ORIGINAL ARTICLE
Application of Abbreviated Injury Scale and Injury Severity Score in Fatal Cases With Abdominopelvic Injuries Nuwadatta Subedi, MD, Bishwanath Yadav, MD, and Shivendra Jha, MD Abstract: In forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management. The study was conducted with an objective to study the relationship of severity of the injuries using Abbreviated Injury Scale and Injury Severity Score (ISS) with survival period and place of death among fatal cases with abdominopelvic trauma. The total number of cases studied was 80. The injuries in all the body parts were allotted using the Abbreviated Injury Scale 2005, Update 2008, and the ISS was calculated. The male/female ratio was 4:1, and the mean (SD) age was 30.76 (15.2) years. The cause of trauma was road traffic accidents in 82.5% of the cases. The median duration of survival was 2 hours. The mean (SD) ISS was 38.90 (14.89). Abbreviated Injury Scale scores of 5 and 4 were the most common in the region. With increase in the ISS, the survival period was decreased. There was a highly significant difference between the mean ISS of the victims who died prehospital and that of who died in the emergency department (P < 0.005). The mean ISS of the victims who died in the emergency department and of those who died in the ward, intensive care unit, or after discharge was also significantly different (P < 0.05). Although the cases with more severe injuries died sooner, there should be provision of treatment on the spot without delay. More time taken to start the treatment increases the fatalities. Key Words: Abbreviated Injury Scale, abdominal injury, autopsy, Injury Severity Score, Nepal, pelvic injury (Am J Forensic Med Pathol 2014;35: 275–277)
I
n forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management. The modern scientific era of injury measurement began in 1952, when DeHaven1 proposed a rudimentary classification of human injury to facilitate his study of light plane crashes. The Abbreviated Injury Scale (AIS), which was first published in 1971, was devised by a collaborative team comprising members from the Association for the Advancement of Automotive Medicine, the Society of Automotive Engineers, and the American Medical Association. The AIS is an anatomically based, consensus-derived, global severity scoring system that classifies an individual injury by body region according to its relative severity on a 6-point scale.2 The AIS attributes a score between 1 and 6 to each individual injury ranging from 1 for minor injury to 5 for critical injury, whereas an AIS score of 6 is given for fatal injury. Since the first edition, the AIS has been revised and updated on several occasions to broaden its applicability to include other forms of trauma, including penetrating injury, electrical injury, hypothermia, burns, Manuscript received September 21, 2013; accepted July 19, 2014. From the Department of Forensic Medicine, College of Medical Sciences, Bharatpur, Chitwan, Nepal. The authors report no conflict of interest. Reprints: Nuwadatta Subedi, MD, Department of Forensic Medicine, College of Medical Sciences, Bharatpur, Chitwan 44207, Nepal. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0195-7910/14/3504–0275 DOI: 10.1097/PAF.0000000000000119
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
and smoke inhalation.3,4 The current edition of Abbreviated Injury Scale 2005, Update 2008,5 is significant in its total restructuring of injury classifications for both the upper and lower extremities and the pelvis, body regions that are significant in nonfatal longterm impairment and disability. The new classifications give researchers and investigators a tool to record injuries in these body regions with greater precision and detail. In 1974, Baker et al6 developed the concept of a whole-body score or Injury Severity Score (ISS), derived from the 3 highest individual AIS scores in different body regions. To calculate the ISS from an array of AIS scores for a patient, the 3 highest AIS scores in different body regions are squared then added together. The ISS considers the body to comprise 6 regions as follows: 1. Head/neck includes injury to the brain or cervical spine, skull, or cervical spine fractures. 2. Face includes those involving mouth, ears, nose, and facial bones. 3. Chest includes all lesions to internal organs. Chest injuries also include those to the diaphragm, rib cage, and thoracic spine. 4. Abdominal or pelvic contents include all lesions to internal organs. Lumbar spine lesions are included in the abdominal or pelvic region. 5. Extremities or pelvic girdle includes sprains, fractures, dislocations, and amputations, except for the spinal column, skull, and rib cage. 6. External (skin) includes lacerations, contusions, abrasions, and burns, independent of their location on the body surface.
