创伤严重度评分法改进的研究

鉴于创伤严重度评分（ＩＳＳ）法在评定多发伤时的某些不足，本文作者通过对４８２例多发伤的研究，提出一种改进评价多发伤的方法（ＲＩＳＳ法）。改进后的ＲＩＳＳ法，将原来ＩＳＳ法评分的三个主要损伤区域３处伤扩展到四个区域的７处伤。两种评分法相比ＩＳＳ法评分涉及的伤处数为全部损伤处数的７２．８４％，而ＲＩＳＳ法将评分伤处数提高到９７．５６％。统计学处理及临床验证结果表明，ＲＩＳＳ法更能准确、合理地反映多发伤的严重度，它避免了ＩＳＳ法对同一区域内多发伤严重度评价过低的缺陷。     

创伤严重度改良评分法在颅脑损伤中的应用评价

目的:探讨创伤严重度改良评分法对颅脑损伤患者伤情严重度的评估价值并与ISS进行比较。方法:对我院收治的221例颅脑损伤患者用RISS和ISS法进行比较分析。结果:死亡组RISS、ISS分值均明显高于存活组(P<0.01),RISS与ISS平均分值与病死率呈正相关,RISS计分平均26.13以上表示伤情严重,死亡率明显增加,各计分段RISS计分值均较ISS计分值高,且变化幅度大。结论:RISS与ISS计分法对颅脑损伤的伤情评估具有同步性,但RISS评分值较高,各计分段变化幅度大,更直观地反映了颅脑损伤的严重程度。     

265例多发伤的严重度评分及临床意义

随着多发伤病人的迅速增加，其严重度量化评分也渐被人们所重视。本文以AIS——90版为依据，总结两院1997．1～2000．6间265例多发伤病人的AIS——ISS评分，探索创伤严重度评分在基层医院的使用及临床意义。     

创伤严重度评分法在护理工作中的运用

创伤评分量化评定伤情的严重程度．对创伤学科的发展有重要意义。损伤定级标准（AIS）是损伤严重度评分（！SS）的基础。AIS始于60年代中期，由美国多学科专家研究，1971年发表，经过6次修改。目前使用的是1990年修改的AIS90［1·ZIAIS的制定为医生研究治疗方案．推测预后；护理工作中判断伤情、制定护理计划均具有十分重要的章义。我院1989～1996年在神经外科、创伤科开展创伤评分，介绍如下。！AIS的表示方法AIS是以解剖损伤为依据，每一处损伤均有其独立的AIS定级。它只评定伤情本身而不涉及后果。在定级时要求资料确切具体，…     

改良创伤严重度评分与药物在预防骨创伤脂肪栓塞的应用

[目的]观察改良创伤严重度评分法(RISS)结合药物预防骨创伤并发脂肪栓塞(FES)的效果。[方法]采用前瞻性研究2016年3月～2017年10月收治的骨创伤患者1305例,根据是否合并胸、腹、颅脑等其他部位的多发损伤和RISS分值,将患者分为四组:A组104例为单纯四肢长管状骨骨折,RISS分值11分;B组256例为单纯四肢长管状骨骨折,RISS分值≥11分;C组358例为四肢长管状骨骨折同时合并有多发损伤,RISS分值18分;D组587例为四肢长管状骨骨折同时合并有多发损伤,且RISS分值≥18分。其中A、C两组不给予药物预防措施,B、D两组给予低分子右旋糖酐加地塞米松药物预防,观察FES的预防效果。[结果] 1 305例骨创伤患者中,发生临床FES 3例,男女比例为2:1,平均年龄为(38.32±13.22)岁。A组和C组均无FES发生;B组发生1例FES,RISS分值为13分;D组发生2例FES,其RISS分值分别为21分和25分。各组患者性别、年龄和入院时间差异无统计学意义(P0.05),各组RISS值比较差异具有统计学意义(P0.05)。[结论]应用RISS评分法对骨创伤易并发FES患者进行快速筛选并给予药物预防,有肋于降低FES的发病率。     

ICISS—一种新的创伤严重度评分法

ＩＣＩＳＳ即第九闪修订的国际疾病分类创伤严重度评分法,是近几年出现的一种以ＩＣＤ０－９编码为基础的创伤严重度评分系统。本文通过对ＩＣＩＳＳ的提出,可行性研究,计算方法和应用,以及与其它评分系统比较后作一综述,旨在说明ＩＣＩＳＳ是一种良好的创伤结局预测和损伤严重度评价的评分系统,值得推广应用。     

