Date post: | 11-May-2015 |
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Health & Medicine |
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• 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