Barry A. McLellan

Abbreviated Injury Scale and Injury Severity Score: a scoring chart

The Abbreviated Injury Scale and the Injury Severity Score are important tools for grading the severity of injury to trauma patients. The Trauma Chart provided is a simple and concise guide for scoring and recording this useful information. The chart is useful in both a large wall-mounted form and in the reduced two-page form included in this article.

Emergent abdominal sonography as a screening test in a new diagnostic algorithm for blunt trauma.

Although there is an interest in emergent abdominal sonography (EAS), the clinical utilization of EAS in North America is minimal. The purpose of this study was to develop a new diagnostic algorithm for blunt abdominal injury based on a prospective blinded comparison of EAS, diagnostic peritoneal lavage (DPL), and computed tomography (CT). EAS (+ = fluid, - = no fluid) was performed before the DPL or CT, in 400 patients with a mean Injury Severity Score of 26; 293 had a CT and 107 had a DPL. The EASs required 2.6 +/- 1.2 minutes with 82% < or = 3 minutes. The accuracy of EAS for free fluid was 94% with a positive and negative predictive value of 82 and 96%, respectively. Only 1 of 338 patients with EAS- had an acute therapeutic laparotomy. Three patients with EAS- had a delayed laparotomy based on evolving clinical findings. The radiologists interpretation of the EAS video disagreed with the clinician sonographer in only 3% of cases. Based on these results, a diagnostic algorithm was developed using EAS as a screening test with selective use of DPL and CT. Emergent abdominal sonography performed by clinician sonographers is a rapid and accurate test for peritoneal fluid in blunt trauma victims, and the need for laparotomy in patients with a negative EAS is rare. Our study supports the routine use of EAS as a screening test in a diagnostic algorithm for the evaluation of blunt abdominal trauma.

Hypotension after blunt abdominal trauma: the role of emergent abdominal sonography in surgical triage.

OBJECTIVE Trauma victims with hypotension require a rapid and reliable localization of bleeding and expedient surgical triage. Our hypothesis is that emergent abdominal sonography (EAS) is a rapid and accurate test of the need for urgent laparotomy in blunt trauma victims with hypotension. METHODS Among 400 blunt trauma victims entered in a prospective blind study of EAS, a subgroup of 69 (17%) patients had a systolic blood pressure < or = 90 mm Hg during their initial assessment. Although the EAS results [(+) = fluid, (-) = no fluid] were not used in clinical decision making, the potential contribution of EAS to patient care was examined. RESULTS The mean Injury Severity Score was 32. Twenty-two (32%) patients were EAS (+), of which 19 required an acute laparotomy. No laparotomies were performed in the 47 EAS (-) patients. The EASs required 19 +/- 5 seconds in the EAS (+) group and 154 +/- 13 seconds in the EAS (-) group. Twenty of the 22 positive EASs had free fluid in Morisons pouch. All 13 patients with an ultrasound score > or = 3 had a laparotomy. The primary etiology of hypotension was blood loss in 42 patients, hemoperitoneum in 18, and retroperitoneal hemorrhage in 12. CONCLUSION EAS is a rapid and accurate indicator of the need for urgent laparotomy in the hypotensive blunt trauma victim. Further, a negative EAS can hasten the search for other causes of hypotension. Diagnostic peritoneal lavage may become obsolete in centers with EAS capabilities.

Infection in hospitalized trauma patients: incidence, risk factors, and complications.

BACKGROUND Several factors place victims of multiple trauma at increased risk for infection. The purpose of this study was to delineate the frequency of, types of, and risk factors for infection in hospitalized trauma patients. METHODS Prospective surveillance for nosocomial infection was conducted for all trauma patients who were admitted for more than 24 hours to a tertiary-care regional trauma center between January 1 and December 31, 1996. RESULTS A total of 563 patients (414 males) with a mean age of 40 years (range, 15-97 years) were followed. Most (86%) sustained blunt traumatic injuries. A total of 367 infections occurred in 209 (37%) patients for an incidence of 32.1/1,000 patient-days. The hospital stay of 37% of patients was complicated by at least one infection, involving the following sites: lower respiratory tract (28%), urinary tract (24%), surgical wound (18%), skin/soft tissue (13%), intra-abdominal (5%), primary bloodstream (5%), and other sites (8%). Infection was complicated by septic shock in 36 (10%) cases, acute respiratory distress syndrome in 32 (9%) cases, and multiorgan failure in 13 (4%) cases. Death was attributed to infection in four patients. In a multivariate analysis, infected patients were more likely to have been ventilated (odds ratio [OR] = 2.6; p<0.001), to have had multiple surgical procedures (OR = 2.8; p = 0.02), to have received multiple blood transfusions (OR = 2.3; p = 0.04), and to have had a spinal cord injury (OR = 5.0; p = 0.002). First surgical procedure within 24 hours of admission was protective (OR = 0.4, p = 0.001). CONCLUSION Trauma patients are at high risk for developing infection. Identifying patients who are at increased risk for infection may allow for early intervention and subsequent decrease in infectious morbidity.

A prospective study of emergent abdominal sonography after blunt trauma.

