The goal of this prospective multicenter cohort study is to evaluate and compare the predictive utility of the EMTRAS, REMS, and GAP scores in determining key outcomes among trauma patients admitted to participating hospitals in Iraq. The primary outcomes of interest include mortality, the need for endotracheal intubation, and length of hospitalization.

The main questions it aims to answer are:

How accurately do EMTRAS, REMS, and GAP scores predict mortality in trauma patients?

How effective are these scores in predicting the need for endotracheal intubation?

How well do these scores correlate with hospitalization duration in trauma patients?

Participants will:

Be assessed using EMTRAS, REMS, and GAP scores upon admission to the emergency department.

Have their clinical outcomes, including survival, intubation requirements, and length of hospital stay, monitored throughout their hospitalization.

Trauma continues to pose a major global public health challenge, accounting for millions of deaths and disabilities each year, with low and middle income countries bearing a disproportionately high burden . Studies suggest that injuries will rise further among the leading causes of mortality, with road traffic accidents, falls, and suicide being among the most prevalent contributors. Approximately 90 percent of trauma deaths occur in low and middle income settings, and a significant portion of these fatalities are considered preventable with the appropriate care.

Efficient risk stratification plays an important role in managing trauma patients, particularly in emergency settings where delays in treatment can have fatal outcomes. Early identification of severely injured individuals supports timely referral and initiation of interventions, both of which are consistently associated with reduced morbidity and mortality.

A wide range of trauma scoring systems have been developed to estimate injury severity, guide triage decisions, and predict outcomes. Yet many established scores, such as the Injury Severity Score and the Trauma and Injury Severity Score, depend on detailed anatomical information that is often unavailable during the critical early phase of emergency care. Others, such as the Revised Trauma Score, are based on physiological indicators but are more complex and may not fully incorporate factors like age or specific injury types. Similarly, scoring systems such as the Acute Physiology and Chronic Health Evaluation II rely on laboratory values, making them less suitable for rapid use in emergency departments.

This limitation becomes even more evident in low and middle income countries, where resource constraints, limited access to complete medical records, and varying trauma patterns make it difficult to apply many existing scoring tools. The need for simple, reliable, and rapid assessment tools that can be applied at the point of care in these environments is especially urgent.

This study focuses on three trauma scores that can be applied early in a patient's clinical course and require only minimal resources: the Emergency Trauma Score, the Rapid Emergency Medicine Score, and the Glasgow Coma Scale Age Pressure score.

The Emergency Trauma Score was developed to estimate the risk of mortality in adult trauma patients using four parameters: age, Glasgow Coma Scale, base excess, and prothrombin time. These values are typically available within 30 minutes of arrival in the emergency department, and this score does not depend on anatomical injury data, making it suitable for early prognostic assessment. The Rapid Emergency Medicine Score is a simplified version of the Acute Physiology and Chronic Health Evaluation II and includes the Glasgow Coma Scale, respiratory rate, oxygen saturation, mean arterial pressure, heart rate, and age. Although originally developed for patients with non-traumatic conditions this score has demonstrated promising predictive ability in trauma populations as well. A modified version of this score, known as the modified Rapid Emergency Medicine Score, was later created to optimize performance in trauma patients. This version adjusts the weight given to age and the Glasgow Coma Scale and replaces mean arterial pressure with systolic blood pressure. The Glasgow Coma Scale Age Pressure score is derived from the Mechanism Glasgow Coma Scale Age Pressure score by removing the mechanism of injury component. It focuses exclusively on physiological variables, specifically Glasgow Coma Scale, age, and systolic blood pressure. The score can be calculated quickly based on a patient's initial clinical status and vital signs, making it especially well-suited for use in settings with limited resources. Previous studies have shown that it has strong predictive ability for mortality.

Although these trauma scores have demonstrated potential, most validation studies have been conducted in high income countries or through single-center retrospective designs. To increase generalizability and relevance to diverse healthcare environments, there is a need for prospective multicenter research, particularly in settings with limited resources and infrastructure.

This current study presents a multicenter prospective cohort analysis from Iraq, a country facing a substantial burden of trauma and significant healthcare challenges. This research compares the accuracy of the Emergency Trauma Score, Rapid Emergency Medicine Score, and Glasgow Coma Scale Age Pressure score in predicting in-hospital mortality among adult trauma patients. The findings aim to offer evidence-based insights that could improve trauma triage and clinical decision-making in resource-constrained environments.

Inclusion Criteria:

• Patients presenting to the emergency department with trauma.
• Patients or their legal guardians must provide informed consent to participate in the study.
• Admission within 12 hours of injury.

Exclusion Criteria:

• Patients with incomplete clinical data or those discharged before scoring can be performed.
• Pregnant patients (due to specific physiological considerations not accounted for by the scoring system).
• Patients who died before arrival or were declared dead on arrival.
• Patients who refuse participation or for whom informed consent cannot be obtained.

The study population will consist of adult trauma patients (≥16 years) admitted to the emergency departments of participating tertiary hospitals in Iraq. Eligible patients will include those with blunt or penetrating trauma who present within 12 hours of injury. Patients will be assessed using EMTRAS, REMS, and GAP scores at admission, with outcomes monitored until discharge or in-hospital death.