RU2454920C1 - Method of predicting outcome of traffic accident trauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine. Evaluation is performed in points by the following criteria: severity by ISS scale, and if severity of trauma by ISS scale is within the interval from 1 to 10, 5 points are given, from 11 to 20 - 10 points, from 21 to 30 - 15 points, from 31 to 40 - 40 points, from 41 and more - 80 points; type of trauma and characteristics of injury, with presence of fractures of scull bones corresponding to 4 points, multiple fractures of the same bone - 4 points, multiple fractures of different bones - 7 points, other fractures - 3 points, injury of internal organs in form of severe craniocerebral injury - 10 points, contusion or rupture of lung - 7 points, contusion or rupture of liver - 17 points, contusion or rupture of kidney - 10 points, contusion or rupture of urethra or urinary bladder - 4 points, contusion or rupture of spleen, or intestine and mesentery, or heart, or contusion of spinal cord - 80 points; background somatic disease, if at the moment of trauma victim had disease of cardiovascular system, 3 points are given, respiratory system organs - 10 points, diabetes mellitus - 10 points, liver cirrhosis - 10 points; category of victim's participation in traffic, if victim is pedestrian, 5 points are given, driver or passenger - 2 points; time of trauma and degree of severity for harm to health, 3 points are given if trauma occurs in autumn, 1 point - in winter, spring, summer, if qualifying signs of severe damage to health are present - 6 points; presence of shock of any degree and genesis is evaluated as 20 points. Obtained points are summed up. In case if total quantity does not exceed 24 points, prognosis is favourable - recovery; from 25 to 49 points - prognosis is conventionally favourable - recovery of disability; from 50 to 69 points - prognosis is conventionally unfavourable - disability, from 70 to 109 points - prognosis is unfavourable - disability or death, from 110 points and higher - prognosis is extremely unfavourable - lethal outcome.

EFFECT: method ensures increase of accuracy in prediction of traffic accident trauma outcome.

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Description

The present invention relates to medicine and can be used to predict the outcome of a road traffic injury.

The Injury Severity Score (ISS) known by S.P.Baker et al. Is known. [Baker S.P. et al. The Injury Severity Score: a method for describing patients with multiple injuries and evaluating emergency care // Unfallchirurg. - 2000. - Bd 103, H 2. - S.137-143]. To assess the severity of damage on the ISS scale, the sum of the squares of the three highest scores in 6 areas of the body is determined (squaring allows you to more clearly distinguish between severe and moderate injuries, and even less so). The obtained digital value (from 1 to 75 points) indicates the severity of the damage. The ISS scale allows you to more objectively express the severity of combined and multiple injuries in numbers, but when localizing injuries in four or more anatomical areas, up to three injuries are unaccounted for, which leads to an inaccurate assessment of the severity of the injury. In addition, this scale for determining the severity of combined trauma does not allow multiple trauma to be expressed in numbers, since only the most severe damage is taken into account within the same area of the body. Thus, the disadvantages of ISS are a high proportion of subjectivity and the inability to conduct assessments on several grounds [V. Sokolov Multiple and combined injuries: Pract.ruk. for traumatologists / V.A.Sokolov. - M .: GEOTAR - Media, 2006. - 512 p.].

Known APACHE scale (Acute Physiology and Chronik Health Evaluation - acute and chronic physiological assessment of the disease) [Knaus W., Wagner D., Draper E. et al. The APACHE-II prognostic system: Risk prediction of hospital mortality for hospitalized adults // Chest. - 1991. - Vol. 100. - P.1619]. The final point score on the ARACNE-II scale is the sum of points for an emergency assessment of physiological functions (EOFF), age points (if the patient is older than 45 years), and points corresponding to severe concomitant diseases. An emergency assessment of physiological functions is carried out using 12 indicators obtained in the first 24 hours of the patient's stay in the intensive care unit. But this scale is dynamic in nature, not focused on the severity of the injury and on the criterion of disability.

The known CITO scale [Shaposhnikov Yu.G. Diagnosis and treatment of wounds. / Yu.G. Shaposhnikov. - M.: Medicine, 1984. - 344 p.], Created by the frequency-regression method in the laboratory of forecasting CITO for a quantitative assessment of the nature and localization of damage. The CITO scale assesses individual injuries or their combination in relation to what chances of surviving a victim with such an injury are, what is the specific contribution of this injury to the severity of the traumatic disease as a whole. This scale is not focused on the risk of disability.