In North America, the role of emergent abdominal sonography [ultrasonography (US)] after blunt trauma requires further definition. The purpose of this prospective study was to compare US to the gold standards, diagnostic peritoneal lavage (DPL), and computed tomography (CT), in a population of adults after blunt trauma. In 206 adults who required either CT or DPL to assess possible abdominal injury, US was performed, before DPL or CT, and was aimed at the detection of intraperitoneal fluid. The mean Injury Severity Score and Glasgow Coma Scale score were 24.0 and 11.9, respectively. One hundred thirty-seven patients (67%) had CT and 69 (33%) had DPL. The positive and negative predictive values of US for intraperitoneal fluid were 90% and 97%, respectively. The sensitivity, specificity, and accuracy of US for free fluid were 81%, 98%, and 96%, respectively. Of the six false-negative USs, only one required surgery. The US examinations required 2.6 +/- 1.4 min. Emergent abdominal sonography is an accurate, rapid test for the presence of intraperitoneal fluid in adult blunt trauma victims and in these patients may prove valuable as a screening test for abdominal injury.

Prospective evidence of the superiority of a sonography-based algorithm in the assessment of blunt abdominal injury.

BACKGROUND Although the routine use of FAST (focused assessment with sonography for trauma) in the evaluation of trauma victims is increasing, to our knowledge, a prospective comparison of contemporary adult trauma victims managed with and without FAST has not been reported in North America. METHODS Adult victims of blunt trauma for whom there was a suspicion of abdominal injury were managed with one of two diagnostic algorithms, FAST or no-FAST. The two algorithms were compared for diagnostic accuracy, cost, time, and delayed diagnoses. RESULTS Among 706 patients (mean Injury Severity Score, 23), 460 were managed with FAST and 246 with no-FAST. The two groups were similar with respect to age, Injury Severity Score, prehospital time, and mortality (p = not significant). There were 3 of 460 (0.7%) delayed diagnoses in the FAST group and 4 of 246 (1.6%) in the no-FAST group (p = not significant). The diagnostic accuracy for the FAST and no-FAST algorithms was 99% and 98%, respectfully. The FAST and no-FAST algorithms led to similar rates of laparotomy, 13% and 14%, respectfully, but nonoperative management was more common in the no-FAST group (p < 0.01). The mean diagnostic cost for the FAST algorithm was

Measuring injury severity : Time for a change?

156, compared with

Head injury in young adults: long-term outcome☆☆☆

540 with the no-FAST algorithm (p < 0.0001) and the mean time required for diagnostic work-up was 53 minutes with the FAST algorithm, compared with 151 minutes with the no-FAST algorithm (p < 0.0001). CONCLUSION This study has provided prospective evidence that a FAST-based algorithm for blunt abdominal injury was more rapid, less expensive, and as accurate as an algorithm that used computed tomography or diagnostic peritoneal lavage only. Trauma centers are encouraged to incorporate a FAST-based algorithm into their initial management of blunt trauma victims.

Lateral impact motor vehicle collisions: Significant cause of blunt traumatic rupture of the thoracic aorta

BACKGROUND The Injury Severity Score (ISS) does not take into account multiple injuries in the same body region, whereas a New ISS (NISS) may provide a more accurate measure of trauma severity by considering the patients three greatest injuries regardless of body region. The purpose of this study was to evaluate the ISS and NISS in patients with blunt trauma. METHODS Consecutive individuals treated from January of 1992 to September of 1996 at one institution were included if they had sustained blunt trauma and satisfied triage standards (n = 2,328). For each patient, we computed the ISS and the NISS to determine how often the two scores were identical or discrepant. Discrepant cases were then further analyzed using receiver operating characteristic curves to determine which score better predicted short-term mortality. RESULTS The mean ISS was 25 +/- 13, and the mean NISS was 33 +/- 18. The two predictive scores were identical in 32% of patients and discrepant in 68% of patients. Patients with identical scores had a lower mortality rate than patients with discrepant scores (10% vs. 13%; p < 0.02). In patients with discrepant scores, the area under the receiver operating characteristic curves was greater for the NISS than the ISS (0.852 vs. 0.799; p < 0.001), and greater amounts of discrepancy were associated with increasing rates of mortality (p < 0.001). CONCLUSIONS The NISS often increases the apparent severity of injury and provides a more accurate prediction of short-term mortality. The benefit associated with using the NISS rather than the ISS must be weighed against the disadvantages of changing a scoring system and the potential for still greater improvements.

Predictors of fetal mortality in pregnant trauma patients.

OBJECTIVE To describe the long-term outcome 5 years after injury of young adults who were 15 to 19 years old at the time of their head injuries. DESIGN A retrospective cohort. The health records of 62 consecutive eligible subjects were abstracted for baseline sociodemographic, health, and injury variables. A telephone interview was administered to assess quality of life, impairment, disability, and handicap. SETTING Canadas largest trauma center, Sunnybrook Health Science Centre, Toronto, Canada. SUBJECTS Of the 58 subjects (94%) who were traced at follow-up, 51 agreed to participate. MAIN OUTCOME MEASURES The Medical Outcomes Study SF-36, Head Injury Symptom Checklist, selected disability measures, Community Integration Questionnaire. RESULTS Of the 8 summary items of the Medical Outcomes Study SF-36, subjects scored lowest on mental health. There were no significant differences between mild and more severely injured groups in all quality of life measures. Subjects classified with mild head injury overall reported more symptoms from the Head Injury Symptom Checklist. Subjects with more severe injuries had lower community integration scores (p < .05). CONCLUSIONS Overall, mental health is an important area of concern at follow-up for all subjects. Adolescents with apparent mild head injury can have disabling symptoms many years after injury.