创伤严重度评分与颌面多发骨折整复预后的相关性分析

目的:探讨创伤严重度评分与颌面多发骨折整复预后的相关性。方法:120例颌面多发骨折患者采用颌面损伤严重度评分(Maxi l l of aci al I nj ur y Sever i t y Scor e,MI SS)进行创伤严重度评分,然后采用积极的手术治疗,观察预后的治愈与并发症发生情况。结果:120例患者入院时平均MISS分值为(20.36±6.32)分;治愈100例,治愈率为83.3%,无死亡患者;发生并发症32例,发生率为26.7%。MI SS≤15分组的治愈率最高,随着MI SS评分的增加,治愈率逐渐降低(P<0.05)。MI SS≤15分组的并发症发生率最低,随着MISS评分的增加,并发症发生率逐渐升高(P<0.05)。结论:对颌面多发骨折患者进行MISS法评分,可以判断出患者的损伤严重度与预后情况,在临床应用中具有较多的优点。     

改良骨盆损伤严重度评分法评价骨盆骨折494例

骨盆创伤的救治在全身骨关节损伤中占有十分重要地位,客观准确地评价骨盆创伤严重度,对创伤的诊断、救治及判断预后有重要意义。国外已使用简明损伤定级（AIS）、损伤严重度评分（ISS）、ASCOT、APACHE等创伤评分方法来预测伤情和生存概率。ISS是目前最常用的评分方法,但也有不足之处。     

胸部创伤损伤严重度评估及死亡原因分析

目的探讨胸部创伤的死亡原因及损伤严重度评估，以提高胸部创伤的诊断及治疗水平。方法回顾性分析我院687例胸部创伤的临床资料，并根据治疗结果（分为生存组、死亡组）、有无合并伤（分为单纯胸伤组、多发伤组）以及是否有胸膜腔与外界沟通（分为闭合伤组、开放伤组）分组进行修正创伤评分（RTS）、简明损伤定级（AIS）、损伤严重度评分（ISS）和计算生存概率（PS），比较不同组间的损伤严重程度，分析死亡的高危险因素。结果闭合伤组488例，其中死亡21例，死亡原因为原发性颅脑损伤10例，急性呼吸衰竭6例，多器官功能不全综合征（M（）DS）4例，低血容量性休克1例；开放伤组199例，其中死亡9例，死亡原因为低血容量性休克9例。创伤评分各指标在生存组、死亡组间差异有统计学意义（GCS：t=4．648，P=0．000，RTS：t=4．382，P=0．000，胸AIS：t=2．296，P=0．027，ISS：t=4．871，P=0．000；Ps：t=4．254，P=0．000）；单纯胸伤组与多发伤组胸AIS差异无统计学意义（t=0．723，P=34．567），但RTS（t=2．553，P=0．032），ISS（t=10．776，P=0．000），Ps（t=3．868，P=0．007）差异有统计学意义；在闭合伤生存组、开放伤生存组间，虽然RTS（t=3．161，P=0．007），ISS（t=4．118，P=0．005）差异有统计学意义，但Ps差异无统计学意义（t=0．857，P=97．453），而在闭合伤死亡组、开放伤死亡组间差异均有统计学意义（GCS：t=4．016，P=0．001；RTS：t=3．168，P=0．006；胸AIS：t=2．303，P=0．043；ISS：t=4．218，P=0．002；Ps：t=4．624，P=0．001）。创伤死亡率随创伤评分增高而增高，全组ISS值在20～25时，死亡率为10．7％，在ISS值相同时，开放伤组死亡率较闭合伤组高。结论胸部创伤应用创伤评分有助于判断损伤严重度，指导临床救治；闭合伤死亡原因较开放伤复杂；严重创伤     

Comparison of the new injury severity score and the injury severity score in multiple trauma patients