Known NISS scale (New Injury Severity Score). It eliminated one of the main weaknesses of ISS - the inability to scale multiple lesions in the same anatomical region (for example, simultaneous ruptures of the liver, spleen, and small intestine). Scoring on the NISS scale is performed by summing up the three most significant lesions, regardless of their location [Osier, T. et al. ICISS: an Internation Classification of Disease-9 based Injury Severity Score / T. Osier, R. Routledge, J. Deis, E. Bedrick J Trauma. 1996. N 41. P.380-388], however, other injuries remain unaccounted for, often not inferior in their severity to the leading injury.

Known ICISS (International Classification Injury Severity Score) - a method for assessing the severity of injury, based on the International classification of diseases of the tenth revision (ISD 10). It has the same drawbacks as ISS, NISS, and TRISS, but more accurately predicts the outcome of the injury [Rutledge R et al. Comparison of APACHE II, Trauma Score and Injury Severity Score as predictors of outcome in critically injured trauma patients / R. Rutledge, S. Fakhry, E Rutherford, F. Muakkassa, A. Meyer. Am J Surg 1993; 166: 244-247]. The injury severity score no ICISS is determined by the ratio of survival risk (SRRs) calculated for each type of anatomical damage ISD 10. In turn, the risk of survival (SRRs) is calculated by the ratio of the number of surviving victims to the total number of patients with this damage. ICISS has some advantages over ISS; the ability to account for all identified injuries, the best prognostic ability to determine the probability of not only death, but also the development of complications and the duration of inpatient treatment. A significant drawback is that it does not take into account either age or the presence of background disease.

The PTS scale (Polytrauma Score [Hannover]), proposed in the early 80s by a group of German doctors [Oestern H.I. Management of polytrauma patients in an international comparison // Unfallchiring. - 1999. - Bd. 102, H.2. - S. 80-89], - Hanoverian polytrauma code based on a discriminant analysis of lesions in five anatomical areas (head, chest, abdomen, pelvis, limbs) and age. Each type of damage (by anatomical areas) is scored. The sum of points for individual areas gives four degrees of severity: I degree - 19 points (mortality forecast up to 10%), II degree - 20-34 points (up to 25%), III degree - 35-48 points (up to 50%), IV degree - above 49 points (up to 75%). The severity of polytrauma is determined by the sum of the severity points of individual injuries and the age score of the victim, but does not take into account the presence of a background disease.

Thus, the known methods for predicting the outcome of an injury are not without significant drawbacks and do not have absolute diagnostic accuracy.

The objective of the invention is to improve the accuracy and optimization of predicting the outcome of a road traffic injury. The problem is solved by summing up the points obtained when assessing the severity of the injury on the ISS scale, the type (soft tissue bruises, skeleton fractures, damage to internal organs) and the characteristics of the damage, background somatic disease, category of participation in the road traffic of the victim (pedestrian, passenger, driver ), the time of the injury (winter, spring, summer, autumn) and the severity of the damage to health.

The proposed method is recommended for use with multiple and combined injuries in the period from 3 to 30 days after the injury.

These points were established on the basis of a statistical study of risk factors for adverse outcomes of road traffic injuries [Zarkov SI, Safin R.Ya. The influence of various factors on the disability of persons injured in traffic accidents. / S.I. Zarkov, R.Ya.Safin // Actual problems of medical science and practical health care. - Proceedings of the scientific session dedicated to the 65th anniversary of the medical academy. - Chelyabinsk: Publishing House "Chelyabinsk State Medical Academy", 2009. - p.17-18; Gubaidullin M.I. et al. Some aspects of hospital mortality among people injured in traffic accidents / M.I. Gubaidullin, R. Ya. Safin, S. I. Zarkov // On the problematic issues of organizing the production of forensic medical examinations: a collection of materials of the All-Russian Scientific -practical conference, Moscow, November 5-6, 2009 / Under the general. ed. prof. V.V.Kolkutina. - M.: RIO FGU RCSME Ministry of Health and Social Development of Russia, 2009, - p.188-192].

