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Background: Resource allocation to hospitals is highly dependent on appropriate case coding. For trauma victims, the major diagnosis-coding category (DCC) is multiple trauma (DCC26), which triggers higher funding. We hypothesized that DCC26 has limited capacity for appropriate identification of severe trauma victims., Methods: We studied Injury Severity Score (ISS), Trauma Related Injury Severity Score (TRISS) and in-hospital mortality using data recorded in three level 1 trauma centers over a 2-year period. Patients were divided into two groups: DCC26 and non-DCC26. For non-DCC26 patients, two subgroups were identified: patients with severe head trauma and patients with spinal trauma. Clinical endpoints were mortality, ISS>15 and TRISS, IGS II. Use of hospital resources was estimated using funding and expenditures associated with each patient., Results: During the study period, 2570 trauma victims were included in the analysis. These patients were 39±18 years old, with median ISS=14, and observed mortality=10 %. Group DCC26 had 811 (31 %) patients, group non-DCC26 1855 (69 %) patients. DCC26 coding identified a more severely injured group of patients. However, in the group non-DCC26, there was a high proportion of severe trauma (ISS>15: 35 %; TRISS<0.95: 9 %)., Conclusion: DCC26 is not an appropriate coding for severe trauma patients. For these patients, expenditures will include intensive care and rare and costly resources. We propose to take into account the TRISS score to improve trauma coding., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

Current forms of medical reports cannot be used for clinical and epidemiological and medical and economic researches because they don't contain information about competitive, associated diseases and its complications. Authors developed the method of clinical and epidemiological monitoring of nosologic structure of patients in military-medical institutions based on personalized record-keeping of patients with additional informational resources for recording of all diagnoses and performed medical service. With the help of the given method were analyzed nosologic structure and treatment results of 548 patients with vehicular trauma from the 442nd District Military Clinical Hospital. Polytrauma was revealed in 22% of patients, concomitant injury--in 39%, combined injures--in 0.4%. Besides, in 8% of patients were revealed associated chronic diseases that not only confound trauma, but also make difficult to diagnose and assess the severity of trauma.

Background: Acute Physiology and Chronic Health Evaluation II (APACHE II) and the Trauma Injury Severity Score (TRISS) are physiological and anatomical severity scores to predict trauma outcome. Nutritional Risk Screening (NRS-2002) is used for the screening of nutritional risk, which can affect outcome adversely. The objective of this study was to determine the reliability of these scales to predict disease severity, complications and mortality, and to compare the reliability of the NRS-2002 in predicting outcome with different scoring systems in trauma-intensive care unit (ICU) patients., Methods: The study enrolled 100 consecutive patients who were admitted to the ICU in a training hospital due to trauma in the six-month study period (1 July 2008 and 1 January 2009). Discrimination characteristics of the scoring systems were evaluated using receiver operating characteristic (ROC) curves., Results: Overall mortality was 14%, and the complication rate was 22%. Nutritional risk at admission was found to be increased in 58% of the patients. The NRS-2002 score was increased in patients with complication. ISS, TRISS and APACHE II at admission had a reliable power of discrimination (AUC>0.8) for mortality and complication prediction. The NRS-2002 score had moderate discrimination power for complication prediction (AUC=0.708) but showed high correlation with increased length of stay (LOS)., Conclusion: A significant percent of trauma patients are at nutritional risk. The NRS-2002 score can be useful in predicting complication and prolonged LOS in trauma patients.

Background: Previous studies have identified a variety of risk factors for occupant fatality in aviation crashes. A simple composite index measuring the risk of fatality in a given crash, however, is lacking., Methods: The FIA Score is a four-point (0-3) index based on the number of three risk factors for occupant fatality present in a given aviation crash: fire, instrument meteorological condition, and being away from airport. We assessed the validity of this risk index using aviation crash investigation data from the National Transportation Safety Board for the years 1983 to 2005. Sensitivity, specificity, and area under the receiver operating characteristic curve according to the type of flight operations were computed. The analysis was first limited to pilot-in-command fatality and then replicated to any fatality., Results: The study sample consisted of 44,828 aviation crashes, in which 7,889 (18%) pilots-in-command were fatally injured. The pilot crash fatality rate was 3%, 18%, 62%, and 89% for FIA Scores of 0 (none of the 3 risk factors present), 1, 2, and 3 (all 3 risk factors present), respectively. The FIA Score performed consistently well in predicting pilot fatality in crashes involving different types of flight operations. The area under receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.78-0.95) for major airline crashes, 0.83 (95% CI: 0.80-0.85) for commuter and air taxi crashes, and 0.81 (95% CI: 0.81-0.82) for general aviation crashes. The results were similar when the outcome was measured by whether or not the crash resulted in any fatality., Conclusions: The FIA Score appears to be a valid tool for measuring fatality risk in aviation crashes. Given its simplicity, the FIA risk index should be readily applicable to trauma research and prevention.

