Annals of the Royal College of Surgeons of England (1992) vol. 74, 212-217
Care of road traffic accident victims in a district general hospital Nadeem Nayeem
FRCS
Registrar
Andrew H Baritrop
Mohindra B Kotecha
FRCS Consultant in Accident and Emergency Medicine
MB BS
Senior House Officer
Accident Service, Luton and Dunstable Hospital, Luton, Bedfordshire
Key words: Trauma centre; Multiple injuries; Death; Injury severity indices
It has been suggested that 20-33% of trauma related deaths preventable. The Accident and Emergency Department of Luton and Dunstable Hospital, therefore, set out to examine its own performance and to attempt to highlight areas of possible improvement. The department sees 65 851 new patients per annum, 3936 of these were victims of road traffic accidents (RTA). There were 184 patients admitted and six died. One death was considered preventable; shortcomings were noted with delay in availability of services. It is recommended that early assessment by experienced clinicians and easy access to theatre facilities and diagnostic imaging be available in district general hospitals to improve the quality of care for trauma victims. are
The report by the Working Party of The Royal College of Surgeons of England (1), recommended that trauma centres should be built in this country where the multiply-injured patient would be treated. This report maintains that 20-33% of deaths following trauma are preventable and the establishment of these centres will reduce this unnecessary mortality. If these recommendations are implemented, patients with multiple injuries would be taken to a trauma centre in which a 24-hour service would be provided by surgical, anaesthetic and radiological staff of consultant level and their trainees, who would have access to a full range of diagnostic facilities and readily available operating theatre and intensive care facilities. In order to assess the quality of care provided in a district general hospital at present, we conducted a prospective study on all the victims of road traffic accidents (RTA) who were brought to the accident and emergency department of one district general hospital Correspondence to: Mr N Nayeem, 148 Wardown Crescent, Luton, Beds LU2 7JU
12-month period, and using the TRISS methodology (2), the results were analysed. In the past, different methods have been used to assess the severity of injuries and to predict the outcome of treatment (3-5). The TRISS methodology is now an internationally recognised system which achieves these objectives. This system is based on a combination of the Injury Severity Score (6-8), the Revised Trauma Score (9,10), and the age of the patient. The Injury Severity Score (ISS) is an index of anatomical injury. It is calculated from the Abbreviated Injury Scale (AIS) (Table I). The Revised Trauma Score is based on scales of three main systems likely to show physiological response to injury-the respiratory system,
over a
Table I. The Abbreviated Injury Scale (AIS) Score 1
2 3 4 5 6
Minor Moderate Serious Severe Critical Fatal
Example Wrist sprain Closed, undisplaced tibial fracture Fractured femur Ruptured spleen Extradural haemorrhage Laceration of brain stem
Injuwy Severity Score A. Score every injury using the Abbreviated Injury Scale. B. Identify the highest AIS in each of the following six areas: Head and neck Abdomen and pelvic contents Bony pelvis and limbs Face Chest Body surface
C. Add together the squares of the three highest area scores
Care of road traffic accident victims
the cardiovascular system, and the central nervous This scale in crude form runs from 0 to 12 (Table II). For the purposes of medical audit a weighted form is used in which the crude coding values are corrected with weighting factors. The coded value derived from the Glasgow Coma Scale is multiplied by 0.9368, the code for systolic blood pressure by 0.7326 and the code for the respiratory rate by 0.2908. After these weights are used, the Revised Trauma Score has a corrected value of between 0 and 8, which correlates very well with survival probability. Using the TRISS methodology, the probability of survival for a patient can be estimated from the following formula: system.
PS = 1/(1 + e- b)
where b = bo + bl(RTS) + b2(ISS) + b3(A) Constants bs3 are derived from analysis of large numbers of patients in the major trauma outcome study (MTOS) in the United States. (A similar study is being conducted in the United Kingdom by the North Western Injury Research Centre.) A is the symbol for age. If the patient's age is 54 years or less, A is equal to 0. A is equal to 1 if the patient is 55 years or more in age. The constant e is equal to 2.718282 (the base of Napierian logarithms). The Luton and Dunstable Hospital serves a population of 284 000 and is situated near a busy stretch of the MI motorway, as well as being close to the A5 and A6 roads. The hospital has resident senior registrars or registrars with consultant cover in accident and emergency, general surgery, orthopaedics and anaesthesiology. The senior members of staff participate from the early stages of resuscitation and the hospital also has a 'flying
squad' which may be called to the scene of an accident at the request of ambulance services. There is a six-bed intensive care unit and limited computerised tomography (CT) scanning facilities (Monday-Friday 0900-1700). The neurosurgical and cardiothoracic centres are 25 and 40 min away by road, respectively.