Possible ISS scores range from 1 to 75. The highest score of 75 may be achieved by a patient who has a critical injury with an AIS score of 5 in 3 different body regions. In addition, any patient with an AIS score of 6 (considered unsurvivable) is automatically given an ISS of 75. The AIS has subsequently been applied to large series of traffic accidents by Bull7 as well as traffic and non–traffic accidents by Semmlow and Cone8 and to multiple traumatized patients by Moylan et al.9 The correlation of ISS with mortality rates was confirmed, and the mortality rates for identical ISS values showed a close match in these 3 publications. It is of value for research and audit and has potential applications in forensic medicine, such as its use as a tool to assist the classification and analysis of injuries sustained by those injured in mass disasters.10 In forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management, to optimally use the scarce intensive care unit (ICU) and other critical care medical facilities and to make the relatives mentally prepared to the ultimate eventuality. For this purpose, the AIS and the ISS for anatomical evaluation are widely used in both forensic and clinical medicine.11 Because of soft and yielding nature of the abdominal wall, application of even a heavy force may not cause any external wound on the abdominal wall, but the transmitted force may cause serious internal wound.12 Therefore, in case of fatalities with such injuries, severity can be underestimated. No published studies from Nepal of this kind have been found up to date so far as our knowledge. The study was conducted with an objective to study the relationship of severity of the injuries www.amjforensicmedicine.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
275
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
Subedi et al
TABLE 1. Age of the Victims Age Range, y 0–10 11–20 21–30 31–40 41–50 51–60 >60 Total
TABLE 3. AIS of the Abdominopelvic Region n (%)
AIS
Frequency (%)
5 (6.3) 16 (20.0) 28 (35.0) 12 (15.0) 6 (7.5) 11 (13.8) 2 (2.5) 80 (100)
2 3 4 5 6 Total
15 (18.8) 19 (23.8) 21 (26.2) 22 (27.5) 3 (3.8) 80 (100)
with survival period and place of death among fatal cases with abdominopelvic trauma.
MATERIALS AND METHODS Materials for the present study were collected from the medicolegal autopsies, showing abdominal and/or pelvic injuries, carried out at the mortuary of B.P. Koirala Institute of Health Sciences in Dharan during the period from April 14, 2010, to April 13, 2011. The total number of cases studied was 80. All the autopsies showing abdominal and/or pelvic injuries caused by mechanical trauma and died either on the spot or on the way to the hospital were included, whereas those bodies that were decomposed and those that did not sustain injuries to the abdominal and pelvic region were excluded from the study. In all the cases, detailed postmortem examination was done. The injuries in all the body parts were noted and allotted the AIS score as described in the Abbreviated Injury Scale 2005, Update 20085 scale book published by the Association for the Advancement of Automotive Medicine. The injuries with their respective scores were entered into a simplified chart, and the 3 highest AIS scores in the 3 among the 6 different body regions were squared and were added to obtain the ISS of the case. If the AIS score in any of the 6 body regions was 6, then the ISS was automatically scored 75. Data analysis was done using Statistical Package for the Social Sciences version 17.0. Independent sample t test was used to test the mean ISS between the different groups of fatalities. The probability of significance was set at 5% and 95% confidence limits.
RESULTS Among the 80 autopsy cases with abdominopelvic trauma, it was observed that 80% of the victims were men, whereas women comprised 20% of the cases. The minimum age was 2 years and the maximum age was 65 years, with the mean (SD) age of 30.76 (15.2) years. The age group of the victims involved is represented in Table 1. The cause of trauma is shown in Table 2, which reflects that road traffic accidents accounted to 82.5% of the cases. TABLE 2. Cause of Trauma Cause of Trauma Road traffic accident Fall from height Firearm injury Stab injury Assault by blunt weapons Total
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n (%) 66 (82.5) 5 (6.3) 4 (5.0) 4 (5.0) 1 (1.3) 80 (100)