When assessing the severity of an injury, the ISS scale is used. To do this, first on the AIS (Abbreviated Injury Scale) scale, all injuries are ranked in increasing order in points (codes) from 1 to 6. Score 1 corresponds to minor injuries requiring outpatient treatment, score 2 - moderate injuries, score 3 - severe injuries without threats to life, a score of 4 to severe injuries with a threat to life, a score of 5 to critical injuries with dubious survival, a score of 6 to unconditionally fatal injuries. Ranking is carried out in the following areas of the human body: head; neck; face; chest; stomach; limbs external integument (wounds and burns) [Sokolov V.A. Multiple and combined injuries: Pract. hands. for traumatologists / V.A.Sokolov. - M.: GEOTAR - Media, 2006. - 512 s] (Table 1).

Table 1 AIS severity score for limb injuries Score Severity Type of damage one Easy Bruises of the elbow, shoulder, hand, ankle; fractures and dislocations of fingers and toes; sprain. 2 Significant Fractures of the humerus, radius, ulna, tibia and fibula, collarbone, scapula, metatarsal, calcaneus, pubic bones; simple pelvic fractures; dislocations; significant wounds to muscles and tendons; internal tears (small wounds of the axillary, brachial, palmar arteries and / or veins). 3 Severe without a threat to life Comminuted fractures of the pelvis; hip fractures; dislocation of the hand, ankle, knee, thigh; amputations below the knee or upper limb; rupture of the knee tendons, sciatic nerve wounds; internal tears, small wounds of the femoral artery; large wounds with or without thrombosis a. axillaris et a.poplitea, vv.axillaris, poplitea or femoralis. four Severe, life threatening Crushed pelvic fractures; traumatic amputations above the knee, crash syndrome; large wounds of the femoral or brachial artery. 5 Critical with dubious survival Open, compressed pelvic fractures. 6 Definitely deadly Crushing brain matter

ISS is the sum of the squares of the codes of the 3 most severe injuries of the following 6 areas of the body: head or neck; face; chest; the abdomen and contents of the pelvis; limbs or pelvic girdle; external damage (skin and soft tissue).

Head or neck injuries include injuries to the brain or cervical spinal cord, fractures of the brain skull or cervical spine. Facial injuries include injuries to the mouth, ears, eyes, nose and facial bones. Damage to the chest, abdomen, or pelvic contents includes all injuries to the internal organs of the corresponding cavities. Breast injuries also include injuries of the diaphragm, ribs, and thoracic spine. Damage to the lumbar spine is included in the abdomen or pelvis. Damage to the limbs, pelvis or bones of the pelvic girdle with the exception of the spinal column, skull and ribs include sprains, fractures, dislocations and amputations. External injuries include bruised and lacerated wounds, bruises and burns, regardless of their location on the surface of the body.

If the severity of the injury on the ISS scale is in the range from 1 to 10, then 5 points are awarded, from 11 to 20 - 10 points, from 21 to 30 - 15 points, from 31 to 40 - 40 points, from 41 and more - 80 points .

The presence of fractures of the skull in a person corresponds to 4 points, multiple fractures of one bone - 4 points, multiple fractures of various bones - 7 points, other fractures - 3 points.

Damage to internal organs in the form of severe traumatic brain injury was evaluated at 10 points, bruise or tear of the lung - at 7 points, bruise or tear of the liver - at 17 points, bruise or tear of the kidney - at 10 points, bruise or rupture of the urethra and bladder - 4 points, bruise or rupture of the spleen, or intestines and mesentery, or heart, or bruise of the spinal cord - 80 points.

Accounting for the somatic background disease and the category of participation in the road traffic of the victim (pedestrian, passenger, driver) is carried out as follows:

- if at the time of the injury the victim suffered from a disease of the cardiovascular system (coronary heart disease, hypertension), 3 points are awarded, respiratory systems (severe COPD, bronchial asthma) - 10 points, diabetes - 10 points, cirrhosis - 10 points .

- if the victim is a pedestrian, 5 points are added, the driver or passenger - 2 points.

3 points are awarded in case of injury in the fall, 1 point - in the winter, spring, summer.

