Correlation of abdominal trauma index and injury severity score with abdominal septic complications in penetrating and blunt trauma.

The Abdominal Trauma Index (ATI) was designed to stratify patients with penetrating injuries, and has been used to classify patients with blunt trauma. The Injury Severity Score (ISS) was originally designed to stratify victims of blunt trauma, and it has also been used for victims of penetrating trauma. We attempted to validate the use of ISS and ATI for both penetrating and blunt trauma. A total of 592 penetrating and 334 blunt trauma patients who underwent laparotomy over a 5-year period were evaluated. The overall rate of abdominal sepsis was 7.5% for blunt trauma and 7.6% for penetrating trauma. Mortality (excluding deaths within 48 hours) was 7% for blunt trauma and 1% for penetrating trauma. In the penetrating injury population, an ATI value greater than 15 and an ATI value greater than 25 were significantly associated with abdominal septic complications (ASCs) (p less than 0.001, both comparisons). An ISS greater than or equal to 16 was also associated with ASCs (p less than 0.001). The ASC rate for gunshots was higher than that for stab wounds (11% vs. 2%; p less than 0.001). In the blunt group, an ATI value greater than 15 and an ATI value greater than 25 were associated with ASCs (p less than 0.01 and p less than 0.001, respectively). The association of ASCs and ISS was linear with increasing ISS in patients with blunt abdominal trauma.(ABSTRACT TRUNCATED AT 250 WORDS)     

Does the severity of spontaneous genital tract trauma affect postpartum pelvic floor function?

We describe the impact of genital trauma on pelvic floor function in a low-risk cohort of women after vaginal birth. Questionnaires (Present Pain Intensity Scale, Incontinence Impact Questionnaire, Fecal Incontinence Score, and Intimate Relationship Scale) were completed up to 12 weeks postpartum. Severity of trauma was recorded at delivery. Overall follow-up was 444/565 (79%). Major trauma (trauma that involved perineal muscles or required suturing) occurred in 20%; 20% delivered intact. At 12 weeks, 10% complained of perineal pain; 24% reported anal (AI) and 27% urinary incontinence (UI). Women with trauma were no more likely than those intact to complain of UI or AI, sexual inactivity, or perineal pain postpartum (all P = NS). Women with major trauma had weaker pelvic floor exercise strength than those who delivered intact or with minor trauma (odds ration 3.06, 95% confidence interval 1.41–6.63). Pelvic floor complaints postpartum were common but not associated with severity of genital trauma in a cohort of low-risk women.     

Magnetic resonance imaging of acute cervical spine trauma. Correlation with severity of neurologic injury

Prior to the advent of computer-assisted imaging techniques, conventional radiographic studies did not accurately depict the severity of soft tissue injury (spinal cord and paravertebral tissue) attending severe spinal trauma. Computed tomography scanning is clearly superior to plain radiography in the demonstration of osseous fractures and impactions, but this modality does not clearly depict ligamentous or disc injuries and does not image the spinal cord directly. The authors' preliminary experience indicates that magnetic resonance imaging (MRI) more accurately defines the extent of soft tissue damage in the zone of injury. In this study, the authors correlate these objective imaging techniques with findings on neurologic exam. Seventy-eight patients with cervical spine injuries admitted to the Regional Spinal Cord Injury Center of the Delaware Valley between August 1987 and January 1989 were evaluated with surface-coil MRI on a 1.5-Tesla unit. Fifty-nine patients were studied within 7 days of injury. Image sequences consisting of T1-, proton density, and T2-weighted images were obtained in saggital views. Axial gradient recalled acquisitions in the steady state (GRASS) images were obtained from most patients. We learned that certain patterns of MRI signal were associated with severe neurologic deficit. These include: 1) intramedullary hematoma and 2) spinal cord contusion associated with edema encompassing more than one spinal segment. Magnetic resonance imaging findings also correlated with less severe injury and include 1) normal spinal cord signal and 2) small focal contusions associated with edema encompassing one spinal segment or less.     