Background: The International Classification Injury Severity Score (ICISS) uses anatomic injury diagnoses to predict probability of survival (Ps) computed as the product of the survival risk ratios (SRR) of the three most severe injuries. SRRs are derived as the proportion of fatalities for every International Classification of Diseases-9th Revision-Clinical Modification diagnosis in a "benchmark" population. Pediatric-specific SRRs were computed from 103,434 entries in the National Pediatric Trauma Registry. We hypothesized that ICISS was a valid pediatric outcome predictor, and that the child's most severe injury; i.e., the lowest SRR, is the major driver of outcome, which can be used alone to predict survival., Methods: Receiver operator characteristic analysis was used to assess the predictive validity of ICISS. SRRs derived from 53,235 phase II patients were used as the training set to calculate the Ps for 50,199 phase III children comprising the test set. The survival probability (Ps) computed from the standard three diagnoses was compared with that computed from only the worst injury (lowest SRR). Records with a single diagnosis or Ps of 1, indicating no mortality potential, were excluded from the analysis. Nagelkerke pseudo R2 defined what proportion of the predicted Ps was the effect of the worst injury alone versus the traditional Ps., Results: A total of 25,239 records with at least two diagnoses with SRRs indicating risk of mortality were analyzed. The area under the receiver operator characteristic curve for traditional Ps was 0.935, compared with 0.932 for that calculated using only the lowest SRR. The difference of 0.003 was not significant (z = 1.061, p = 0.2888, NS). Nagelkerke pseudo R2 for the lowest SRR was 0.455 compared with 0.462 for the traditional three diagnosis Ps, which shows that the majority of Ps predictive power is related to the single injury with the lowest SRR. Further analysis demonstrated that this effect was related to frequency of coexistent injuries with no mortality risk rather than definable difference in severity., Conclusion: These data validate ICISS as predictive of pediatric injury survival. The dominant effect of the worst injury reflects an epidemiologic characteristic of pediatric trauma that will identify specific injuries for best practice analysis and focused injury prevention.

Background: Triage of the trauma patient in the field is a complex and challenging issue, especially deciding when to use aeromedical transport. The American College of Surgeons Committee on Trauma recently defined an acceptable under-triage rate [seriously injured patient not taken to a trauma center (TC)] as 5%, whereas over-triage rates may be as high as 25% to 50%. Effective utilization of prehospital helicopter transport requires both accurate assessment of patients and effective communication. The rural county adjacent to our developed trauma system uses standardized triage criteria to identify patients for direct transport to our TCs. We hypothesized these criteria accurately identify major trauma victims (MTV) and further that communication could be simplified to expedite transport., Methods: Prehospital personnel use a MAP (mechanism, anatomy, and physiology) scoring system to triage trauma patients. Patients with > or = 2 "hits" are defined as MTV. In 2004, the triage policy was changed so that MTV would be transported directly to a TC without base hospital consultation (previously required). The Emergency Medical Services (EMS) Medical Director reviewed cases transported to the TC to determine the appropriateness of triage decisions (over- and under-triage using the American College of Surgeons Committee on Trauma definitions). Data were compared before and after this policy change., Results: For 2004 to 2006, we evaluated 676 air transports to TC and compared them to 468 in the prior 56 months. The overall transport rate increased slightly 7% to 10%. During the study period the over-triage rate was 31% compared with 21%, before the policy change. The MAP triage tool yielded a 93.8% sensitivity and a 99.5% specificity. Therefore, it determined the need for air-medical transport out of a rural environment into an established trauma system with > 90% accuracy., Conclusions: Prehospital personnel can accurately use a trauma triage tool to identify MTV. Eliminating base station contact, a potential for introducing communication error, did increase over-triage but still well within accepted limits. The system change also resulted in the transport of a greater proportion of minor trauma patients who later proved to have major injuries.

The application of scores for the assessment of injury severity allows a decision on the optimal strategy of treatment of patients with multiple and associated traumas at all stages of trauma disease. The correct choice of time, method and volume of surgery allows minimization of complications associated with the operative aggression on the one hand, and forced adynamia and asthenic syndrome on the other hand.

Current trauma triage protocols lack sensitivity to occult injuries in older persons, resulting in unacceptable undertriage rates. We identified crash scene information that could be used by emergency personnel to identify the need for trauma center care in older persons injured in motor vehicle crashes. Crash records of 7,883 persons 65 years and older were explored using classification and regression trees (CART) analysis. CART analysis of 26 crash scene variables resulted in two classification trees from which triage decision rules were stated for persons with severe and moderate injuries. Sensitivity and specificity of the rules were 95.15% and 76.47% for severe injury and 83.1% and 81.5% for moderate injury.