Shock of any degree and genesis (shock index over 0.5) is estimated at 20 points.

The presence of qualifying signs of grievous bodily harm (bodily harm, dangerous to human life, significant permanent loss of overall working capacity by at least one third [according to the order of the Ministry of Health and CP RF №194n of April 24, 2008 “Medical criteria for determining the severity of harm caused human health ”]) - 6 points.

Prediction of the outcome of a road traffic injury is carried out by adding up points for each of the items:

- if the sum of the points of all the listed signs is in the range from 0 to 24 points, the prognosis is favorable (recovery);

- if the total score corresponds to 25-49 points, the prognosis is conditionally favorable (recovery / disability);

- with the sum of points 50-69 - conditionally unfavorable prognosis (disability);

- a score of 70-109 corresponds to an unfavorable prognosis (disability / death);

- with a value of 110 points or more, the prognosis is considered extremely unfavorable (fatal outcome).

This outcome determination scheme has not been developed for combined damage.

Clinical examples.

Example 1

A 65-year-old woman, a pensioner, suffering from a disease of the cardiovascular system (coronary heart disease).

In December, she was injured in a traffic accident as a pedestrian. An ambulance team was taken to the hospital from the scene. During the diagnosis and treatment, the hospital was diagnosed with the same diagnosis (no change on the 4th day): “Closed head injury: severe brain contusion. Bruises, abrasions of the head. Dull chest injury. Bruised lungs. Bilateral small hemopneumothorax. Closed comminuted fracture of the bones of the right tibia. Transdermal fracture of the bones of the left leg. Bruises, hematomas of the right thigh. Traumatic shock 3 tbsp. ICE. Bilateral lower lobar pneumonia. " Conducted therapeutic measures were unsuccessful and on the 9th day the patient died. During the forensic medical examination of the corpse, the following diagnosis was established: “Closed head injury. Subarachnoid hemorrhages. Fracture of the spine between the thoracic and lumbar vertebrae. Closed fragmented-comminuted fracture of the bones of the right tibia. Intra-articular fracture of the external condyle of the left tibia. Fracture of the left fibula in the upper third. Soft hemorrhage in both thighs. Bruised wound and abrasion of the face, lower extremities. Bilateral pneumonia. "

We calculate the points for this case:

1. Injured bodily injuries: multiple fractures of various bones (7 points), severe head injury (10 points), bruised lungs (7 points), traumatic shock (shock index 1.8) (20 points).

2. According to the ISS scale, the injury was assessed as extremely severe - 45 points (80 points).

3. These damages are qualified as serious harm to health (harm to health, dangerous to human life), therefore 6 points are awarded.

4. The victim at the time of the injury suffered from a disease of the cardiovascular system (3 points), in an accident she was a pedestrian (5 points).

5. Injured in the winter (1 point).

The total score was 139 points, in which the forecast is extremely unfavorable - fatal.

Example 2

A 29-year-old woman without a concomitant pathology, being a driver in March, was injured in an accident. After providing medical attention at the scene of the incident, the ambulance team was hospitalized. After examination in a hospital the diagnosis was made: “Open craniocerebral injury. Fracture of the base of the skull (middle cranial fossa on the right) is clinical. Mild brain contusion. Traumatic rupture of the eardrum on the right. An open fracture of the left thigh in the middle third with a shift. An open fracture of the distal metaepiphysis of the left tibia with displacement. Bruised wounds, abrasions of the left thigh, lower leg, foot. ” On the second day after stabilizing and applying skeletal traction, it was transferred to another health care facility for aftercare. In the last hospital, on the second day (the third day after the injury), the diagnosis was made (unchanged until discharge): “Open craniocerebral injury. Fracture of the base of the skull (middle cranial fossa on the right) is clinical. Mild brain contusion. Traumatic rupture of the eardrum on the right. An open fracture of the left thigh in the middle third with a shift. An open fracture of the distal metaepiphysis of the left tibia with displacement. Bruised wounds, abrasions of the left thigh, lower leg, foot. Fracture of 2 metatarsal bones of the left foot with displacement. " 8 days after the injury, the final fixation of bone fragments (bone MOS) was performed. Discharged on the 28th day after the injury. In the outcome of the trauma, a pseudoarthrosis of the left thigh formed, and the ITU authorities established the 2nd disability group.

