementary Material

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