Introduction: This prospective study assessed the efficacy of the predicting power for mortality of two different prehospital scoring systems in trauma with ISS > 14. We present an improved Mainz Emergency Evaluation Scoring system (MEES) in combination with capnometry (MEESc). MEESc is a new scoring system., Patients and Methods: In a prehospital setting, the values of MEES and capnometry (initial and final) were collected from each patient. We added final values of partial pressure of end-tidal CO2 (petCO2) to the MEES scoring system and ranked them from 0 to 2 so that the final maximum sum of this scoring system would be 30 without any change in the minimal score being 10. This study was performed over 4 years (from January 2000 to December 2004) and included 114 consecutive patients hospitalized for major trauma with ISS >14, requiring intubation at the roadside and in whom prehospital petCO2 had been recorded. Patients younger than 16 years and those with severe hypothermia (core temperature less than 30 degrees C) were excluded from the study. There were 81 males and 34 females, age range 16 to 82, mean 41.8 +/- 16.4 years. For every scoring system, the sensitivity, specificity, correct outcome prediction and area under the ROC curve were determined. Results were compared with McNemar's test in Z score. A significant difference was p < 0.05., Results: For prediction of mortality, the best cutoff points were 20 for MEES and 23 for MEESc. The area under the ROC curve was 0.63 for MEES and 0.81 for MEESc (p < 0.05)., Conclusion: There were significant differences between MEES and MEESc. MEESc improved the results of MEES in predicting trauma outcome with ISS > 14. The prehospital use of the improved MEESc system could be an efficient communication protocol between the prehospital and hospital settings.

Background and Aims: Since 1999, the Dutch trauma care has been regionalized into ten trauma systems. This study is the first to review such a trauma system. The aim was to examine the sensitivity of prehospital triage criteria [triage revised trauma score (T-RTS)] in identifying major trauma patients and to evaluate the current level of trauma care of a regionalized Dutch trauma system for major trauma patients., Patients and Methods: Major trauma patients (n=511) (June 2001-December 2003) were selected from a regional trauma registry database. The prehospital T-RTS was computed and standardized W scores (Ws) were generated to compare observed vs expected survival based on contemporary US- and UK-norm databases., Results: The T-RTS showed low sensitivity for the prehospital identification of major trauma patients [34.1% (T-RTS< or =10)]. Nevertheless, 78.0% of all major trauma patients were directly managed by the trauma center. These patients were more severely injured than their counterparts at non-trauma-center hospitals (p<0.001). No significant difference emerged between the mortality rates of both groups. The Ws {-0.46 calculated on the US model [95% confidence interval (CI) ranging from -1.99 to 1.07]} [0.60 calculated on the UK model (95% CI ranging from -1.25 to 2.44)] did not differ significantly from zero., Conclusion: The trauma center managed most of the major trauma patients in the trauma system but the triage criteria need to be reconsidered. The level of care of the regional trauma system was shown to measure up to US and UK benchmarks.

Objectives: To test (a) the prognostic performance of TRISS and SAPS II scoring systems in a large sample of trauma patients admitted to Austrian ICUs, and (b) the hypothesis that the prognostic performance of TRISS could be improved by adding SAPS II., Methods: Prospective multicenter cohort study comprising 5,538 trauma patients out of 35,637 patients admitted to 31 ICUs in Austria over a 4-year period., Results: Separately, TRISS and SAPS II showed lack of calibration in the cohort of trauma patients. The database was then split into two equal samples, development and validation. Using the development sample, a new scoring system was developed, with vital status at hospital discharge as the dependent variable and TRISS and SAPS II as independent variables. The prognostic performance of the new TRISS-SAPS system was then assessed in the validation cohort: Both, discrimination (as shown by area under the ROC curve), and calibration (using Hosmer-Lemeshow goodness-of-fit statistics) was excellent., Conclusions: We improved risk adjustment in critically ill trauma patients by combining TRISS and SAPS II. This new scoring system might aid in evaluating and comparing specialized trauma ICUs.

Objectives: To describe the patterns of nosocomial infections in patients with traumatic injuries and to compare the associations between injury severity, derived from various severity scoring systems, and subsequent nosocomial infections., Design: Prospective observational study., Setting: A 750-bed university hospital serving as a medical school and referral center for the southern part of Thailand., Participants: All trauma patients admitted to the hospital for more than 3 days during 1996 to 1999 were eligible for this study., Methods: The severity of injuries was measured in terms of injury severity score (ISS), revised trauma score (RTS), new injury severity score (NISS), and trauma injury severity score (TRISS). Infections acquired during hospitalization were categorized using Centers for Disease Control and Prevention criteria. The association between severity of injury and nosocomial infection was examined with Poisson regression models., Results: There were 222 nosocomial infections identified among 146 patients, yielding an infection rate of 0.8 infections per 100 patient-days. Surgical-site infection was the most common site-specific infection, accounting for 31.1% of all infections. The incidence of intravenous catheter-related bloodstream infection was 1.6 infections per 100 catheter-days. The bladder catheter-related urinary tract infection rate was 2.8 infections per 100 catheter-days. The rate of ventilator-associated pneumonia was 3.2 infections per 100 ventilator-days. The incidence of infection correlated well with injury severity. The infection incidence rate ratios for one severity category increment of ISS, NISS, RTS, and TRISS were 1.65 (95% confidence interval [CI95], 1.42 to 1.92), 1.79 (CI95, 1.55 to 2.05), 1.64 (CI95 1.43 to 1.88), and 1.32 (CI95, 1.14 to 1.52), respectively., Conclusions: Surgical-site infection was the most common site-specific nosocomial infection. The NISS might be the most appropriate severity scoring system for adjustment of infection rates in trauma patients.

