Ian D. Civil

Comparing measures of injury severity for use with large databases

BACKGROUND After recent debate about the best measure of anatomic injury severity, this study aimed to compare four measures based on Abbreviated Injury Scale scores derived using ICDMAP-90-the Modified Anatomic Profile (ICD/mAP), Anatomic Profile Score (ICD/APS), Injury Severity Score (ICD/ISS), and New Injury Severity Score (ICD/NISS)-with the International Classification of Diseases-based Injury Severity Score (ICISS). METHODS Data were selected from New Zealand public hospital discharges from 1989 to 1998. There were 349,409 patients in the dataset, of whom 3,871 had died. Models were compared in terms of their discrimination and calibration using logistic regression. Age was included as a covariate. RESULTS The ICISS and ICD/mAP were the best performing measures. Adding age significantly improved the discrimination and calibration of almost all the models. CONCLUSION The ICISS is a viable alternative to ICDMAP-based measures for coding anatomic injury severity on large datasets.

Computed tomography in the initial evaluation of the cervical spine

Unstable injury of the cervical spine must be considered in all victims of blunt trauma. To evaluate the role of limited, directed computed tomography (CT) in the initial evaluation of the cervical spine, a one-year study involving 104 high-risk patients was undertaken. Sensitivity was 0.78 overall, but in the group of patients scanned after inadequate plain radiographs, CT had a sensitivity of 1.0 for unstable cervical injury. All false-negative studies involved atlantoaxial rotary subluxation. We conclude that limited, directed CT of the cervical spine is appropriate in the initial evaluation of patients at risk, particularly if plain radiographs are inadequate, but is of limited value in the evaluation of ligamentous injury of the upper cervical spine.

Routine pelvic radiography in severe blunt trauma: Is it necessary?

To evaluate the hypothesis that all victims of severe blunt trauma require a pelvic radiograph, we prospectively studied all such patients admitted to the Southern New Jersey Regional Trauma Center during a seven-month period. All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior-posterior radiograph of the pelvis. A total of 265 patients were studied and 26 pelvic fractures were identified. These occurred in seven of 36 unconscious patients, 11 of 96 impaired patients, and eight of 23 symptomatic patients. No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001). We conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.

Injury scaling at autopsy: the comparison with premortem clinical data.

The difference between injury scaling performed in the same patients on the basis of clinical information only and postmortem examination only is largely unknown. We compared scores in all 279 trauma patients who died in the Department of Critical Care Medicine at Auckland Hospital from 1982 through 1987 (93% blunt trauma, 4% penetrating trauma, 3% burns; median time until death--2 days) using both the 1980 and 1985 revisions of the Abbreviated Injury Scale (AIS-80, AIS-85) and derived Injury Severity Scores (ISS-80, ISS-85) where such scoring was based on clinical information only (CLAIS, CLISS) or postmortem findings only (PMAIS, PMISS). For the group as a whole, there was little difference in the distribution of scores between CLAIS and PMAIS or between CLISS and PMISS. However, CLISS-80 was different from PMISS-80 in 68% of individual patients. Most major differences between CLAIS and PMAIS (two AIS grades or more) occurred in the Head region, where injury scoring based on physiological features (e.g. coma) occurred without an anatomic injury of similar AIS grade, or in the Thorax region where therapy had either abolished the evidence of injury (e.g. pneumothorax) or injuries were discovered at postmortem examination which had not been appreciated clinically. Injury scaling data derived only from postmortem examination is not equivalent to that derived clinically. For maximum accuracy, postmortem data must be derived from an examination specifically guided by the needs of injury scaling and in full cognizance of injuries recognised and treated clinically.

Placental laceration and fetal death as a result of blunt abdominal trauma

Placental laceration as a result of blunt maternal trauma has rarely been reported. Herein, we report a case of a 17-year-old, 37-week-pregnant woman who presented after a motor vehicle accident. Initial examination showed no fetal heart sounds or movements. Evaluation included enhanced CT scan of the abdomen. Laparotomy and Caesarian section were precipitated by the development of a coagulopathy, at which time the uterus was found to be filled with blood. Although there were no signs of external uterine injury, examination of the placenta showed a large radial laceration. The fetus had no signs of direct trauma.

Injury severity scoring: A comparison of early clinical versus discharge diagnosis

The Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS) are objective means of assessing injury. Accepted methodology involves retrospective scoring of injury based on discharge diagnoses. Recently, early clinical scoring, supplemented by review at discharge, has been introduced. A prospective study was instituted to compare these methodologies. Four hundred sixty consecutive victims of blunt trauma were scored using both clinical and retrospective methodologies by independent, blinded observers. Of these, 333 patients had a change in ISS, 174 with a change of greater than four points. The population mean ISS remained unchanged; however, paired values were significantly different (p less than .03). We conclude that either methodology is applicable for studies of large populations of trauma victims. When accurate individual AIS or ISS scoring is required, the clinical method combined with discharge review is most appropriate.

Injury in Auckland, New Zealand: an unexplored epidemic

The applicability of regionalization of injury care in New Zealand has not yet been investigated. In a first attempt to define the extent of the problem, all injured patients presenting to the resuscitation room in the emergency department of a large teaching hospital over a 1-year period were studied. Data on mechanism of injury, injury severity, resource utilization, management and outcome were recorded. A total of 602 patients was evaluated. Of these 37 per cent had Injury Severity Scores greater than or equal to 16 and 24 per cent were admitted to intensive care. Overall mortality was 10 per cent with the mean ISS for CNS related deaths being 39; for non-CNS related deaths, 46. The study confirmed that the characteristics of nonpenetrating injury in New Zealand were similar to the USA. Extrapolating from US data, one could anticipate that up to 30 per cent of deaths following injury in NZ annually may be preventable. If regionalization could reduce this rate to just 10 per cent, 360 lives could be saved annually with a contribution of

Clinical prospective injury severity scoring: when is it accurate?

8 million to the GNP and

SIMULTANEOUS ANTERIOR AND POSTERIOR BILATERAL TRAUMATIC DISLOCATION OF THE HIPS: A CASE REPORT

2.2 million to the annual government tax accounts.