Assessing the severity of trauma and the quality of trauma care

  • G. Berlot
  • H. Delooz
  • A. Gullo
Part of the Topics in Anaesthesia and Critical Care book series (TIACC)


Despite major technological and therapeutic advances, in developed countries trauma remains the leading cause of death in patients younger than 30 years of age [1]. In these subjects, mortality shows a trimodal distribution: roughly 50% of patients die within 1 h after the accident due to injuries incompatible with life; preventive measures (i.e., implementation of speed limits, airbags etc.) appear to be the only way to reduce this burden. Another 30% of subjects die within 3–4 h after the trauma: it is likely that the outcome of many of them could have been different with a better triage or a more rapid transfer to specialized centers (so-called regionalization). The remaining patients die in the Intensive Care Units (ICU) days or weeks after the trauma, mainly due to the consequences of head injuries, infection or multiple organ dysfunction syndrome (MODS). Independent of the clinical course, the final outcome of patients in the two latter groups is likely influenced by two different, interacting categories of factors. The first is represented by direct consequences of the injuries, which can be heavily influenced, in various ways, by the quality of care either in the prehospital or in the hospital phase. Good example of the potential effects of trauma care are the reduction of the incidence and severity of secondary brain injury [2], or the early achievement of proposed resuscitation goals [3]. Conversely, the second category of factors cannot be affected by the quality of care, and includes the victim’s age and the presence of coexisting disease [4]. Thus, since outcome relies upon multiple factors acting in different time frames, it appears that: a) any consideration of the probability of survival and/or of the quality of care must be based on careful assessment of the trauma-induced anatomic and physiologic alterations and the preexisting organ functional reserve; b) the quality of treatment must be assessed using a methodologic approach aimed at reducing as much as possible any subjective bias of judgement.


Trauma Patient Injury Severity Score Multiple Organ Dysfunction Syndrome Trauma Care Emergency Medical Helicopter Service 