Patients and methods During the 12-month period of study (1 August 1989 to 31 July 1990), all patients who were brought to the accident and emergency department after an RTA were included in the study. A record was maintained by the casualty officer of all admitted patients with details of their physiological parameters (as given in the Revised Trauma Score), the injuries sustained and treatment carried out in the department. Death, discharge or 3 months from the date of admission was taken as the endpoint of the study, and the hospital notes were then retrieved. Patients who died after resuscitation in the department, or if their death occurred after admission, their management and post-mortem reports were reviewed by two independent assessors, one a consultant anaesthetist and the other a consultant general surgeon, neither of whom was involved in the patients' management.
Results There were 65 851 new patients seen in the department during the 12-month period of study, of whom 3936 (6%) were the victims of road traffic accidents, 184 patients were admitted, 18 patients' notes contained insufficient
Table II. Values for Revised Trauma Score (crude form) Glasgow Coma Scale
Systolic blood pressure
13-15 9-12 6-8 4-5 3
>89 76-89 50-75 1-49 0
Respiratory rate 10-29 >29 6-9 1-5 0
Coded value 4 3 2 1 0
Coding for Glasgow Coma Scale Eye opening
Spontaneously To speech To pain None Best verbal response Orientated
4 3 2 1
Confused Inappropriate words Incomprehensible sounds
5 4 3 2
None
1
213
Motor response Obeys command Purposeful movement (to pain) Withdrawal (pain) Flexion Extension None
6
5 4 3 2 1
214
N Nayeem
et
al.
information (such as omission of respiratory rate) and were excluded from the study; hence, 166 patients (125 males, 41 females, age range 1-86 years, mean age 23 years) have been studied. An Injury Severity Score (ISS) of 16 or more is considered to represent severe injury. In our study, 27 patients were in this category, details of their injuries are given in Table III. The probability of survival (PJ) for these patients is also shown in Table III. The distribution of these
patients according to the TRISS methodology is shown in Fig. 1 or Fig. 2 depending on their age. The line drawn (P50) is at the survival probability of 50% and is used as a reference of whether survival was expected or not.
There were six deaths in this study. Four patients died from their injuries. Another death occurred when active treatment was withheld in the postoperative period after neurosurgery. One death was considered preventable. There were also two unexpected survivors.
Table III. Details of patients with ISS > 15 Injuries
RTS
ISS
PS
Outcome
1 Multiple rib fractures with unilateral pneumothorax 2 Fractures of the pelvis 3 Laceration on arm
7.5500
19
0.930
L
15 years
1 Extradural haematoma 2 Fractures of the pelvis 3 Fractures of the body of the mandible
7.5500
38
0.954
L
3
67 years
1 Head injury with loss of consciousness 2 Ruptured spleen and ruptured diaphragm 3 Displaced fracture of the humerus
6.9040
34
0.695
L
4
56 years
1 Subdural haematoma 2 Fractured clavicle 3 Laceration leg
4.7396
30
0.282
D
5
18 years
1 Lung laceration with haemothorax 2 Fracture of base of the skull with diffuse brain injury 3 Fractures of the tibia and fibula
0
41
0.012
D
6
25 years
1 Subdural haematoma 2 Fracture of the sternum (undisplaced)
5.972
20
0.948
L
7
19 years
1 Fractured rib with unilateral pneumothorax 2 Fractures of the metatarsals 3 Head injury with amnesia
7.5500
17
0.991
L
8
23 years
1 Le Fort II fracture 2 Subdural haematoma 3 Fracture of the femur
4.0936
43
0.345
L
9
27 years
1 Fracture of base of skull with CSF rhinorrhoea 2 Ruptured medial collateral of left knee
6.909
20
0.983
L
10
16 years
1 Depressed skull fracture 2 Dislocation of hip
6.904
25
0.968
L
11
25 years
1 Fractures of temporal and parietal bones with extradural haematoma
6.904
25
0.968
L
12
49 years
1 Fracture of base of skull 2 Diffuse subdural and subarachnoid bleed 3 Gross primary cerebral injury
2.9304
75
0.015
D
13
73 years
1 Compound fracture of occipito-parietal-temporal bones 2 Contusions and haemorrhages in occipital and frontal lobes
5.9672
75
0.039
D
No.