Evaluation of polytrauma patient's status by using scoring system is very important for selection of patient's placement and management, prophylaxis and diagnosis of early complications. In the article trauma classification systems are presented and discussed. Clinical evidences of Kaunas Medical University Hospital are presented as well. There are suggestive recommendations on evaluation of polytrauma patient's status and proper separation of severely injured.

Objective: To assess the Pediatric Risk of Mortality (PRISM) score and to identify other prognosis factors in severe, multiple trauma in children., Design: Retrospective study over a 9-year period., Setting: A Pediatric Intensive Care Unit (PICU) in a University Hospital., Patients and Participants: One hundred and thirty-three traumatized children, 8.6 years (8 months-16 years), were reviewed., Interventions: None., Measurements and Results: Pediatric Trauma Score (PTS), Injury Severity Score (ISS), New ISS (NISS), Glasgow Coma Scale (GCS) score, and PRISM were calculated. The areas under the Receiver Operating Characteristic (ROC Az) curves, were compared. Univariate and multivariate analyses were performed. The mortality rate was 25.6%. PRISM performed well for discrimination between survivors and non-survivors. Az PRISM 0.9387 (0.029) was not different from Az GCS score 0.9451 (0.027) (P=0.568), but was significantly different from Az ISS 0.756 (0.052) (P<0.001), Az NISS 0.7606 (0.051) (P<0.001), and Az PTS 0.8244 (0.047) (P=0.016). Death was significantly associated with head trauma (P=0.014), PRISM >35, PTS <5, GCS <7, and ISS or NISS >32 (P<0.00001). PRISM >35 (P=0.001) and GCS <7 (P=0.003) were independent risk factors of death., Conclusions: PRISM is a reliable tool for evaluating the prognosis of multiple, severely traumatized children. Its relative simplicity and the fact that it is extremely widespread as a general prognosis score in PICUs represent other arguments for its use. Due to the leading influence of head trauma on mortality, GCS, a score even simpler than PRISM, showed identical accuracy regarding survival prediction.

This article describes the most important scoring systems in trauma care and their application to quality control. Development and contents of the Glasgow Coma Scale (GCS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Trauma Score (TS), Revised Trauma Score (RTS) and of the TRISS-method are described. The advantages and the limitations of the mentioned scoring systems are discussed critically.

Objective: Mortality prediction in trauma is assessed using the Injury Severity Score (ISS) and Revised Trauma Score using Trauma Injury Severity Score (TRISS) methodology. The Pediatric Risk of Mortality (PRISM) score assesses mortality risk in critically ill children. We compared the ability of PRISM and ISS (using TRISS methodology) to predict resource utilization and outcome in pediatric trauma., Design: Retrospective chart and database review., Setting: Pediatric intensive care unit (PICU)., Patients: Consecutive admissions to a PICU over a 2-yr period., Measurements and Main Results: Demographic data including PICU resource utilization and outcome were recorded. Data were recorded on 1,052 admissions (31 deaths), including 125 pediatric trauma patients (11 deaths). Patients were stratified into low- and high-risk categories based on PRISM and ISS scores. Patients with PRISM scores <6 and ISS scores <10 were classified as low risk. While both low-risk PRISM and ISS scores readily identified survivors, PRISM was the more sensitive indicator of resource utilization. PRISM, however, performed less well in determining risk-adjusted mortality as compared with ISS., Conclusion: PRISM readily stratifies pediatric trauma patients for resource utilization. PRISM appears to underestimate mortality in pediatric trauma as compared with ISS using TRISS methodology.

When comparing two populations of multiply injured patients differences in patient characteristics must be controlled for. To measure the overall severity of injury, scaling systems are used. If after adjustment for injury severity, the proportion of deaths in the two data sets are still different, the difference is to be considered as due to the quality of care. However, this conclusion is only valid after excluding the possibility that the scale in use fails to adequately reflect certain injuries. The scope of the study is to demonstrate a method for examining this potential interference. As an example, four widely used scales were applied to the data of 418 multiply injured patients. By means of multiple logistic regression analysis, variables were selected which have an influence on prognosis in addition to a scale, thus indicating a subgroup of patients who are underrepresented by the respective scoring system. For the scales examined, these additional variables were: Head and thoracic trauma for the Polytrauma score (Oestern), abdominal and thoracic trauma for the Trauma index (Schreinlechner), thoracic trauma and age for the Trauma score (Champion), head trauma and age for the Injury Severity Score (Baker). We conclude that each score analyzed had its characteristic weak points. Prognostic quality was affected by casemix. Therefore, comparisons between groups of polytraumatized patients may be invalidated. The method outlined here is a useful means for checking a scoring system for these types of interfering variables. Therefore, it is recommended to search routinely for potentially interfering variables before applying a scale. In a given data set of multiply injured patients, appropriate adjustments can then be made for the deficiencies of the scoring system.

