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Injury. 2014 Oct;45 Suppl 3:S64-9. doi: 10.1016/j.injury.2014.08.020.

How to define severely injured patients? -- an Injury Severity Score (ISS) based approach alone is not sufficient.

Author information

1
Department of Orthopaedic and Trauma Surgery, University Witten/Herdecke, Cologne-Merheim Medical Center (CMMC), Cologne, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany. Electronic address: PaffrathT@kliniken-koeln.de.
2
Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany.
3
Department of Trauma and Hand Surgery, University Hospital Duesseldorf, Duesseldorf, Germany; Committee on Emergency Medicine, Intensive Care and Trauma Management (Sektion NIS) of the German Trauma Society (DGU), Germany.

Abstract

INTRODUCTION:

Multiple injured patients, polytrauma or severely injured patients are terms used as synonyms in international literature describing injured patients with a high risk of mortality and cost consuming therapeutic demands. In order to advance the definition of these terms, we analysed a large trauma registry. In detail, we compared critically ill trauma patients first specified on a pure anatomical base according to the ISS or NISS, second in the original "polytrauma definition" with two body regions affected and finally all of them combined with a physiological component.

PATIENTS AND METHODS:

Records that were collected in the TraumaRegister DGU(®) of the German Trauma Society (Deutsche Gesellschaft für Unfallchirurgie, DGU) between 1993 and 2011 (92,479 patients) were considered for this study. All patients with primary admission from scene with a minimum hospital stay of 48 h and an Injury Severity Score (ISS)≥ 16 were included. Pre-hospital and early admission data were used to determine physiological risk factors and calculate individual risk of death using the Revised Injury Severity Classification (RISC).

RESULTS:

45,350 patients met inclusion criteria. The overall hospital mortality rate was 20.4%. The predicted mortality according to the RISC-Score was 21.6%. 36,897 patients (81.4%) had injuries in several body regions. The prevalence of the five physiological risk factors varied between 17% (high age) and 34% (unconsciousness). There were 17,617 patients (38.8%) without any risk factor present on admission, while 30.6% (n=13,890) of the patients had one and 30.5% (n=13,843) had two or more factors present. Patients with ISS ≥ 16 but no physiological risk factor present had a very low mortality rate of 3.1% (542 of 17,617). With an increasing number of physiological factors there was an almost linear increase in mortality up to an 86% rate in patients with all five factors present. The 'polytrauma' definition of Butcher and colleagues with AIS ≥ 3 in at least two different body regions would apply to only 56.2% of patients in the present group with ISS ≥ 16. The mortality in this subgroup is only marginally higher (21.8%; 5559 of 25,494) than in the group of patients with only one severely affected body region (18.5%; 3675 of 19,875).

CONCLUSIONS:

In our opinion the principle of sharpening an anatomically based definition by a defined physiological problem will help to specify the really critically ill trauma patients.

KEYWORDS:

Classification; Definition; Injury Severity Score (ISS); Multiple trauma; Polytrauma; Revised Injury Severity Classification (RISC-Score); Trauma registry

PMID:
25284238
DOI:
10.1016/j.injury.2014.08.020
[Indexed for MEDLINE]

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