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  1. 1.
    Trunkey DD (1991) Initial treatment of patients with severe trauma. New Engl J Med 324:1259–1263.PubMedCrossRefGoogle Scholar
  2. 2.
    Chestnut RM, Marshall Lf, Klauber MR et al (1993) The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222.CrossRefGoogle Scholar
  3. 3.
    Porter JM, Ivatury RR (1998) In search of the optimal end points of resucitation in trauma patients: a review. J Trauma 44:908–914.PubMedCrossRefGoogle Scholar
  4. 4.
    Sacco WJ, Copes WS, Bain LW et al (1993) Effect of preinjury illness on trauma patient survival outcome. J Trauma 35:538–543.PubMedCrossRefGoogle Scholar
  5. 5.
    LeGall JR, Lemeshow S, Saulnier F (1993) A new simplified acute physiology score (SAPS II) based on an European/North American multicenter study. JAMA 270:2957–2963.CrossRefGoogle Scholar
  6. 6.
    Knaus WA, Draper EA, Wagner DP, Zimmermenn JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829.PubMedCrossRefGoogle Scholar
  7. 7.
    Knaus WA, Draper EA, Wagner DP et al (1991) The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest 100:1619–1636.PubMedCrossRefGoogle Scholar
  8. 8.
    Lemeshow S, Teres D, Klar J, Avrunin JS, Gelblach SH, Rapoport J (1993) Mortality Prediction Models (MPM II) based on an international cohort of intensive care unit patients. JAMA 270:2478–2486.PubMedCrossRefGoogle Scholar
  9. 9.
    Vassar MJ, Wilkerson CL, Duran PJ et al (1992) Comparison of APACHE II, TRISS and a proposed 24 hour ICU point system for prediction of outcome in ICU trauma patients. J Trauma 32:490–499.PubMedCrossRefGoogle Scholar
  10. 10.
    Wong DT, Barrow PM, Gomez M, McGuire GP (1996) A comparison of the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Trauma Injury Severity Score (TRISS) for outcome assessment on intensive care unit trauma patients. Crit Care Med 24:1642–1648.PubMedCrossRefGoogle Scholar
  11. 11.
    Moreno R (1998) Performances of the ICU: are we able to measure it? In: Vincent JL (ed) Yearbook of intensive care and emergency medicine. Springer-Verlag, Berlin Heidelberg New York, pp 729–743.Google Scholar
  12. 12.
    Baker SP, O’Neil B (1976) The Injury Severity Score: an update. J Trauma 16:882–885.PubMedCrossRefGoogle Scholar
  13. 13.
    Champion HR, Sacco WJ, Copes WS et al (1989) A revision of the trauma score. J Trauma 29:623–629.PubMedCrossRefGoogle Scholar
  14. 14.
    Rutledge R (1996) The Injury Severity Score is unable to differentiate between poor care and severe injury. J Trauma 40:944–950.PubMedCrossRefGoogle Scholar
  15. 15.
    Klasen HJ, ten Duis HJ, Kingma J (1995) Methods of registration and injury severity score scoring. In: Goris RJA, Trenz O (eds) The integrated approach to trauma care the first 24 hours. Springer-Verlag, Berlin Heidelberg New York pp 13–24.CrossRefGoogle Scholar
  16. 16.
    Boyd CR, Toison MA, Copes WS (1987) Evaluating trauma care: the TRISS method. J Trauma 27:370–378.PubMedCrossRefGoogle Scholar
  17. 17.
    Bull JP, Dickson GR (1991) Injury scoring by TRISS and ISS/age. Injury 21:127–131.CrossRefGoogle Scholar
  18. 18.
    Oestern HJ, Kabus K (1994) Comparison of various trauma score systems. Unfallchirurg 97:177–184.PubMedGoogle Scholar
  19. 19.
    Champion HR, Copes WS, Sacco WJ et al (1996) Improved prediction from A Severity Characterization of Trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): result of an independent study. J Trauma 40:42–49.PubMedCrossRefGoogle Scholar
  20. 20.
    Markle J, Cayten CG, Byrne DW, Moy F, Murphy JG (1992) Comparison between TRISS and ASCOT methods in controlling for injury severity. J Trauma 33:326–332.PubMedCrossRefGoogle Scholar
  21. 21.
    Markle J, Cayten CG, Bryne DW et al (1992) Comparison between TRISS and ASCOT methods in controlling for injury severity. J Trauma 31:A1719.CrossRefGoogle Scholar
  22. 22.
    Rutledge R, Osier T, Emery S, Kromhout Shiro (1998) The end of the Injury Severity Score (ISS) and the Trauma-Injury Severity Score (TRISS): ICISS, an international classification of disease, 9th revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges and hospital lenght of stay. J Trauma 44:41–49.PubMedCrossRefGoogle Scholar
  23. 23.
    Pories SE, Gamelli RL, Pilcher DB et al (1989) Practical evluation of trauma deaths. J Trauma 29:1607–1610.PubMedCrossRefGoogle Scholar
  24. 24.
    Wilson DS, McElligot J, Fielding LP (1992) Identification of preventable trauma deaths: counfounded inquiries? J Trauma 32:45–51.PubMedCrossRefGoogle Scholar
  25. 25.
    Karmy-Jones R, Copes WS, Champion HR et al (1992) Results of a multi-institutional outcome assessemnt: results of a structured peer review of TRISS-designated unexpected outcomes. J Trauma 32:196–203.PubMedCrossRefGoogle Scholar
  26. 26.
    Sampalis JS, Boukas S, Lavoie A et al (1995) Preventable death evaluation of the appropriateness of the on-site trauma care provided by Urgences-Santé physicians. J Trauma 39:1029–1035.PubMedCrossRefGoogle Scholar
  27. 27.
    Nardi G, Massarutti D, Muzzi A et al (1994) Impact of emergency medical helicopter service on mortality for trauma in north east Italy: a regional prospective audit. Eur J Emerg Med 1:69–77.PubMedCrossRefGoogle Scholar
  28. 28.
    Bickell WH, Wall MJ, Pepe PE et al (1994) Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. New Engl J Med 331:1105–1109.PubMedCrossRefGoogle Scholar
  29. 29.
    Stocchetti N, Pagliarini G, Gennari M et al (1994) Trauma care in Italy: evidence of in-hospital preventable deaths. J Trauma 36:401–405.PubMedCrossRefGoogle Scholar
  30. 30.
    Davis JW, Hoyt DB, McArdle MS et al (1991) The significance of critical care errors in causing preventable deaths in trauma patients in a trauma system. J Trauma 31:813–819PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Italia 1999

Authors and Affiliations

  • G. Berlot
  • H. Delooz
  • A. Gullo

There are no affiliations available

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