We calculate the points for this case:

1. Injured injuries: multiple fractures of various bones (7 points), severe traumatic brain injury (10 points).

2. According to the ISS scale, the injury was rated as severe - 31 points (40 points).

3. These injuries are classified as causing serious damage to health according to the following criteria: danger to life (MTCT. Fracture of the base of the skull) and permanent loss of general disability by 55% (6 points).

4. According to the category of participation in traffic - the driver - 2 points.

5. Season of the accident - spring - 1 point.

The total score was 66 points, which corresponds to a conditionally unfavorable prognosis in the form of disability.

Thus, the developed method improves accuracy and optimizes the forecast estimate, creates the opportunity for the right tactics in cases of offenses; for psychological, material preparation of the victim, relatives or legal representatives for a possible adverse outcome.

The signs developed by the authors and a point assessment of risk factors for an adverse outcome of a road traffic injury are presented in Table 2.

table 2 Signs and scoring of them in cases of road traffic injuries Signs Point (s) Damage to internal organs: severe traumatic brain injury 10 bruise, lung rupture 7 bruise, rupture of the liver 17 bruise, kidney rupture 10 bruise, rupture of the urethra and bladder four bruise, rupture of the spleen 80 bruise, rupture of the intestines and mesentery 80 bruise, heart rupture 80 spinal cord injury 80 Skeleton bone fractures: multiple fractures of one bone four multiple fractures of various bones 7 skull fractures four other fractures 3 Shock index over 0.5 twenty The presence of background somatic pathology: diseases of the cardiovascular system (coronary heart disease, hypertension) 3 respiratory system diseases (severe COPD, bronchial asthma) 10 diabetes 10 cirrhosis of the liver 10 Severity of injury on the ISS scale: 1-10 points 5 11-20 points 10 21-30 points fifteen 31-40 points 40 41 or more points 80 Category of participation in traffic: a pedestrian 5 driver 2 passenger 2 Injury season: winter one Spring one summer one autumn 3 The presence of qualifying signs of serious harm to health (harm to health, dangerous to human life, significant permanent loss of general disability by 35% or more) 6

Claims (1)

A method for predicting the outcome of a road traffic injury, including ranking according to the severity score of the injury according to the ISS scale, the type of injury and the characteristics of the damage, background physical illness, the category of participation in the road traffic of the injured person, the time of the injury and the severity of the damage to health, characterized in that they are evaluated in points according to the criteria: the severity of the injury on the ISS scale, while if the severity of the injury on the ISS scale is in the range from 1 to 10, then 5 points are awarded, from 11 to 20 - 10 points, from 21 to 30 - 15 points, from 31 up to 40 - 40 points, from 41 and more - 80 points; type of injury and damage characteristics, while the presence of skull fractures corresponds to 4 points, multiple fractures of one bone - 4 points, multiple fractures of various bones - 7 points, other fractures - 3 points, damage to internal organs in the form of a severe head injury - 10 points, contusion or rupture of the lung - 7 points, contusion or rupture of the liver - 17 points, contusion or rupture of the kidney - 10 points, contusion or rupture of the urethra and bladder - 4 points, contusion or rupture of the spleen, or intestines and mesentery, or heart, or at sheba of the spinal cord - 80 points; somatic background disease, in this case, if at the time of the injury the victim suffered from a disease of the cardiovascular system, 3 points are awarded, respiratory systems - 10 points, diabetes - 10 points, cirrhosis - 10 points; categories of participation in the road traffic of the injured person, while if the injured pedestrian accrues 5 points, the driver or passenger - 2 points; the time of the injury and the severity of the damage to health, it is estimated at 3 points in case of injury in the fall, at 1 point in the winter, spring, summer, with qualifying signs of serious harm to health - at 6 points; the presence of shock of any degree and genesis is estimated at 20 points; summarize the points received, and if their total number does not exceed 24 points, then the prognosis is favorable - recovery; from 25 to 49 points - conditionally favorable prognosis - recovery or disability; from 50 to 69 points - conditionally unfavorable prognosis - disability, from 70 to 109 points - unfavorable prognosis - disability or death, from 110 points or more - extremely unfavorable prognosis - death.