Age
1
67 years
2
Care of road traffic accident victims
215
Table III (continued) Injuries
RTS
ISS
PS
Outcome
1 Contusion occipital lobe 2 Fracture of the femur 3 Facial laceration
6.9040
16
0.989
L
25 years
1 Severe brain laceration 2 600 ml blood in right pleural cavity 3 Fractures of radius and ulna
3.5120
75
0.025
D
16
30 years
1 Renal contusion 2 Compound displaced fracture of the tibia
7.5500
18
0.990
L
17
56 years
1 Ruptured spleen 2 Head injury with unconsciousness
6.6132
25
0.755
D
18
27 years
1 Fracture of the base of the skull 2 Fracture of the fibula 3 Deep facial laceration
7.8408
17
0.993
L
19
59 years
1 Incomplete transection of aorta 2 Head injury with loss of consciousness 3 Delayed rupture of spleen
6.6132
50
0.336
L
20
23 years
1 Comminuted fractures of radius and ulna 2 Contusion right kidney with haematuria
6.9040
18
0.981
L
21
9 years
1 Head injury with loss of consciousness 2 Fracture of the shaft of the femur 3 Superficial wound left arm
5.9672
19
0.952
L
22
6 years
1 Fracture of the parietal bone 2 Fracture of the left 5, 6, 7th ribs with pneumothorax 3 Undisplaced fracture of the tibia
7.5500
22
0.986
L
23
53 years
1 Fracture of the skull with extradural haematoma 2 Laceration on face
4.0936
26
0.660
L
24
32 years
1 Fracture of the base of the skull with CSF leak
7.8408
16
0.993
L
25
60 years
1 Le Fort II fracture 2 Fracture of the ribs with lung contusion 3 Superficial laceration of liver
7.8408
26
0.912
L
26
63 years
1 Flail chest 2 Fracture of spinous process cervical spine
7.5500
25
0.894
L
27
25 years
1 Diffuse brain injury 2 Fracture of the pelvis 3 Superficial abrasion on the back
5.967
35
0.853
L
No.
Age
14
16 years
15
L = Live. D = Dead
Discussion Trauma is recognised as the main cause of death among children and young adults in the Western world. Death following trauma exceeds the combined deaths from heart disease and cancer, but despite being the principal cause of death in the most economically active section of
the population, trauma has attracted little support in the allocation of finances for research.
Unexpected survivors There were two unexpected survivors in this study. One patient (patient 19, Table III), after initial resuscitation
216
N Nayeem et al.
care, and being able to utilise on-site diagnostic imaging facilities, thus avoiding unnecessary transfers.
D
D L
L
LL
LL
L L L LL
L
LL
60 40 50 INJURY SEVERITY SCORE
70
Figure 1. Revised Trauma Score vs Injury Severity Score for RTA victims under 55 years of age.
Deaths There were six deaths in this study. Four patients died as a result of their injuries. Another death occurred when active treatment was withheld from a patient (patient 4, Table III) when he developed complications after evacuation of a large subdural haematoma. This was done in full consultation with our neurosurgical unit as, at the time of his operation, it was noted that he had diffuse brain injury. As this case highlights, a disadvantage of using any scoring system in trauma audit is that it does not reflect permanent severe brain damage. The one preventable death was in a 56-year-old patient who, on arrival, was stable but drowsy. A request for brain CT scan was made but there was a delay of 4 h before this was carried out. The CT scan was normal. During this time, his condition deteriorated and the patient went into hypovolaemic shock. He was ultimately taken to the operating theatre 7 h after his arrival, splenectomy was performed but he died 48 h after his operation. The post-mortem did not reveal any other
injury.
40
50
60
INJURY SEVERITY SCORE
Figure 2. Revised Trauma Score vs Injury Severity Score for RTA victims over 55 years of age.