The effect of trauma on serum C3 activation and its correlation with injury severity score in man

The sera of 12 patients with mechanical trauma were studied to determine C3 levels and activation. The injury severity score (ISS) was then related to serum C3 levels and activation. It was found that in the immediate postinjury period, serum C3 activation occurred in cases where ISS was greater than or equal to 12. The mean ISS of patients with complement activation was 25.2. In comparison, in patients with nonactivation of complement, the mean ISS was 9.5 (p less than 0.05). Serum C3 levels were inversely related to ISS. The mean serum C3 level of patients with ISS greater than or equal to 12 was 73.3 mg% and mean serum C3 level with ISS less than 12 was 109.4 mg%. This difference was again statistically significant (p less than 0.05). There is indication that complement depletion occurs in the immediate postinjury period in moderate to severe injury (ISS greater than or equal to 12). This finding could explain, in part, the immunosuppressive effect of trauma and can be used as a marker to predict possible septic complications.     

Defining the major trauma patient and trauma severity

Criteria for defining the major trauma patient have been specified by physicians using Injury Patient Management Categories (PMCs), a computerized classification that can be used effectively with routinely collected discharge abstract data from non-trauma center hospitals as well as trauma centers. These criteria for major trauma not only include the more severe and complex single injuries, but also include criteria for identifying combinations of injuries that require tertiary level care. Major trauma patients identified as tertiary using PMCs are compared with existing and frequently used measures of injury severity such as AIS and ISS. Analyses suggest that the Injury PMCs identify major trauma patients accurately and more specifically than other indicators of severity that are commonly used. In addition, unlike other measures that are generally limited to registries, PMC tertiary patient criteria differentiate major trauma patients at both trauma centers and non-trauma centers without additional data collection. Using this method thus facilitates trauma systems evaluation and patient outcome assessment.     

严重创伤患者PCT与脏器损伤严重程度及预后的相关性分析

目的：探讨严重创伤患者血清前降钙素（PCT）与脏器损伤严重程度及预后的关系。方法90例严重创伤患者根据并发症发生情况分为多脏器功能衰竭组（MODS组）20例,炎症反应综合征组（SIRS组）26例以及无并发症组44例,对三组患者入院时、入院第1、3、5、7、9天外周血清PCT浓度的检测及APACHRⅡ评分评估,及损伤第5天脏器损伤相关生化指标的记录。结果入院时无并发症组PCT略升高,在入院第3天水平即恢复正常;MODS组及SIRS组入院时PCT浓度均明显高于无并发症组（P均<0.05）,MODS组在入院第9天PCT仍高于无并发症组（P<0.05）,SIRS组入院至入院第5天PCT高于无并发症组（P<0.05）,但在入院第7天PCT水平与无并发症组无异（P>0.05）.(2) MODS组及SIRS组死亡率明显高于无并发症组（P均<0.05）,其中MODS组升高的趋势更为明显。（3）入院第5天时MODS组及SIRS组患者血清丙氨酸氨基转移酶（ALT）、天门冬氨酸转移酶（AST）、血尿素氮（BUN）、肌酐（Cr）、血清肌酸激酶（CK）、肌酸激酶同工酶（CK-MB）浓度均较无并发症组升高（P均<0.05）,PO2明显低于无并发症组（P均<0.05）,其中MODS组变化的幅度更为明显。（4）入院第1天时SIRS组及MODS组患者APACHEⅡ评分均明显高于无并发症组患者,其中MODS组患者升高的趋势更明显,入院第9天时无并发症组APACHE Ⅱ评分趋近于0,直到入院第9天,MODS组患者APACHEⅡ评分仍明显高于其余2组。（5）AST、BUN、Cr、CK、CK-MB、APACHRⅡ评分及PCT水平呈非正态分布,使用Spearman法进行相关参数相关性分析,结果发现AST、BUN、Cr、CK、CK-MB、APACHRⅡ及PCT水平的表达存在相关性。结论严重创伤不同脏器损伤程度患者外周血清PCT变化不尽相同,动态监测PCT浓度变化对严重创伤患者的病情及预后有评估价值。     

Correlation between injury severity scores and subjective ratings of injury severity: a basis for trauma audit.

