Muhm M, Danko T, Madler C, Winkler H
Klinik für Unfall- und Wiederherstellungschirurgie, Westpfalz-Klinikum Kaiserslautern, Deutschland.
Anaesthesist. 2011 Jun;60(6):534-40. doi: 10.1007/s00101-010-1846-z. Epub 2011 Jan 28.
The prognosis of polytraumatized patients is basically dependent on the quality of emergency room (ER) management and a smooth transition from prehospital emergency therapy to ER therapy is essential. The accurate prediction of the prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. Furthermore it helps to provide medical resources on time. Overestimation of injury severity wastes resources, underestimation puts patients at risk. Prehospital misjudgement of injury severity is common. The aim of this study was to evaluate reliability of the injury severity estimated by emergency physicians.
For comparison of the prehospital and hospital injury severity the Injury Severity Score (ISS) and Trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the Revised Trauma Score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the Abbreviated Injury Scale (AIS). The concordance of prehospital and hospital injury severity at different ranges and according to different body regions was evaluated. A difference of more than 25% between the prehospital injury severity and the injury severity calculated after ER diagnostics was considered as being relevant and judged as overestimation or underestimation. The documented injury severity in the emergency physician protocol was judged as detailed, satisfactory and poor.
Of the patients 73% reached the ER during on-call hours. The mean ER-ISS was 19 (1-50). At a range of ±25% referring to the ER-ISS, 30% overestimation and 36% underestimation of the prehospital injury severity was observed. A concordance of 34% was found. At a range of ±50% the concordance between the prehospital injury severity and the injury severity calculated after ER diagnostics was 57%, at a range of ±75% the concordance was 73%. The mean ER-TRISS was 6.9 points (0.3-98.6) and the mean ER-RTS was 7.569 points (0-7.841). Using the TRISS with a range of ±25% a concordance of 28% was observed. A high concordance of the prehospital and hospital injury severity was found in the region of the face (70%) and external soft tissue injuries (80%). The concordance in the body region of the abdomen was 55%, of the thorax 40%, of the extremities and pelvis 37% and of the head 33%. Underestimation in the region of the abdomen was 32%, of the head 37%, of the thorax 42% and of the extremities and pelvis 47%. Missed injuries were the reason for underestimation in the body region of extremities and pelvis in half of the cases. Of the patients 61% suffered a traffic accident, 25% a fall of less than 3 m and 8% of more than 3 m. In 5% of the cases other mechanisms of injury were observed. Injury severity was documented in a detailed manner in 61% and satisfactory in 26%.
The prediction of prehospital injury severity is difficult and less reliable. Relevant underestimation of injury severity was observed in visceral cavities. In order to evaluate injury severity the use of anatomical trauma scores alone might be not sufficient. In addition, the mechanism of injury and the deduced consequences, such as prehospital therapy, the choice of destination hospital and the need of ER treatment should be taken into account.
多发伤患者的预后基本上取决于急诊室（ER）的管理质量，从院前急救治疗平稳过渡到急诊室治疗至关重要。急诊医生对院前损伤严重程度的准确预测会影响院前治疗及目的地医院的护理水平。此外，这有助于及时提供医疗资源。损伤严重程度估计过高会浪费资源，估计过低则会使患者处于危险之中。院前对损伤严重程度的误判很常见。本研究的目的是评估急诊医生估计的损伤严重程度的可靠性。
为比较院前和院内损伤严重程度，计算损伤严重度评分（ISS）和创伤-ISS（TRISS）。TRISS由ISS和修订创伤评分（RTS）组成。收集院前和入院病历的所有诊断信息，并根据简明损伤定级标准（AIS）分配损伤严重程度。评估不同范围及不同身体部位的院前和院内损伤严重程度的一致性。院前损伤严重程度与急诊室诊断后计算出的损伤严重程度之间相差超过25%被视为具有相关性，并判断为高估或低估。急诊医生记录中的损伤严重程度被判定为详细、满意和差。
73%的患者在值班时间到达急诊室。急诊室ISS的平均值为19（1 - 50）。以急诊室ISS为参照，在±25%的范围内，观察到院前损伤严重程度高估30%，低估36%。一致性为34%。在±50%的范围内，院前损伤严重程度与急诊室诊断后计算出的损伤严重程度之间的一致性为57%，在±75%的范围内，一致性为73%。急诊室TRISS的平均值为6.9分（0.3 - 98.6），急诊室RTS的平均值为7.569分（0 - 7.841）。使用±25%范围内的TRISS时，观察到一致性为28%。面部区域（70%）和体表软组织损伤（80%）的院前和院内损伤严重程度一致性较高。腹部区域的一致性为55%，胸部为40%，四肢和骨盆为37%，头部为33%。腹部区域低估32%，头部低估37%，胸部低估42%，四肢和骨盆低估47%。在一半的病例中，漏诊损伤是四肢和骨盆区域低估的原因。61%的患者遭遇交通事故，25%的患者从低于3米处坠落，8%的患者从高于3米处坠落。5%的病例观察到其他损伤机制。61%的损伤严重程度记录详细，26%记录满意。
院前损伤严重程度的预测困难且可靠性较低。在内脏腔隙观察到损伤严重程度存在相关低估情况。仅使用解剖学创伤评分来评估损伤严重程度可能并不足够。此外，应考虑损伤机制及其推断后果，如院前治疗、目的地医院的选择以及急诊治疗的需求。