and assessment was referred to the Regional Cardiothoracic Centre for repair of his thoracic aorta. In the postoperative period he suffered a delayed rupture of the spleen, but made a full recovery after splenectomy. The other patient (patient 8, Table III) a 23-year-old male, had a fractured shaft of the femur, facial injuries and a small subdural haematoma. He was ventilated electively and, after consultation with the neurosurgeon, he was closely monitored in the intensive care unit. Subsequently his fractures were reduced and he made a complete recovery. We attribute these survivals to prompt diagnosis, early involvement of senior members of medical staff in their
In patients who have either unexplained hypotension or equivocal abdominal signs in addition to head injury, a diagnostic peritoneal lavage should be carried out (11) as their hypotension cannot be due to intracranial bleeding (because of the limitation of the volume of the cranium). The benefits of establishing trauma centres is being debated among clinicians (12,13). We feel that, with the present financial restraints, it may not be possible to establish these centres in the near future and, hence, measures have to be taken to improve the quality of care under the present system. Participation by senior doctors at early stages of resuscitation of patients has been shown to reduce errors in their management (14), and hence we have taken steps to ensure that senior members of medical staff participate in the early management of these
patients. To improve the quality of care further, we suggest that in district general hospitals the victims of trauma be assessed on arrival by experienced clinicians, and the hospital should have easy access to operating theatres, CT scanning and intensive care facilities 24-hours a day. The provision of advanced trauma life support (ATLS) training to the clinicians involved in the care of trauma victims in this country is also expected to improve the care provided. The rate of preventable deaths reported from trauma centres in North America is less than 10% (15,16), and until similar centres are established in this country this may be a difficult target to achieve. The number of patients in our study is small, but our one preventable death, while being unacceptable, would be considered to be encouraging when compared with the report by the Royal College of Surgeons of England (1), and hence, although we agree in principle with the concepts of trauma centres, we feel much can be achieved
Care of road traffic accident victims under the present system if resources are spent on improving the existing facilities.
References I Royal College of Surgeons of England. The Management of Patients with Major Injuries. London RCS (Eng), 1988. 2 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care. The TRISS method. J Trauma 1987;27:370-8. 3 Kirkpatrick JR, Youmans RL. Trauma index. An aid in the evaluation of injury victims. J Trauma 1971;11:711-14. 4 Gormican SP. CRAMS Scale: Field triage of trauma victims. Ann Emerg Med 1982;11:132-5. 5 Koehler JJ, Baer LJ, Malafa SA et al. Pre-hospital index: a scoring system for field triage of trauma victims. Ann Emerg Med 1986;15:178-82. 6 American Association for Automotive Medicine. The Abbreviated Injury Scale: 1985 Edition. 2350 E Devon Avenue, Suite 205, Des Plains, IU 60018, USA. 7 Baker SP, O'Neill B, Haddon W Jr et al. The Injury Severity Scale: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 1974;14: 187-96.
217
8 Baker SP, O'Neill B. The Injury Severity Score. An up-date. J Trauma 1976;16:882-5. 9 Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. The Trauma Score. Crit Care Med 1981;9:672-6. 10 Champion HR, Gainer PS, Acklee EY. A progress report on the trauma score in predicting a fatal outcome. J Trauma 1986;26:927-31. 11 American College of Surgeons. Advanced Trauma Life Support Course for Physicians, 1989. 12 Kinny S J, Jones DHA. Trauma services requirement in a district general hospital serving a rural area. Br Med J 1990;300:504-8. 13 Spence MT, Redmond AD, Edwards JD. Trauma audit-the use of TRISS. Health Trends 1988;20:94-7. 14 Fisher RB, Dearden CH. Improving the care of patients with major trauma in the accident and emergency department. Br Med J 1990;300:1560-63. 15 West JG, Trunkey DD, Lim RC. Systems of trauma care: a study of two county experience. Arch Surg 1979;114:45560. 16 West JG, Cales RH, Gazzaniga AB. Impact of regionalisation: the Orange County experience. Arch Surg 1983; 118:740-4.