The AIS of the abdominopelvic region is presented in Table 3. The fatalities in our study are not solely due to abdominopelvic trauma. Some of the cases had sustained minor injuries (AIS 2 in 18.8% of the cases) in the concerned region, although some died because of injuries in other body parts. Abbreviated Injury Scale scores of 5 and 4 were the most common in the region. The median duration of survival was 2 hours. A total of 61.25% deaths occurred within 3 hours. The lowest ISS was 13 and the maximum ISS was 75. The mean ISS was 38.90 with SD of 14.89, with median ISS being 38. Seven victims had an ISS of 75. Five of them died at the site of accident and 1 victim died while he was being brought to hospital, whereas the other died in the emergency department. Six victims had an ISS of 20 or less. Table 4 shows the range of duration of survival along with corresponding ISS. It is evident that, with increase in the ISS, the survival period is decreased. When the ISS was analyzed with time of survival, the mean ISS was significantly different in the groups except that for 6.01 to 24 hours and 1 to 3 days. In the present study, 30 (37.5%) were prehospital deaths, among which 17.5% were on-the-spot deaths and 20% died while they were being carried to the hospital. Thirty-nine (48.75%) of thevictims died in the emergency department and 11 (13.75%) victims died in the ward/ICU or after discharge (Table 4). In 1 case of blunt abdominal trauma with minor laceration without perforation of duodenum, conventional treatment was done, and later after discharge, she developed infection and further peritonitis when she died. Table 5 shows the ISS of the victims who died prehospital and at various places in the hospital along with their median survival period. The mean ISS of the victims who died prehospital (ie, at the scene or while they were being brought to hospital), in the emergency department, and in the operating theater, ward, or after discharge is shown in the table. Independent samples t test was used to test the mean difference of ISS of the victims who died prehospital and in different stages after admission in the hospital. There was a highly significant difference between the mean ISS of the victims who died prehospital and that of those in the TABLE 4. Duration of Survival and ISS Duration of Survival 3 d Total
n (%)
Mean ISS (SD)
P
49 (61.25) 7 (8.75) 7 (8.75) 10 (12.5) 10 (12.5) 7 (8.75) 7 (8.75) 7 (8.75) 80 (100)
44.59 (15.173) 38.86 (3.024) 38.86 (3.024) 29.90 (7.880) 29.90 (7.880) 29.86 (7.841) 29.86 (7.841) 21.00 (6.63) 38.90 (14.89)
0.023* 0.006* 0.991 0.042*
*P < 0.05.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
AIS and ISS in Fatal Abdomino-Pelvic Cases
TABLE 5. Place of Death and ISS Place of Death Prehospital Emergency Emergency Ward, ICU, or discharged
No. Cases (%)
Median Duration of Survival
Mean ISS (SD)
P
30 (37.5) 39 (48.75) 39 (48.75) 11 (13.75)
30 min 3.5 h 3.5 h 96 h
51.52 (15.165) 35.08 (9.864) 35.08 (9.864) 23.45 (8.287)
Application of Abbreviated Injury Scale and Injury Severity Score in Fatal Cases With Abdominopelvic Injuries Nuwadatta Subedi, MD, Bishwanath Yadav, MD, and Shivendra Jha, MD Abstract: In forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management. The study was conducted with an objective to study the relationship of severity of the injuries using Abbreviated Injury Scale and Injury Severity Score (ISS) with survival period and place of death among fatal cases with abdominopelvic trauma. The total number of cases studied was 80. The injuries in all the body parts were allotted using the Abbreviated Injury Scale 2005, Update 2008, and the ISS was calculated. The male/female ratio was 4:1, and the mean (SD) age was 30.76 (15.2) years. The cause of trauma was road traffic accidents in 82.5% of the cases. The median duration of survival was 2 hours. The mean (SD) ISS was 38.90 (14.89). Abbreviated Injury Scale scores of 5 and 4 were the most common in the region. With increase in the ISS, the survival period was decreased. There was a highly significant difference between the mean ISS of the victims who died prehospital and that of who died in the emergency department (P < 0.005). The mean ISS of the victims who died in the emergency department and of those who died in the ward, intensive care unit, or after discharge was also significantly different (P < 0.05). Although the cases with more severe injuries died sooner, there should be provision of treatment on the spot without delay. More time taken to start the treatment increases the fatalities. Key Words: Abbreviated Injury Scale, abdominal injury, autopsy, Injury Severity Score, Nepal, pelvic injury (Am J Forensic Med Pathol 2014;35: 275–277)
I
n forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management. The modern scientific era of injury measurement began in 1952, when DeHaven1 proposed a rudimentary classification of human injury to facilitate his study of light plane crashes. The Abbreviated Injury Scale (AIS), which was first published in 1971, was devised by a collaborative team comprising members from the Association for the Advancement of Automotive Medicine, the Society of Automotive Engineers, and the American Medical Association. The AIS is an anatomically based, consensus-derived, global severity scoring system that classifies an individual injury by body region according to its relative severity on a 6-point scale.2 The AIS attributes a score between 1 and 6 to each individual injury ranging from 1 for minor injury to 5 for critical injury, whereas an AIS score of 6 is given for fatal injury. Since the first edition, the AIS has been revised and updated on several occasions to broaden its applicability to include other forms of trauma, including penetrating injury, electrical injury, hypothermia, burns, Manuscript received September 21, 2013; accepted July 19, 2014. From the Department of Forensic Medicine, College of Medical Sciences, Bharatpur, Chitwan, Nepal. The authors report no conflict of interest. Reprints: Nuwadatta Subedi, MD, Department of Forensic Medicine, College of Medical Sciences, Bharatpur, Chitwan 44207, Nepal. E-mail: [email protected]. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0195-7910/14/3504–0275 DOI: 10.1097/PAF.0000000000000119
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
and smoke inhalation.3,4 The current edition of Abbreviated Injury Scale 2005, Update 2008,5 is significant in its total restructuring of injury classifications for both the upper and lower extremities and the pelvis, body regions that are significant in nonfatal longterm impairment and disability. The new classifications give researchers and investigators a tool to record injuries in these body regions with greater precision and detail. In 1974, Baker et al6 developed the concept of a whole-body score or Injury Severity Score (ISS), derived from the 3 highest individual AIS scores in different body regions. To calculate the ISS from an array of AIS scores for a patient, the 3 highest AIS scores in different body regions are squared then added together. The ISS considers the body to comprise 6 regions as follows: 1. Head/neck includes injury to the brain or cervical spine, skull, or cervical spine fractures. 2. Face includes those involving mouth, ears, nose, and facial bones. 3. Chest includes all lesions to internal organs. Chest injuries also include those to the diaphragm, rib cage, and thoracic spine. 4. Abdominal or pelvic contents include all lesions to internal organs. Lumbar spine lesions are included in the abdominal or pelvic region. 5. Extremities or pelvic girdle includes sprains, fractures, dislocations, and amputations, except for the spinal column, skull, and rib cage. 6. External (skin) includes lacerations, contusions, abrasions, and burns, independent of their location on the body surface.
Possible ISS scores range from 1 to 75. The highest score of 75 may be achieved by a patient who has a critical injury with an AIS score of 5 in 3 different body regions. In addition, any patient with an AIS score of 6 (considered unsurvivable) is automatically given an ISS of 75. The AIS has subsequently been applied to large series of traffic accidents by Bull7 as well as traffic and non–traffic accidents by Semmlow and Cone8 and to multiple traumatized patients by Moylan et al.9 The correlation of ISS with mortality rates was confirmed, and the mortality rates for identical ISS values showed a close match in these 3 publications. It is of value for research and audit and has potential applications in forensic medicine, such as its use as a tool to assist the classification and analysis of injuries sustained by those injured in mass disasters.10 In forensic casework, investigation of injury severity is important in evaluating the mortality, occasionally in terms of the adequacy of clinical management, to optimally use the scarce intensive care unit (ICU) and other critical care medical facilities and to make the relatives mentally prepared to the ultimate eventuality. For this purpose, the AIS and the ISS for anatomical evaluation are widely used in both forensic and clinical medicine.11 Because of soft and yielding nature of the abdominal wall, application of even a heavy force may not cause any external wound on the abdominal wall, but the transmitted force may cause serious internal wound.12 Therefore, in case of fatalities with such injuries, severity can be underestimated. No published studies from Nepal of this kind have been found up to date so far as our knowledge. The study was conducted with an objective to study the relationship of severity of the injuries www.amjforensicmedicine.com
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
275
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
Subedi et al
TABLE 1. Age of the Victims Age Range, y 0–10 11–20 21–30 31–40 41–50 51–60 >60 Total
TABLE 3. AIS of the Abdominopelvic Region n (%)
AIS
Frequency (%)
5 (6.3) 16 (20.0) 28 (35.0) 12 (15.0) 6 (7.5) 11 (13.8) 2 (2.5) 80 (100)
2 3 4 5 6 Total
15 (18.8) 19 (23.8) 21 (26.2) 22 (27.5) 3 (3.8) 80 (100)
with survival period and place of death among fatal cases with abdominopelvic trauma.