Objective： To assess whether these characteristics of less misclassification and greater area under receiver operator characteristic （ROC） curve of the new injury severity score （NISS） are better than the injury severity score （ISS） as applying it to our multiple trauma patients registered into the emergency intensive care unit （EICU）.
Methods： This was a retrospective review of registry data from 2 286 multiple trauma patients consecutively registered into the EICU from January 1,1997 to December 31, 2006 in the Second Affiliated Hospital, Medical School of Zhejiang University in China. Comparisons between ISS and NISS were made using misclassification rates, ROC curve analysis, and the H-L statistics by univariate and multivariate logistic progression model.
Results： Among the 2 286 patients, 176 （7.7%） were excluded because of deaths on arrival or patients less than 16 years of age. The study population therefore comprised 2 1 10 patients. Mean EICU length of stay （LOS） was 7.8 days ± 2.4 days. Compared with the blunt injury group, the penetrating injury group had a higher percentage of male, lower mean EICU LOS and age. The most frequently injured body regions were extremities and head/neck, followed by thorax, face and abdomen in the blunt injury group; whereas, thorax and abdomen were more frequently seen in the penetrating injury group. The minimum misclassification rate for NISS was slightly less than ISS in all groups （4.01% versus 4.49%）. However, NISS had more tendency to misclassify in the penetrating injury group. This, we noted, was attributed mainly to a higher false-positive rate （21.04% versus 15.55% for IS S, t=-3.310, P〈0.001）, resulting in an overall misclassification rate of 23.57% for NISS versus 18.79% for ISS （t=3.290, P〈0.001）. In the whole sample, NISS presented equivalent discrimination （area under ROC curve： NISS=0.938 versus ISS=0.943）. The H-L statistics showed poorer calibration （48.64 versus 32.11, t=3.305, P〈0.001） in     

Application of injury severity score to multiple injuries headed by spinal cord injury

Objective： To evaluate the application of injury severity score （ISS） to multiple injuries headed by spinal cord injury. Methods： The data of 55 cases （40 males and 15 females, aged 17-69 years, mean = 41 years） of multiple injuries headed by spinal cord injury treated in our hospital from January 2000 to December 2004 were reviewed and analyzed with ISS （Version of AIS-2005 ） to explore their relationship. Results ： The ISS values increased with the number of injured regions, so did the complications. The recovery rate was negatively related to ISS values. During the period of immunity observation, the patients with ISS 〉 25 could undergo planned operations safely. Conclusions： Treatment for multiple injuries headed by spinal cord injury closely depends on the general and local conditions of the patients. ISS may provide useful data for the choice of treatment methods.     

两种损伤严重程度评分对腹部闭合性损伤病人死亡率预测价值的对比分析

目的探讨新损伤严重程度评分(new injury severity score,NISS)与损伤严重程度评分(injury severity score,ISS)对腹部损伤病人预后预测价值的差异。方法自2010年1月至2015年5月,按照连续采样的方法收集就诊的腹部损伤病人的临床资料,根据病人是否死亡将所有病人分为死亡组和生存组。比较组间病人年龄、性别、入院时脉搏、收缩压、NISS、ISS以及受伤机制的差异,多元回归分析法判定腹部损伤病人死亡的相关危险因素,并绘制相关危险因素预测病人死亡的ROC曲线,以比较两种评价体系对病人预后预测价值的差异,并确定相关危险因素预测病人死亡的临界值。结果组间病人入院情况相比,生存组病人入院时平均脉搏相对较慢,收缩压相对较高,ISS、NISS评分相对较低,就病人致伤因素分布情况来看,死亡组病人交通事故伤病人比例相对较高,以上组间相比差异均有统计学意义(P均0.05)。病人死亡危险因素的多元回归分析结果显示,病人入院时收缩压、ISS、NISS评分是腹部损伤病人死亡的独立危险因素(OR值均1.0,P值均0.05)。ISS、NISS预测病人死亡的对比分析结果显示,NISS[曲线下面积(AUC)=0.96,95%置信区间(CI):0.57~1.93,P0.001]预测病人死亡风险的AUC较ISS(AUC=0.75,95%CI:0.92~1.00,P=0.003)相对较大,准确性相对较高,在NISS=14时,其预测腹部损伤病人死亡的敏感性和特异性分别为90.2%和88.6%。结论 ISS、NISS两种评分体系均是腹部闭合性损伤病人死亡风险的独立危险因素,但在病人死亡风险预测上,NISS评分的预测价值相对较大,值得临床进一步研究证实。     

New injury severity score (NISS) outperforms injury severity score (ISS) in the evaluation of severe blunt trauma patients