Received 5 September 1991
Assessor's comment The authors of this paper are to be congratulated in frankly reporting the relatively typical work of a large district general hospital accident and emergency department. The fact that in the United Kingdom there is relatively little penetrating trauma and that blunt trauma is diluted among district general hospitals, sometimes with accident departments seeing as few as 25 000 new patients a year, means that junior and middle grade staff and, dare we say, consultant staff, risk having relatively little practical experience of the management of trauma. The patient with a ruptured spleen is still at great risk in the average district general hospital accident and emergency
department. This is an entirely preventable cause of death-even in the very young and very old. Therefore, not only is it important to improve facilities in district general hospitals, it is also important to 'centralise' trauma care and improve the teaching of the management of trauma, eg ATLS Certification, while continually highlighting how we could have done better. Hence the worth of this paper, which also delineates trauma scoring. R TOUQUET RD FRCS Consultant in Accident and Emergency Medicine St Mary's Hospital London
Care of road traffic accident victims in a district general hospital Nadeem Nayeem
FRCS
Registrar
Andrew H Baritrop
Mohindra B Kotecha
FRCS Consultant in Accident and Emergency Medicine
MB BS
Senior House Officer
Accident Service, Luton and Dunstable Hospital, Luton, Bedfordshire
Key words: Trauma centre; Multiple injuries; Death; Injury severity indices
It has been suggested that 20-33% of trauma related deaths preventable. The Accident and Emergency Department of Luton and Dunstable Hospital, therefore, set out to examine its own performance and to attempt to highlight areas of possible improvement. The department sees 65 851 new patients per annum, 3936 of these were victims of road traffic accidents (RTA). There were 184 patients admitted and six died. One death was considered preventable; shortcomings were noted with delay in availability of services. It is recommended that early assessment by experienced clinicians and easy access to theatre facilities and diagnostic imaging be available in district general hospitals to improve the quality of care for trauma victims. are
The report by the Working Party of The Royal College of Surgeons of England (1), recommended that trauma centres should be built in this country where the multiply-injured patient would be treated. This report maintains that 20-33% of deaths following trauma are preventable and the establishment of these centres will reduce this unnecessary mortality. If these recommendations are implemented, patients with multiple injuries would be taken to a trauma centre in which a 24-hour service would be provided by surgical, anaesthetic and radiological staff of consultant level and their trainees, who would have access to a full range of diagnostic facilities and readily available operating theatre and intensive care facilities. In order to assess the quality of care provided in a district general hospital at present, we conducted a prospective study on all the victims of road traffic accidents (RTA) who were brought to the accident and emergency department of one district general hospital Correspondence to: Mr N Nayeem, 148 Wardown Crescent, Luton, Beds LU2 7JU
12-month period, and using the TRISS methodology (2), the results were analysed. In the past, different methods have been used to assess the severity of injuries and to predict the outcome of treatment (3-5). The TRISS methodology is now an internationally recognised system which achieves these objectives. This system is based on a combination of the Injury Severity Score (6-8), the Revised Trauma Score (9,10), and the age of the patient. The Injury Severity Score (ISS) is an index of anatomical injury. It is calculated from the Abbreviated Injury Scale (AIS) (Table I). The Revised Trauma Score is based on scales of three main systems likely to show physiological response to injury-the respiratory system,
over a
Table I. The Abbreviated Injury Scale (AIS) Score 1
2 3 4 5 6
Minor Moderate Serious Severe Critical Fatal
Example Wrist sprain Closed, undisplaced tibial fracture Fractured femur Ruptured spleen Extradural haemorrhage Laceration of brain stem
Injuwy Severity Score A. Score every injury using the Abbreviated Injury Scale. B. Identify the highest AIS in each of the following six areas: Head and neck Abdomen and pelvic contents Bony pelvis and limbs Face Chest Body surface
C. Add together the squares of the three highest area scores
Care of road traffic accident victims
the cardiovascular system, and the central nervous This scale in crude form runs from 0 to 12 (Table II). For the purposes of medical audit a weighted form is used in which the crude coding values are corrected with weighting factors. The coded value derived from the Glasgow Coma Scale is multiplied by 0.9368, the code for systolic blood pressure by 0.7326 and the code for the respiratory rate by 0.2908. After these weights are used, the Revised Trauma Score has a corrected value of between 0 and 8, which correlates very well with survival probability. Using the TRISS methodology, the probability of survival for a patient can be estimated from the following formula: system.
PS = 1/(1 + e- b)
where b = bo + bl(RTS) + b2(ISS) + b3(A) Constants bs3 are derived from analysis of large numbers of patients in the major trauma outcome study (MTOS) in the United States. (A similar study is being conducted in the United Kingdom by the North Western Injury Research Centre.) A is the symbol for age. If the patient's age is 54 years or less, A is equal to 0. A is equal to 1 if the patient is 55 years or more in age. The constant e is equal to 2.718282 (the base of Napierian logarithms). The Luton and Dunstable Hospital serves a population of 284 000 and is situated near a busy stretch of the MI motorway, as well as being close to the A5 and A6 roads. The hospital has resident senior registrars or registrars with consultant cover in accident and emergency, general surgery, orthopaedics and anaesthesiology. The senior members of staff participate from the early stages of resuscitation and the hospital also has a 'flying
squad' which may be called to the scene of an accident at the request of ambulance services. There is a six-bed intensive care unit and limited computerised tomography (CT) scanning facilities (Monday-Friday 0900-1700). The neurosurgical and cardiothoracic centres are 25 and 40 min away by road, respectively.