Aim: To test the usefulness of the Pediatric Trauma Score (PTS) in a university hospital setting., Methods: All injured children who were admitted to our emergency room during a one year period were prospectively studies. The study was performed at the Pediatric University Hospital of Geneva. Patients were divided into two groups: group one included severely injured children with a PTS equal or lower 8 and group two included patients with a PTS greater than 8., Results: A total of 6804 injured children were admitted to our emergency room and 927 (14%) were hospitalized. In group one (104 children, 1.5%), six patients died whereas in group two (823 children, 12%), all patients survived. In addition, children in group one demonstrated a significant higher number of general anesthesia, a longer stay in the ICU and a longer stay, and an increased number of sequelae 3 months after trauma., Discussion: Our result confirm the usefulness of the PTS and the cutoff value of 8 in pediatric trauma. In addition, the study underlines the important morbidity and the residual sequelae after severe trauma in children., Conclusion: The PTS should be used in all injured children in order to identify patients at risk. This would allow to begin an appropriate treatment or, if necessary, initiate a transfer to a surgical pediatric center without delay.

The paper presents a review study on score systems in current emergency surgery including its classification, application and value, based on the experiences of other authors, the paper suggests application of score systems in different phases of polytraumatized patients treatment (in prehospital, as well as in early and late phases of the inpatient period). The paper also points out certain objective difficulties in everyday scoring of patients at the Department of the Emergency Surgery (daily engagement, computer center, etc.). As a conclusion, the authors present their opinion indicating that in absence of introduction of these systems into the practice, the approach to a polytraumatized patient cannot be adequate.

Objective: To compare the Injury Severity Score (ISS) and Polytraumaschlüssel (PTS) in patients with multiple peacetime and wartime injuries., Design: Prospective and retrospective study., Setting: General hospital, Croatia., Subjects: 71 patients with multiple injuries admitted between 1 January 1993 and 30 September 1994; 41 had peacetime (road traffic accident) injuries and 30 had been injured in battle., Interventions: ISS and PTS scores., Main Outcome Measure: Correlation of scores with morbidity and mortality., Results: All patients with wartime injuries were men, compared with 30/41 (73%) of those with peacetime injuries (p < 0.0001). Those with wartime injuries were slightly but not significant younger (mean 35 years, range 17-69, compared with 44 years, range 17-87). Mortality was higher among those with peacetime injuries, but not significantly so (11/41 compared with 5/30, p=0.39). The two scores correlated well for all injuries (r=0.76), and peacetime (r=0.71) and wartime injuries (r=0.84) separately (all correlations p < 0.0001). In both groups, patients who subsequently died scored significantly higher with both scores (p < 0.001)., Conclusions: The two scores were equally good at describing the severity of injury, and the likelihood of subsequent death, however the injuries were caused.

Salvage of lower-extremity Gustilo type IIIC fractures is difficult, time-consuming for the patients and physicians, and not universally successful because of poor functional outcomes. Even if successful with limb salvage, the functional result may be unsatisfactory because of mutilating injuries to muscle and nerve, bone loss, and the presence of chronic infection. From July 1991 until July 1994, revascularizations of open IIIC fractures were attempted for wounds with Mangled Extremity Severity Score (MESS) < or = 10. The functional results were evaluated at 2 years after injury. Thirty-six lower-extremity revascularizations were performed on 34 patients, including 1 patient with bilateral distal tibial IIIC fractures and a child with IIIC femoral fracture accompanied by ipsilateral distal tibial amputation. Excluded were patients with below-ankle IIIC fractures as well as patients who underwent immediate amputation at admission. After the revascularization, seven patients with IIIC fractures (7 of 36, 19.4%) underwent secondary amputation within 1 week. At the 2-year follow-up, the overall secondary amputation rate was 25% (9 of 36) and the salvage rate was 75% (27 of 36). Those were no deaths. Of the 29 salvaged limbs among these 27 patients, 23 limbs (23 of 29, 79.3%) required secondary coverage procedures that included 12 free flap transfers (12 of 29, 41.4%). Every patient needed subsequent reconstructive surgery to achieve an acceptable functional result. In this series, MESS was able to predict the secondary amputation rate and the functional result. Sixteen of the 17 limb-salvaged patients with MESS < or = 7 were able to achieve minimal functional requirements, whereas 3 of the 10 patients with MESS = 8 to 10 failed to achieve minimal functional requirements at the 2-year follow-up. Using statistical analysis, we found that the salvaged limbs with MESS < or = 9 exhibited a significant difference in achieving adequate function compared with limbs with MESS > 9. Using our protocol for treatment for IIIC fractures, the threshold for immediate amputation can be raised from MESS = 7 to MESS = 9. Our conclusions are (1) more severely injured limbs have poor functional results, (2) every patient needs subsequent reconstructive surgery, and (3) the MESS may be helpful in decision-making.

