• Outcome of any injury are: complete recovery Recovery with residual effect disability death.Outcome depends on:• Timing of hospital care• Mechanism of injury• Vital signs in field and on arrival• Outcome measures-ICU days, ventilator days

It has been suggested that trauma(commonest cause of unnatural death) follows tri-modal distribution:

Immediate: severe head injury, aorta dissection.

dealt only by prevention and public education.

Early :epidural, subdural hematoma, hemothorax etc.

Correctable injury, pre hospital coordinated care

and definitive t/t can benefit these pt.

Late: sepsis, consequences of initial management

Morbidity and mortality

• Hypoxia• Microatelectasis

• Hypovolemia

• Chest injury• Head injury

• Physiological status

Glasgow coma scale

Revised trauma score• Anatomical scores

Abbreviated injury scale

Injury severity score

System used to : ∞ stratify injury pattern

∞ assess injuries to predict pt. survival

∞ predict functional outcome of injuries• ∞ resource utilization

Glasgow coma scaleEye opening : spontaneously 4 verbal command 3 pain 2 no response 1Best motor response: to verbal command: obeys 6 painful stimulus: localized pain 5 withdrawal / flexion 4 abnormal flexion 3 extension decerebrate 2 none 1Best verbal response: oriented 5 disoriented 4 inappropriate words 3 incomprehensible words 2 nil 1 total 3—15

• Head injuries GCS score

Minor 13 – 15Majority recover fully

Moderate 9 – 12

Severe <8 degree of eventual recovery depends on initial brain injury

Revised trauma score <RTS>

GCS score 13 -15 4 9 -12 3 6 -8 2 4 -5 1 3 0Systolic BP >90 4 76 -89 3 50 -75 2 1 - 49 1 o 0Respiratory rate 10 -29 4 >29 3 6 -9 2 1 -5 1 0 0 total score 0 – 12

used for pre-hospital emergency room triage or forcomparative reassessment

during and after resuscitation without need for accuratediagnosis

• As score diminishes --------- progressively probability

of survival decreases

• A score >4 for any variable --- survival rate of <90%

• A score <4 --------------------a survival rate of just over 45%

ABBREVIATED INJURY SCALE

o Developed to rate and compare injuries.o Scores based on t/t period, life threatening injuries,

expected permanent impairment & energy dissipation.o Coding is done for anatomical site nature severity 1 minor 2 moderate 3 serious 4 severe 5 critical 6 fatal

Score <10: death rare in pt under age of

50

Score 10-15: response to t/t

Score 10-20: mortality 4-30% depending on

age

Score >50: only rare survival

INJURY SEVERITY SCORE

BODY IS DIVIDED INTO 6 PARTS: Head Face Chest Abdomen Extremities (including pelvis) External structures ISS=A2+B2+C2

The total ISS score is calculated from the sum of the squares of the three worst regional valuesGenerally, multiple trauma patient are defined as patient with iss≥16.ISS<30 good prognosis, unless associated with head injury. ISS>60 usually fatal.The score gives a correlation between ISS and mortality

ISS is the most frequently used injury scoring methodology• Has major limitation i.e.• Can underestimate injury severity of patient with multiple

injuries in same body region.• When used as predictor of survival ISS tends to

overweigh combined non lethal injuries, like

Isolated severe head injury ,AIS=5,ISS=25

Liver laceration AIS=4 & femur fracture AIS=3 ,ISS=25

Despite equal ISS, mortality, short and long term complication rate, resource utilization in these 2 injuries are probably very different.

Prognostic factors in head injury• Increasing age

• Pupil abnormalities

• Massive lesions

• Increasing ICP

• Diffuse B/L CT lesions

• Multiple injuries resulting

in hypovolaemia

• Immediate coma/lucid interval

Prognostic factors in thoracic trauma:• Mechanical ventilation• High PEEP(flial chest)• Pulmonary contusion –progressive hypoxia

due to edematous lung leading to v-p mismatch.

• Emergency surgery• Hemodynamic instability

Immediately life threatning conditions• Tension pneumothorax• Sucking chest wound• Flial chest• Cardiac tamponade• Massive hemothorax

Early interventions by trained personnel (paramedics,fire fighters,police) and well equipped transport system and emergency team are likely to modify the outcome

Complications like ARDS, fat embolism syndrome, DIC, crush syndrome, multi system organ failure have less favourable outcome.

 

NEPAL TRAUMA INDEX (NTI) For trauma scoring in developing countries (Multifactoral scoring system)

factors criteria score

Age < 12 years of > 55 years12-55 years

21

Time gap after sustaining trauma and reporting to hospital

> 12 hours 6-12 hours< 6 hours

321

Med. t/t received elsewhere after trauma

nonesome

21

Pulse pulse less100 – 120 per minute100 per minute

321

b.P not recordable< 100 syst.> 100 syst

321

respiration cyanosis / gasping tachypnoeanone

321

Level of consciousness no response to verbal commandsreposed but irritable or incoherentnormal response

321

Areas of suspected injuries - Viscera head face open arterial, associated burns long bone fracture, fracture spine

- more than 2 long bone fractures, open or closed or dislocations (no visceral injuries)

- one long bone injury or dislocation or closed soft tissue injury

321

Hb. At first sample < 8 grams % 8-10 grams % > 10 grams %

321

•Maximum (worst score)- 25

•Safest score-10 for extremes of age groups

9 for 12 – 55 years of age groups

 

.

• Rock wood n Green`s

fractures in adults, vol. 1• Appley’s system of orthopedics n fracture• Orthopedics' principle and their

applications Samuel L turek

THANK YOU