Patients and methods During the 12-month period of study (1 August 1989 to 31 July 1990), all patients who were brought to the accident and emergency department after an RTA were included in the study. A record was maintained by the casualty officer of all admitted patients with details of their physiological parameters (as given in the Revised Trauma Score), the injuries sustained and treatment carried out in the department. Death, discharge or 3 months from the date of admission was taken as the endpoint of the study, and the hospital notes were then retrieved. Patients who died after resuscitation in the department, or if their death occurred after admission, their management and post-mortem reports were reviewed by two independent assessors, one a consultant anaesthetist and the other a consultant general surgeon, neither of whom was involved in the patients' management.
Results There were 65 851 new patients seen in the department during the 12-month period of study, of whom 3936 (6%) were the victims of road traffic accidents, 184 patients were admitted, 18 patients' notes contained insufficient
Table II. Values for Revised Trauma Score (crude form) Glasgow Coma Scale
Systolic blood pressure
13-15 9-12 6-8 4-5 3
>89 76-89 50-75 1-49 0
Respiratory rate 10-29 >29 6-9 1-5 0
Coded value 4 3 2 1 0
Coding for Glasgow Coma Scale Eye opening
Spontaneously To speech To pain None Best verbal response Orientated
4 3 2 1
Confused Inappropriate words Incomprehensible sounds
5 4 3 2
None
1
213
Motor response Obeys command Purposeful movement (to pain) Withdrawal (pain) Flexion Extension None
6
5 4 3 2 1
214
N Nayeem
et
al.
information (such as omission of respiratory rate) and were excluded from the study; hence, 166 patients (125 males, 41 females, age range 1-86 years, mean age 23 years) have been studied. An Injury Severity Score (ISS) of 16 or more is considered to represent severe injury. In our study, 27 patients were in this category, details of their injuries are given in Table III. The probability of survival (PJ) for these patients is also shown in Table III. The distribution of these
patients according to the TRISS methodology is shown in Fig. 1 or Fig. 2 depending on their age. The line drawn (P50) is at the survival probability of 50% and is used as a reference of whether survival was expected or not.
There were six deaths in this study. Four patients died from their injuries. Another death occurred when active treatment was withheld in the postoperative period after neurosurgery. One death was considered preventable. There were also two unexpected survivors.
Table III. Details of patients with ISS > 15 Injuries
RTS
ISS
PS
Outcome
1 Multiple rib fractures with unilateral pneumothorax 2 Fractures of the pelvis 3 Laceration on arm
7.5500
19
0.930
L
15 years
1 Extradural haematoma 2 Fractures of the pelvis 3 Fractures of the body of the mandible
7.5500
38
0.954
L
3
67 years
1 Head injury with loss of consciousness 2 Ruptured spleen and ruptured diaphragm 3 Displaced fracture of the humerus
6.9040
34
0.695
L
4
56 years
1 Subdural haematoma 2 Fractured clavicle 3 Laceration leg
4.7396
30
0.282
D
5
18 years
1 Lung laceration with haemothorax 2 Fracture of base of the skull with diffuse brain injury 3 Fractures of the tibia and fibula
0
41
0.012
D
6
25 years
1 Subdural haematoma 2 Fracture of the sternum (undisplaced)
5.972
20
0.948
L
7
19 years
1 Fractured rib with unilateral pneumothorax 2 Fractures of the metatarsals 3 Head injury with amnesia
7.5500
17
0.991
L
8
23 years
1 Le Fort II fracture 2 Subdural haematoma 3 Fracture of the femur
4.0936
43
0.345
L
9
27 years
1 Fracture of base of skull with CSF rhinorrhoea 2 Ruptured medial collateral of left knee
6.909
20
0.983
L
10
16 years
1 Depressed skull fracture 2 Dislocation of hip
6.904
25
0.968
L
11
25 years
1 Fractures of temporal and parietal bones with extradural haematoma
6.904
25
0.968
L
12
49 years
1 Fracture of base of skull 2 Diffuse subdural and subarachnoid bleed 3 Gross primary cerebral injury
2.9304
75
0.015
D
13
73 years
1 Compound fracture of occipito-parietal-temporal bones 2 Contusions and haemorrhages in occipital and frontal lobes
5.9672
75
0.039
D
No.