Background: Most standard trauma score systems have been developed and validated in the United States. However, trauma differs between the United States and Germany. This prospective study tested the validity of eight current trauma scoring systems (Glasgow Coma Scale, Trauma Score, Revised Trauma Score, Injury Severity Score, TRISSTS, TRISSRTS, Prehospital Index, Polytraumaschluessel) in 612 patients in Cologne., Methods: Between January 1, 1987, and December 31, 1987, 2,136 trauma related emergencies were seen by emergency physicians in the field. All trauma patients with a Trauma Score below 16 and a random sample of 10% of patients with a Trauma Score of 16 were included in the study (n = 625). Follow-up was successfully completed for 612 patients (97%). Their hospital outcome was correlated with their individual score result., Results: All trauma score systems under study showed high accuracy rates. TRISSRTS and TRISSTS performed best with values of above 0.97 for the area under the receiver operating characteristics curve., Conclusion: We conclude that the standard trauma score systems are valid tools for patient classification and support TRISSRTS as the international reference score system for the assessment of injury severity. This validation will allow comparisons between different trauma care systems.

A new method of estimation of trauma victim risk is presented. This new score--UWR--trauma risk score is created by multiplication product of LSO value and logarithmic age index. The influence of age of trauma patient on all stages of "trauma disease" is proved in two groups of trauma victims, contain 2485 and 3407 patients. Frequency of accidents, localisation and severity of injuries, and on results of treatment depends on age. This is the cause to consider an age into trauma scale. The new UWR is correlated not only with mortality, but a LSO with percentage and severity of disability.

Measurement of severity of injuries is by all means needed in contemporary traumatology. Objective assessment of several different injuries is helpful in different comparisons concerning different groups of trauma patients. The authors have chosen 4 number scales: Trauma Scale (TS), Abbreviated Injury Scale (AIS), Injury Severity Score (ISS) and APACHE (Acute Physiology and Chronic Health Evaluation) in order to assess their application in traumatological practice. Advantages and disadvantages of number scaling describing of severity of injuries in trauma patients have been discussed.

Data base for assessment of results of treatment of politrauma patients is presented. It was created on the basis of Abbreviated Injury Scale, Injury Severity Score and Revised Trauma Score. Examination was supplemented with TRISS method inclusive of graphic assessment PRE-CHART and statistic Z and M. The software was created on the basis of Excel 7.0 and Windows 95.

Objective: To develop a quantitative severity stratification within the framework of a Physiologic State Classification (PSSC) system that can be applied to critically ill post-trauma patients with "sepsis/SIRS" and to relate PSSC to the nature of the plasma cytokine response., Materials and Methods: At each study time period, a patient was classified into one of seven physiologic States previously derived from clustering 17 cardiopulmonary and metabolic variables from 338 critically ill patients: R = reference, A = normal stress response, B = metabolic insufficiency, C1 (early) and C2 (late) = respiratory insufficiency, D = cardiogenic insufficiency, H = nonshock hypovolemia., Main Results: The PSSC used State data from a developmental set of 159 trauma patients in a logistic model (L2PDEATH) to provide a quantitative index of severity. This severity index was tested on 80 new trauma patients (mean injury Severity Score (ISS) = 27.6, 64% survivors). Using PSSC State distributions for evaluation of enzyme-linked immunosorbent assay (ELISA) measured cytokines interleukin (IL)-1, IL-6, IL-8, tumor necrosis factor (TNF) showed the multicytokine score to be greatest in those C2- and B-State regions associated with a higher severity as measured by L2PDEATH. Compared with ARDEATH of the Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system, L2PDEATH provided a better indicator of severity of sepsis/systemic inflammatory response syndrome (SIRS) for posttrauma patients., Conclusions: PSSC allows classification of the physiologic and cytokine mediator response to trauma and permits stratification of severity in posttrauma critical illness.

Prostanoids are inflammatory mediators which originate from endothelial cells following local tissue damage. That is why plasma levels of prostanoids are possible markers of inflammatory response and severity of trauma. We were able to demonstrate that the systemic release of prostanoids does not depend on the score values (ISS, PTS) but rather on different trauma patterns (chest trauma, head injury). Influencing vascular permeability and resistance elevated plasma levels of prostanoids may explain the impairment of pulmonary function in traumatized patients. It seems to be useful to re-evaluate the scoring systems with respect to chest trauma and head injury.

Trauma Score Systems attempt to summarize the severity of injury in a single value. They provide a better classification of trauma patients and translate different severities of injury in a common language. They enable thereby comparisons between hospitals or trauma systems. Young doctors can control their clinical judgement with scoring systems and will gain experience. Scoring systems therefore increase safety and can help in decision making. As accuracy of scoring systems is never 100% individual decisions can never rely on scores only. Glasgow Coma Scale, Revised Trauma Score, Injury Severity Score and TRISS are the most often used international scores for severely injured patients. Their sensitivity and specificity, validity, reliability and practicability have been studied and proved in many trials. The role of these scoring systems for quality management purposes in the treatment of severe trauma is actually studied with the Trauma Registry of the German Society for Trauma Surgery.