MATERIALS AND METHODS Materials for the present study were collected from the medicolegal autopsies, showing abdominal and/or pelvic injuries, carried out at the mortuary of B.P. Koirala Institute of Health Sciences in Dharan during the period from April 14, 2010, to April 13, 2011. The total number of cases studied was 80. All the autopsies showing abdominal and/or pelvic injuries caused by mechanical trauma and died either on the spot or on the way to the hospital were included, whereas those bodies that were decomposed and those that did not sustain injuries to the abdominal and pelvic region were excluded from the study. In all the cases, detailed postmortem examination was done. The injuries in all the body parts were noted and allotted the AIS score as described in the Abbreviated Injury Scale 2005, Update 20085 scale book published by the Association for the Advancement of Automotive Medicine. The injuries with their respective scores were entered into a simplified chart, and the 3 highest AIS scores in the 3 among the 6 different body regions were squared and were added to obtain the ISS of the case. If the AIS score in any of the 6 body regions was 6, then the ISS was automatically scored 75. Data analysis was done using Statistical Package for the Social Sciences version 17.0. Independent sample t test was used to test the mean ISS between the different groups of fatalities. The probability of significance was set at 5% and 95% confidence limits.
RESULTS Among the 80 autopsy cases with abdominopelvic trauma, it was observed that 80% of the victims were men, whereas women comprised 20% of the cases. The minimum age was 2 years and the maximum age was 65 years, with the mean (SD) age of 30.76 (15.2) years. The age group of the victims involved is represented in Table 1. The cause of trauma is shown in Table 2, which reflects that road traffic accidents accounted to 82.5% of the cases. TABLE 2. Cause of Trauma Cause of Trauma Road traffic accident Fall from height Firearm injury Stab injury Assault by blunt weapons Total
276
www.amjforensicmedicine.com
n (%) 66 (82.5) 5 (6.3) 4 (5.0) 4 (5.0) 1 (1.3) 80 (100)
The AIS of the abdominopelvic region is presented in Table 3. The fatalities in our study are not solely due to abdominopelvic trauma. Some of the cases had sustained minor injuries (AIS 2 in 18.8% of the cases) in the concerned region, although some died because of injuries in other body parts. Abbreviated Injury Scale scores of 5 and 4 were the most common in the region. The median duration of survival was 2 hours. A total of 61.25% deaths occurred within 3 hours. The lowest ISS was 13 and the maximum ISS was 75. The mean ISS was 38.90 with SD of 14.89, with median ISS being 38. Seven victims had an ISS of 75. Five of them died at the site of accident and 1 victim died while he was being brought to hospital, whereas the other died in the emergency department. Six victims had an ISS of 20 or less. Table 4 shows the range of duration of survival along with corresponding ISS. It is evident that, with increase in the ISS, the survival period is decreased. When the ISS was analyzed with time of survival, the mean ISS was significantly different in the groups except that for 6.01 to 24 hours and 1 to 3 days. In the present study, 30 (37.5%) were prehospital deaths, among which 17.5% were on-the-spot deaths and 20% died while they were being carried to the hospital. Thirty-nine (48.75%) of thevictims died in the emergency department and 11 (13.75%) victims died in the ward/ICU or after discharge (Table 4). In 1 case of blunt abdominal trauma with minor laceration without perforation of duodenum, conventional treatment was done, and later after discharge, she developed infection and further peritonitis when she died. Table 5 shows the ISS of the victims who died prehospital and at various places in the hospital along with their median survival period. The mean ISS of the victims who died prehospital (ie, at the scene or while they were being brought to hospital), in the emergency department, and in the operating theater, ward, or after discharge is shown in the table. Independent samples t test was used to test the mean difference of ISS of the victims who died prehospital and in different stages after admission in the hospital. There was a highly significant difference between the mean ISS of the victims who died prehospital and that of those in the TABLE 4. Duration of Survival and ISS Duration of Survival 3 d Total
n (%)
Mean ISS (SD)
P
49 (61.25) 7 (8.75) 7 (8.75) 10 (12.5) 10 (12.5) 7 (8.75) 7 (8.75) 7 (8.75) 80 (100)
44.59 (15.173) 38.86 (3.024) 38.86 (3.024) 29.90 (7.880) 29.90 (7.880) 29.86 (7.841) 29.86 (7.841) 21.00 (6.63) 38.90 (14.89)
0.023* 0.006* 0.991 0.042*
*P < 0.05.
© 2014 Lippincott Williams & Wilkins
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Am J Forensic Med Pathol • Volume 35, Number 4, December 2014
AIS and ISS in Fatal Abdomino-Pelvic Cases
TABLE 5. Place of Death and ISS Place of Death Prehospital Emergency Emergency Ward, ICU, or discharged
No. Cases (%)
Median Duration of Survival
Mean ISS (SD)
P
30 (37.5) 39 (48.75) 39 (48.75) 11 (13.75)
30 min 3.5 h 3.5 h 96 h
51.52 (15.165) 35.08 (9.864) 35.08 (9.864) 23.45 (8.287)