Age
1
67 years
2
Care of road traffic accident victims
215
Table III (continued) Injuries
RTS
ISS
PS
Outcome
1 Contusion occipital lobe 2 Fracture of the femur 3 Facial laceration
6.9040
16
0.989
L
25 years
1 Severe brain laceration 2 600 ml blood in right pleural cavity 3 Fractures of radius and ulna
3.5120
75
0.025
D
16
30 years
1 Renal contusion 2 Compound displaced fracture of the tibia
7.5500
18
0.990
L
17
56 years
1 Ruptured spleen 2 Head injury with unconsciousness
6.6132
25
0.755
D
18
27 years
1 Fracture of the base of the skull 2 Fracture of the fibula 3 Deep facial laceration
7.8408
17
0.993
L
19
59 years
1 Incomplete transection of aorta 2 Head injury with loss of consciousness 3 Delayed rupture of spleen
6.6132
50
0.336
L
20
23 years
1 Comminuted fractures of radius and ulna 2 Contusion right kidney with haematuria
6.9040
18
0.981
L
21
9 years
1 Head injury with loss of consciousness 2 Fracture of the shaft of the femur 3 Superficial wound left arm
5.9672
19
0.952
L
22
6 years
1 Fracture of the parietal bone 2 Fracture of the left 5, 6, 7th ribs with pneumothorax 3 Undisplaced fracture of the tibia
7.5500
22
0.986
L
23
53 years
1 Fracture of the skull with extradural haematoma 2 Laceration on face
4.0936
26
0.660
L
24
32 years
1 Fracture of the base of the skull with CSF leak
7.8408
16
0.993
L
25
60 years
1 Le Fort II fracture 2 Fracture of the ribs with lung contusion 3 Superficial laceration of liver
7.8408
26
0.912
L
26
63 years
1 Flail chest 2 Fracture of spinous process cervical spine
7.5500
25
0.894
L
27
25 years
1 Diffuse brain injury 2 Fracture of the pelvis 3 Superficial abrasion on the back
5.967
35
0.853
L
No.
Age
14
16 years
15
L = Live. D = Dead
Discussion Trauma is recognised as the main cause of death among children and young adults in the Western world. Death following trauma exceeds the combined deaths from heart disease and cancer, but despite being the principal cause of death in the most economically active section of
the population, trauma has attracted little support in the allocation of finances for research.
Unexpected survivors There were two unexpected survivors in this study. One patient (patient 19, Table III), after initial resuscitation
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care, and being able to utilise on-site diagnostic imaging facilities, thus avoiding unnecessary transfers.
D
D L
L
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LL
L L L LL
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60 40 50 INJURY SEVERITY SCORE
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Figure 1. Revised Trauma Score vs Injury Severity Score for RTA victims under 55 years of age.
Deaths There were six deaths in this study. Four patients died as a result of their injuries. Another death occurred when active treatment was withheld from a patient (patient 4, Table III) when he developed complications after evacuation of a large subdural haematoma. This was done in full consultation with our neurosurgical unit as, at the time of his operation, it was noted that he had diffuse brain injury. As this case highlights, a disadvantage of using any scoring system in trauma audit is that it does not reflect permanent severe brain damage. The one preventable death was in a 56-year-old patient who, on arrival, was stable but drowsy. A request for brain CT scan was made but there was a delay of 4 h before this was carried out. The CT scan was normal. During this time, his condition deteriorated and the patient went into hypovolaemic shock. He was ultimately taken to the operating theatre 7 h after his arrival, splenectomy was performed but he died 48 h after his operation. The post-mortem did not reveal any other
injury.
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INJURY SEVERITY SCORE
Figure 2. Revised Trauma Score vs Injury Severity Score for RTA victims over 55 years of age.