A Physiologic State Severity Classification (PSSC) derived from clustering of 17 cardiorespiratory variables was used to predict cytokine response in critically ill posttrauma patients. The PSSC defined physiologic states: A-State (A), normal stress response; B-State (B), metabolic insufficiency; C2-State (C), respiratory insufficiency. Bayesian analysis of these states defined a probability of death (Pdeath). 416 studies from 60 newly studied multiple trauma patients (70% males, Injury Severity Score = 27.5) were analyzed; 45 (75%) had sepsis (s), 28 (47%) had sepsis-adult respiratory distress syndrome (s-ARDS). Of 35 survivors (66% s, 37% s-ARDS, mean Pdeath = .42) 23% were predominantly A, 66% B, and 11% C. Of 25 deaths (88% s, 60% s-ARDS, mean Pdeath = .64) 0% were A, 44% B, and 56% C. PSSC States were correlated with incidence and mean plasma levels (pl) in picograms/mL of cytokines. 23 samples from recovering nonseptic trauma patients were used as controls.

Among the more than 50 scoring systems available for quantitative evaluation of injury severity, only a few have proved effective in clinical practice. In particular, the Revised Trauma Score (RTS), referring to physiological variables, has proved effective in preclinical use and otherwise, the Injury Severity Score (ISS), referring to anatomical data. There is a tendency in the development of new scoring systems to aim at higher predictive accuracy, forfeiting practicability. The initial purpose of scoring--an early assessment of the risks--is being pushed into the background. The TRISS method, which includes the RTS, ISS, patient's age, and mechanism of injury, is regarded as the international standard. However, it has the disadvantage of a low sensitivity of 60% for blunt trauma, resulting in a high rate of unexpected deaths. Reasons for this are underestimation of head injuries, multiple injuries to one body region, and failure to take full account of the individual patient's age. The new ASCOT method, in which the ISS is replaced by the Anatomic Profile, and the age of the patient is given more consideration, hardly brings better results--in spite of quite time-consuming methods. When the scoring systems currently available are applied their specific deficiencies and limited evidence must be borne in mind. Nevertheless, they are an important scientific instrument for comparative examinations, and indispensable for quality assurance and economic analyses. To improve the predictive accuracy, biochemical parameters and chronic diseases should be considered, in addition to existing scores.

In January 1992 the German Society of Trauma Surgery founded the working group "Scoring" with the aim of developing guidelines for a standardized use of scoring systems in severely injured patients. The study group developed the "Trauma Register" for prospective data collection in severely injured patients, from the scene of the accident up to discharge from hospital. The register contains routinely available anatomical and physiological variables, diagnostic and therapeutic interventions, and any complications. Calculation of different scores is possible from the data collected. The completed registers will be collected and processed together. Statistical analyses are possible for the total population as well as for single trauma centres. The aim of the Trauma Register is the definition of standards on diagnostic and therapeutic concepts and the evaluation of trauma care. Trauma centres can compare their own performance against given standards (quality control). If there are deviations from the norms the reasons have to be identified and necessary countermeasures should be implemented (quality assurance). The register has been tested in a feasibility phase in six German trauma centres and will hopefully have an impact comparable to that of the Major Trauma Outcome Study (MTOS) in the USA.

Scoring systems are nowadays said to be helpful in decision-making in preclinical and early clinical treatment of multiple trauma patients. To evaluate the importance of these scores in daily routine, we analysed the scores routinely used in our department at the Hannover Medical School. We present three scoring systems: the Polytrauma Score, the Pelvis Score, and the Hannover Fracture Scale. All of these have certain qualities relevant to the aspects of decision-making and prognostic value. The evaluation demonstrates that these scoring systems are genuinely helpful, especially for the inexperienced.

Trauma can be defined as either a somatic injury or a psychological reaction in the person affected. The emotional disturbances and psychosocial problems of trauma patients in particular, though still measurable a year or even longer after the event, have rarely been taken into account in surgical studies. Quality of life is a relevant endpoint in multiple trauma patients, insofar as rehabilitation seems to be complicated by non-efficient psychological coping. With reference to the prerequisites for a scientifically sound measuring method four instruments are described that seem to be suitable for measuring quality of life in multiple trauma patients. In addition, practical advice is given for the design of longitudinal studies focused on quality of life in trauma patients.

A variety of different scoring systems are in current use, with an increasing impact on intensive care treatment. Originally these scoring systems were applied to evaluate objective grading and to estimate survival and mortality. More recently, other potential applications have been investigated. While clinical monitoring and assessment of therapeutic success are the primary goals, scoring systems can be used to define comparable patient collectives and to delineate predefined patient groups for clinical trials. Scoring systems are gaining increasing importance in evaluation of the level of therapeutic intervention and care provided as well as in quality assessment. On the whole, however, accuracy, the probability that outcome will be correctly predicted for an individual patient, is still inadequate. Although desirable, individual patient prediction is therefore not allowed, and therapeutic strategies and therapy evaluation based on scoring systems cannot be implemented, or only in a limited way. For daily use in individual patient evaluation--monitoring, therapy response, prognosis--biochemical monitoring is still of primary importance. Scoring systems have now found a useful application as a supplement, rather than a rival, to clinical patient evaluation.