A retrospective review of 1900 road accident victims attending the emergency departments of two Melbourne hospitals was undertaken to identify Injury Severity Score levels which could distinguish between minor, moderate, severe and critical injury. Injuries scoring ISS 6 or below were designated 'minor' because they were associated with a low risk of requiring admission to hospital. Case notes of patients scoring above ISS 6 were then reviewed by a panel of clinicians, who independently rated each patient's overall injury severity as moderate, severe or critical according to what was recorded in the notes and their 'clinical' judgement. ISS values were compared with clinicians' ratings. Measures of each clinician's individual rating consistency, and correlation between pairs of clinicians with respect to inter-rater consistency, were made. By combining data from both hospitals it emerged that 'moderate' injury corresponded to ISS 8-13, 'severe' to ISS 14-20 and 'critical' to ISS 21 and above. These ISS breakpoints will be useful in selecting groups of injured patients for future trauma audit studies.     

Correlation of revised trauma score and injury severity score (TRISS) predicted probability of survival with peer-reviewed determination of trauma deaths

Trauma deaths at our institution are evaluated by a multidisciplinary trauma committee. The purpose of this study was to evaluate preventable trauma deaths (PRDs) as determined by our review committee and correlate them with the Revised Trauma Score and Injury Severity Score (TRISS) probability of survival (PS). A total of 10,002 patients were identified. The PS was calculated using the TRISS method. The Z scores were calculated and the predicted number of deaths was established. The actual number of deaths was compared with the predicted number of deaths. PRDs were compared with the actual and predicted deaths. The Z score was 0.79, which meant we observed more deaths than predicted by TRISS. We had 281 deaths compared with 271 deaths predicted by TRISS. Peer review characterized 45 deaths as preventable. Although we performed well when our outcomes were compared with TRISS predicted outcomes our PRD rate was higher. The higher the PS the more likely the death was found preventable by peer review. We conclude that for our patient population the peer review process is very sensitive and may be more discerning in identifying PRD than TRISS.     

Measuring severity in trauma resuscitation

ISS is the most widely used anatomic trauma severity index. This scale uses clinical judgement. It is therefore a subjective method, the validity of which is somewhat questionable. The aim of this study was to compare the clinical index ISS with a new non-specific score; the "simplified acute physiology score" (SAPS). Five-hundred trauma patients were checked retrospectively. Were excluded small traumas which did not require ICU hospitalization. ISS were all calculated by the same specialist and SAPS was drawn out of the initial blood sample examination. The sensitivity (proportion of true positive) and the specificity (proportion of true negative) were calculated for the two scores at all different cut-off points. "Receiver operating characteristic curves" (ROC) were drawn and their areas were compared by means of the Hanley test. The best Youden index, i.e. the fewest false positives for the most true positives, was also calculated. Mean ISS was 23.3 +/- 9.2. Youden index was 0.1; sensitivity and specificity were respectively 57 and 52% for the cut-off points. Mean SAPS was 8.7 +/- 4.3. Youden index was 0.3 and sensitivity and specificity were respectively 68 and 62%. ROC curve area for SAPS was 0.69 +/- 0.02. ROC curve area for ISS was 0.56 +/- 0.03 (p = 0.0001). In trauma, SAPS seemed to be a better predictor of outcome than ISS.     

Correlation between crash severity, injury severity, and clinical course in car occupants with thoracic trauma: a technical and medical study

BACKGROUND: The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS: A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS: Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION: The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.     

Effect of agitation on platelet aggregation and microaggregate formation in banked blood.

Blood stored at 4 C in ACD or CPD solution develops microaggregates composed primarily of fibrin and platelets. This debris has been implicated in the pathogenesis of posttraumatic pulmonary insufficiency in man. Recent work indicates that gentle agitation of the blood during storage appears to decrease debris formation. These studies were undertaken to establish more clearly the effect of agitation on debris formation. Blood was drawn in CPD from healthy young males, non-aspirin ingesting donors and stored at 4 C. One-half of the bags were gently and continuously agitated for 21 days and the other half remained stationary. At the end of the storage period, platelet counts and screen filtration pressures were measured. Agitated blood showed significantly less debris formation and significantly higher platelet counts. Gentle agitation was shown to be an effective method for preventing debris formation in banked blood.     

Objective assessment of trauma severity in patients with combined injuries

The work presents an analysis of using scales VPH-P(MT) and VPH-P(SP) on the basis of a retrospective investigation of results of treatment of 268 patients with a combined injury of the abdomen. A conclusion is made that these scales have reserves for an improvement. The authors propose to supplement the scale VPH-P(SP) with the index of the patient's age, and the scale VPH-P(MT)--with an index of the blood loss volume.