and assessment was referred to the Regional Cardiothoracic Centre for repair of his thoracic aorta. In the postoperative period he suffered a delayed rupture of the spleen, but made a full recovery after splenectomy. The other patient (patient 8, Table III) a 23-year-old male, had a fractured shaft of the femur, facial injuries and a small subdural haematoma. He was ventilated electively and, after consultation with the neurosurgeon, he was closely monitored in the intensive care unit. Subsequently his fractures were reduced and he made a complete recovery. We attribute these survivals to prompt diagnosis, early involvement of senior members of medical staff in their
In patients who have either unexplained hypotension or equivocal abdominal signs in addition to head injury, a diagnostic peritoneal lavage should be carried out (11) as their hypotension cannot be due to intracranial bleeding (because of the limitation of the volume of the cranium). The benefits of establishing trauma centres is being debated among clinicians (12,13). We feel that, with the present financial restraints, it may not be possible to establish these centres in the near future and, hence, measures have to be taken to improve the quality of care under the present system. Participation by senior doctors at early stages of resuscitation of patients has been shown to reduce errors in their management (14), and hence we have taken steps to ensure that senior members of medical staff participate in the early management of these
patients. To improve the quality of care further, we suggest that in district general hospitals the victims of trauma be assessed on arrival by experienced clinicians, and the hospital should have easy access to operating theatres, CT scanning and intensive care facilities 24-hours a day. The provision of advanced trauma life support (ATLS) training to the clinicians involved in the care of trauma victims in this country is also expected to improve the care provided. The rate of preventable deaths reported from trauma centres in North America is less than 10% (15,16), and until similar centres are established in this country this may be a difficult target to achieve. The number of patients in our study is small, but our one preventable death, while being unacceptable, would be considered to be encouraging when compared with the report by the Royal College of Surgeons of England (1), and hence, although we agree in principle with the concepts of trauma centres, we feel much can be achieved
Care of road traffic accident victims under the present system if resources are spent on improving the existing facilities.
References I Royal College of Surgeons of England. The Management of Patients with Major Injuries. London RCS (Eng), 1988. 2 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care. The TRISS method. J Trauma 1987;27:370-8. 3 Kirkpatrick JR, Youmans RL. Trauma index. An aid in the evaluation of injury victims. J Trauma 1971;11:711-14. 4 Gormican SP. CRAMS Scale: Field triage of trauma victims. Ann Emerg Med 1982;11:132-5. 5 Koehler JJ, Baer LJ, Malafa SA et al. Pre-hospital index: a scoring system for field triage of trauma victims. Ann Emerg Med 1986;15:178-82. 6 American Association for Automotive Medicine. The Abbreviated Injury Scale: 1985 Edition. 2350 E Devon Avenue, Suite 205, Des Plains, IU 60018, USA. 7 Baker SP, O'Neill B, Haddon W Jr et al. The Injury Severity Scale: A method for describing patients with multiple injuries and evaluating emergency care. J. Trauma 1974;14: 187-96.
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8 Baker SP, O'Neill B. The Injury Severity Score. An up-date. J Trauma 1976;16:882-5. 9 Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. The Trauma Score. Crit Care Med 1981;9:672-6. 10 Champion HR, Gainer PS, Acklee EY. A progress report on the trauma score in predicting a fatal outcome. J Trauma 1986;26:927-31. 11 American College of Surgeons. Advanced Trauma Life Support Course for Physicians, 1989. 12 Kinny S J, Jones DHA. Trauma services requirement in a district general hospital serving a rural area. Br Med J 1990;300:504-8. 13 Spence MT, Redmond AD, Edwards JD. Trauma audit-the use of TRISS. Health Trends 1988;20:94-7. 14 Fisher RB, Dearden CH. Improving the care of patients with major trauma in the accident and emergency department. Br Med J 1990;300:1560-63. 15 West JG, Trunkey DD, Lim RC. Systems of trauma care: a study of two county experience. Arch Surg 1979;114:45560. 16 West JG, Cales RH, Gazzaniga AB. Impact of regionalisation: the Orange County experience. Arch Surg 1983; 118:740-4.
Received 5 September 1991
Assessor's comment The authors of this paper are to be congratulated in frankly reporting the relatively typical work of a large district general hospital accident and emergency department. The fact that in the United Kingdom there is relatively little penetrating trauma and that blunt trauma is diluted among district general hospitals, sometimes with accident departments seeing as few as 25 000 new patients a year, means that junior and middle grade staff and, dare we say, consultant staff, risk having relatively little practical experience of the management of trauma. The patient with a ruptured spleen is still at great risk in the average district general hospital accident and emergency
department. This is an entirely preventable cause of death-even in the very young and very old. Therefore, not only is it important to improve facilities in district general hospitals, it is also important to 'centralise' trauma care and improve the teaching of the management of trauma, eg ATLS Certification, while continually highlighting how we could have done better. Hence the worth of this paper, which also delineates trauma scoring. R TOUQUET RD FRCS Consultant in Accident and Emergency Medicine St Mary's Hospital London