The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)

Trauma scores are used in emergency medicine to classify the severity of injuries. Score systems are applied in science and epidemiological investigations in emergency and intensive care. Moreover, trauma scores are intended to support the decisions in triage and predict the prognosis of mortality. Scores are based on anatomicmorphological or physiological parameters by which the intensity of injury is graded and valued. Commonly used scores are the Injury Severity Score (ISS) and the Revised Trauma Score (RTS). The Glasgow Coma Scale (GCS) is a system that is used worldwide to classify neurologic deficiencies after injury of the brain. Trauma scores have a good prognostic potential by comparing large data bases of different patient groups. Individual prognosis of mortality by trauma scores in the routine of emergency medicine are rapid classification of the injury after trauma and early identification of critically ill patients. Score systems can support decisions and the training of emergency staff. Future studies should go into the grade of rehabilitation and the quality of life after trauma as a -possibly score-aided-prognostic parameter.

We reviewed 374 consecutive trauma patients over age 65 years to determine (1) if the emergency room Trauma Score (TS) could predict mortality, thereby improving ICU triage, and (2) the frequency of preventable complications in patients who died (n = 31). Fifty-two percent of deaths (n = 16) occurred in patients with TS = 15 or 16. Multiple organ failure/sepsis (MOF/S) was the most common cause of death overall (42%) and was also the most frequent cause of death in patients with a TS = 15-16 (63%). Nonsurvivors in the TS = 15-16 subgroup were older (80.9 +/- 2.0 vs. 74.9 +/- 0.5 years, p less than 0.02) and had greater ISSs (15.8 +/- 3.7 vs. 8.0 +/- 0.4, p = 0.001) than survivors. Patients with a TS less than 15 suffered high overall mortality (45%). Preventable complications contributed to mortality in 32% of all deaths and in 62% of MOF/S deaths. Aggressive care to prevent avoidable complications may improve survival in elderly trauma victims.

The use of trauma indices for characterisation of polytraumatized patients concerning prognoses is being discussed for nearly 30 years. In the seventies a couple of trauma indices were developed. Some of them are in use all over the world. In the Department for Trauma surgery in the General Hospital of Salzburg three of the common trauma scores were analysed and compared with one another: Injury Severity Score (Baker), Polytraumascore of the University Clinic of Hannover, Trauma index (Schreinlechner and Eber). As a rule most studies presently published are based on the Injury Severity Score. In a retrospective analysis of 62 polytraumatized patients we could show that the Trauma index of Schreinlechner and Eber is more practicable for classification of polytrauma because it shows a good correlation of score, fatality and prognoses.

A prospective registration was carried out of all patients with multiple injuries who were admitted to hospital in 1990 during the first 24 hours after the accident. The total number was 441, and included 47 patients with penetrating injuries. Such patients constituted 5 per cent of a total of 9,000 admitted patients, and 19 per cent of a total of 2,266 injured persons. The injuries were scored using the Trauma Score and Injury Severity Score (ISS) and the probability for survival was calculated by the TRISS method. 148 patients were seriously injured, having an Injury Severity Score 16 or more. Traffic accidents were most common, and were the cause of injury in more than 50 per cent of the patients. 15 per cent of the patients with such injuries were under the influence of alcohol and 5 per cent were drug abusers. The percentage under the influence of alcohol was three times as high, however, among patients injured by violence. Median ISS was 26 for the whole series, and 41 for the 41 patients who died. Mortality was significantly higher in patients older than 54 years of age than among younger patients. No patients were reduced to a vegetative state, but 13 per cent of the surviving patients were considerably disabled. Among the 41 patients who died the main cause of death was haemorrhage in 17, and airway obstruction in five. Estimation of probability of survival showed that the mortality in this series compared well with the mortality in larger series of injured persons in America. None the less, improvement is still feasible.

The ability to forecast the course and outcome of severe mechanical trauma would aid clinicians in making decisions concerning the treatment of patients. Multifactorial regression models, developed from data obtained from 933 patients with polytrauma and shock, have a high predictive value. A two-part data sheet was developed to give a rating system that predicts the duration of shock in patients that survive and the life span in patients that eventually die. Factors considered in developing the rating system include systemic hemodynamics, hematocrit number, blood density, arteriovenous difference in oxygen saturation, and rectocutaneous temperature gradient, among others.

The authors have substantiated the necessity of elaboration and introduction of a single all-state++ system of objective quantitative evaluation of the severity of the injuries. A brief comparative characteristic of the most popular Soviet and foreign systems of the severity of the injuries is presented. The synthesized scales (elaborated at the prognosis laboratory of the Central Institute of Traumatology and Orthopedics ) for a quantitative evaluation of the character and the localization of the fractures are presented.

The prognosis of fracture healing depends upon the severity of injury sustained to the soft tissues and the blood supply left to the bone. The soft tissue injury cannot be precisely graded until after the fracture has been stabilized and radical debridement performed. Subsequent steps in the therapeutic strategy of compound fractures are determined mainly by the type and severity of soft tissue injury. Therefore fractures with soft tissue lesions need to be classified again after bone fixation and wound revision. Later treatment steps for restoration of the soft tissues are easily derived from the classification.