Purpose: The injury severity score (ISS) and new injury severity score (NISS) have been widely used in trauma evaluation. However, which scoring system is better in trauma outcome prediction is still disputed. The purpose of this study is to evaluate the value of the two scoring systems in predicting trauma outcomes, including mortality, intensive care unit (ICU) admission and ICU length of stay. Methods: The data were collected retrospectively from three hospitals in Zhejiang province, China. The comparisons of NISS and ISS in predicting outcomes were performed by using receiver operator characteristic (ROC) curves and Hosmer-Lemeshow statistics. Results: A total of 1825 blunt trauma patients were enrolled in our study. Finally, 1243 patients were admitted to ICU, and 215 patients died before discharge. The ISS and NISS were equivalent in predicting mortality (area under ORC curve [AUC]: 0.886 vs. 0.887, p ¼ 0.9113). But for the patients with ISS 25, NISS showed better performance in predicting mortality. NISS was also significantly better than ISS in predicting ICU admission and prolonged ICU length of stay. Conclusion: NISS outperforms ISS in predicting the outcomes for severe blunt trauma and can be an essential supplement of ISS. Considering the convenience of NISS in calculation, it is advantageous to promote NISS in China’s primary hospitals.     

Developing a burn injury severity score (BISS): Adding age and total body surface area burned to the injury severity score (ISS) improves mortality concordance

Background

There is limited research validating the injury severity score (ISS) in burns. We examined the concordance of ISS with burn mortality. We hypothesized that combining age and total body surface area (TBSA) burned to the ISS gives a more accurate mortality risk estimate.

Methods

Data from the Royal Perth Hospital Trauma Registry and the Royal Perth Hospital Burns Minimum Data Set were linked. Area under the receiver operating characteristic curve (AUC) measured concordance of ISS with mortality. Using logistic regression models with death as the dependent variable we developed a burn-specific injury severity score (BISS).

Results

There were 1344 burns with 24 (1.8%) deaths, median TBSA 5% (IQR 2–10), and median age 36 years (IQR 23–50). The results show ISS is a good predictor of death for burns when ISS ≤ 15 (OR 1.29, p = 0.02), but not for ISS > 15 (ISS 16–24: OR 1.09, p = 0.81; ISS 25–49: OR 0.81, p = 0.19). Comparing the AUCs adjusted for age, gender and cause, ISS of 84% (95% CI 82–85%) and BISS of 95% (95% CI 92–98%), demonstrated superior performance of BISS as a mortality predictor for burns.

Conclusion

ISS is a poor predictor of death in severe burns. The BISS combines ISS with age and TBSA and performs significantly better than the ISS.     

Missed injury in major trauma patients

OBJECTIVES: To determine the incidence, aetiology and contributing factors to injuries being missed during the primary and secondary surveys in patients with major trauma managed on a general Adult Intensive Care Unit (AICU). METHODS: The records for patients admitted to the AICU following severe injury (defined as injury severity score (ISS) >16) over a 1-year period were reviewed. Diagnostic imaging performed during the resuscitation was reviewed in cases where missed injuries were discovered. RESULTS: Forty-five patients with a median injury severity score of 26 were included in the study. Twelve missed injuries were discovered in 10 patients during the intensive care admission; three required an additional surgical procedure. There was no significant difference in Glasgow Coma Score, revised trauma score, ISS or admission systolic blood pressure between patients with missed injuries and those patients where all injures were found at resuscitation (P > 0.05). Three quarters of the undetected injuries were orthopaedic. CONCLUSIONS: Significant injuries can be missed during the primary and secondary surveys in severely injured patients. A tertiary survey should be completed in all trauma patients admitted to an intensive care unit.     

胸腰椎损伤分类及损伤程度评分系统的评估及初步应用

目的评估胸腰椎损伤分类及损伤程度评分系统(thoracolumbar injury classification and severity score,TLICS)的可信度(interobserver reliability)和可重复性(intraobserver reproducibility),及其对胸腰椎损伤治疗的指导作用。方法2006年1月~2007年1月入院的胸腰段骨折患者38例,均行胸腰椎X线、CT、MRI检查,经过神经学查体将神经损伤状态分为:无损伤、神经根损伤、马尾神经损伤、完全性脊髓损伤(ASIA A)及不完全性脊髓损伤。对于不完全性脊髓损伤按照ASIA系统进行运动功能分级(ASIA B、C、D)。根据影像学检查将骨折形态分为:压缩型、爆裂型、减力及旋转型、牵张型;将后纵韧带复合体(posterior ligamentous complex,PLC)损伤分为:无损伤型、不确定型、断裂型。分6组医生根据TLICS系统进行评定,计算损伤程度评分,并根据评分决定其治疗方案。3个月后进行再次评估。使用Cohen加权kappa系数(unweighted Cohen kappa coefficients)对TLICS总评分、骨折形态分型、神经损伤分型、PLC损伤分型、最终治疗方案等观察项间的可信度和可重复性进行分析。根据TLICS评分选择治疗方法,评估此组病例的神经功能恢复情况、并发症发生情况。结果计算TLICS亚类(骨折形态、PLC损伤状态、TLICS总分数、治疗推荐),Kappa系数位于中度和较高一致性之间(0.46~0.73),针对神经损伤状态亚类的Kappa系数为0.93,为高度一致性,诊断可信度较高,2次可信度评估的Kappa值差异无统计学意义。以相同方法分析TLICS系统可重复性,Kappa系数也位于中度和较高度一致性之间(0.42~0.75),针对神经损伤状态的Kappa系数为0.94,为高度一致性。TLICS系统诊断准确率为95.3%,敏感性为87.6%,特异性为97.3%。38例患者中6例TLICS总分≤3的患者均选择非手术治疗;6例=4分的患者其中2例行非手术治疗,4例行手术治疗;26例≥5分的患者均选择手术治疗。无神经损伤的患者8例,均未手术;有神经损伤30例患者均行手术治疗,根性损伤6例,不完全脊髓损伤14,完全性脊髓损伤5例,马尾神经损伤5例,术后22例患者神经功能得到不同程度的恢复,恢复率为73.3%。术后无神经损伤加重,并发症发生率低。结论TLICS分类系统具有较高的可靠性和可重复性,且使用简单,易于掌握,此方法对胸腰椎损伤的评估较全面和准确,可以作为患者临床治疗选择的依据。     

Using the injury severity score to adjust for comorbid trauma may be double counting burns: implications for burn research

Background

The injury severity score considers burn size and inhalation injury in estimating overall anatomical injury severity. Models that adjust for injury severity score in addition to total burn size and inhalation injury may therefore be double counting the risk from these individual burn characteristics, and obscuring (or overemphasizing) the contribution of risk from each source. The primary aim of this study was to compare differences in the estimated mortality risk of burn trauma using the traditional injury severity score (ISS) calculation and the non-burn injury severity score (NBISS) to examine how separating out the risk attributable to the burn injury versus other trauma changes the interpretation and clinical assessment.

Assessment of the severity of hand injuries using "hand injury severity score", and its correlation with the functional outcome

INTRODUCTION: Objective assessment of hand injuries is a complex subject. However, an objective assessment, leading to a score, can help in predicting outcome and can be used as a research tool. Campbell and Kay have devised one such score known as "hand injury severity score" or HISS [J. Hand. Surg. [Br.] 21 (3) (1996) 295]. A study on this score has been carried out in our institute. The idea was to see if the hand injury severity score, correlates with the functional outcome as measured by disability arm shoulder and hand score (DASH), after a period of minimum 2 years. METHOD: All the hand injury patients admitted in the hospital were assessed at the time of admission, and objective information was documented on a hand injury documentation form. The form captured all the data required to calculate "hand injury severity score" . A sample of 70 patients admitted during the first 6 months of 1999 was taken and their scores were calculated. The sample was selected such, that it had a reasonable representation of hand injuries of all severities. After obtaining a due approval from ethics committee, all these 70 patients were sent a DASH questionnaire. A total of 23 patients replied. Spearman's rank correlation test was used to analyse the correlation between the severity of hand injury as assessed using HISS, and functional outcome as measured using DASH. Correlations between the outcome and skeletal component score, outcome and motor component scores, and outcome and Integument component scores, were assessed separately. RESULTS: The study shows a statistically significant association ( r = 0.7182, P = 0.000165) between the severities of injury and the functional outcome. The functional outcome also shows a statistically significant association with the severity of injury to skeletal component (r = 0.5151, P = 0.014083) and motor component (r = 0.6797, P = 0.000507). However, the severity of injury to integument component, as measured by HISS, does not show any association with the outcome (r = 0.3571, P = 0.102736). This study supports the overall structure of the HISS. However an improvement in the integument component scoring is required to improve overall accuracy.