wounds

  

The wounded man (Hans von Gersdorff)

Source: Wikipedia

 

Any doctor may be asked to examine a person who has been wounded, particularly in the Emergency Unit/ Trauma Unit setting.

In addition, forensic physicians and pathologists are frequently required to examine wounds in both the living and the dead.

The identification and description of wounds may have serious medico-legal implications at a later stage - often after some considerable time has passed since the wounding.

It is therefore essential that different types of wounds can be correctly identified and described, with a full description being made in notes taken at the time of, or shortly after the examination ('contemporaneous notes').

Studies have shown that doctors incorrectly identify common wounds and injuries (Jones 2003; Reijnders et al 2005; Bajanowski et al 2001), and even where they do correctly identify a wound type, they ascribe an incorrect 'mechanism' to that wound (i.e. incorrect differentiation between blunt force and sharp force injury).

In general terms (lay and medical, but not legal), 'wound' and 'injury' are used interchangeably, and are used to describe tissue damage caused by;

  

wound classification

 

There are several ways in which wounds can be classified. Surgeons, for example, may classify wounds into ‘clean’ and ‘dirty’ or ‘tidy’ and ‘untidy’ (Russell et al 2000).

'Tidy wounds' are those made by sharp instruments and contain no dead tissue, and which can be closed and allowed to heal by primary intention.

'Untidy wounds', however, such as those caused by crushing or tearing mechanisms often contain devitalised tissue that must be debrided (i.e. surgically removed) in order for healing to take place (after closing the wound or allowing it to heal by secondary intention).

It is essential in a medico-legal arena that the correct nomenclature is used to describe wounds, and the following sections will cover each of these wound types in detail.

Wounds can also be categorised by the manner of infliction, via the WHO International Classification of Disease (ICD) ‘E’ codes, such as ‘accidental’ or ‘suicidal’ (Saukko and Knight 2004). (See also ICD Chapter XIX codes for injury, poisoning and 'external causes'.)

 

trauma scoring

 

Triage 'Smart Tags'

Source: TSG Associates Ltd

 

In order to predict outcome in trauma, researchers have developed scoring systems that evaluate the severity of injury. This section will look at the main instruments that have been used.

Bull (1999) explains that the Egyptians attempted to attribute severity to different types of injuries, but it was not until the 1950’s that severity scoring was utilised. Injury severity was, for example, considered by those investigating aircraft accidents, with the aim of understanding how to prevent the most serious injuries.

 

Anatomical systems

 

The Abbreviated Injury Scale (AIS)

This scoring system was developed primarily for use in the safe design of automobiles, and surfaced in the early 1970’s. Separate codes are given for penetrating and blunt injury, and scores run from 1 to 6 - where 1 is a mild injury whilst 6 is fatal. However, the AIS does not assess the combined effects of multiple injuries - the Injury Severity Score (ISS) being a more appropriate tool in these circumstances (Chao et al 2000).

 

Organ Injury Scaling

The American Association for the Surgery of Trauma developed injury severity scores for individual organs or body structures. The resultant classification scheme is a systematic, graded anatomic description scaled from I to VI (with increasingly complex injuries encountered). A grade VI lesion, for example, is incompatible with life.

A grade III injury to the chest wall corresponds to a full thickness laceration including pleural penetration, which in turn corresponds to an AIS 2 injury. The tables for each organ were originally published individually in the Journal of Trauma, but have been compiled for ease of reference (Moore et al 1995).

 

Injury Severity Score (ISS)

Injuries are coded using AIS and divided into body ‘regions’ such as head and neck etc.

The ISS equals the sum of the 3 most seriously injured regions (squared), and a score of 16 is said to be associated with a mortality rate of 10% (Greaves et al 2001).

This system has been updated (the New Injury Severity Score (NISS) (Osler et al 1997)) to include the highest 3 scores regardless of body region, so that, for example, bilateral fractures of the femur are included separately rather than as a combined score, which would reflect injury severity more realistically in someone who had broken both legs, but had little in the way of other traumatic injuries, (and in whom the ISS would group the leg injuries together to under-score these injuries).

 

International Classification of Disease Injury Severity Score (ICISS)

This system utilises the ICD classification system, and allows the calculation of ‘Survival Risk Ratios’ (SRRs). SRRs have been calculated for different injury types, and one simply adds the SRRs detailed for the 10 worst injuries (Rutledge et al 1993).

 

Wesson’s Criteria

This is a crude calculation of the effectiveness of a trauma system based upon the proportion of ‘salvageable’ people who survive. A ‘salvageable’ patient is one who has major trauma (defined as an ISS of >15) but who does not have injuries incompatible with life (for example they must have an ISS <60) (Greaves et al 2001).

 

Physiological Scoring Systems

Glasgow Coma Scale

This scale was first introduced in the early 1970s (Teasdale and Jennett 1974), as a research tool for studying head injuries.

 

Response

Score
Best eye response (E)  
  •  

Spontaneously

4
  •  

To speech

3
  •  

To pain

2
  •  

None

1

Best Verbal response (V)

 
  •  

Orientated

5
  •  

Confused

4
  •  

Inappropriate words

3
  •  

Incomprehensible sounds

2
  •  

None

1
Best motor response (M)  
  •  

Obeys commands

6
  •  

Localises to painful stimulus

5
  •  

Withdraws from painful stimulus

4
  •  

Abnormal (spastic) flexion (decorticate)

3
  •  

Extension (decerebrate)

2
  •  

None

1
 

Children under 4 years

 

  
Best verbal response  
  •  

Smiles and follows, interacts

5
  •  

Cries consolably, inappropriate interactions

4
  •  

Cries occasionally consolably, moaning sounds

3
  •  

Irritable, inconsolable

2
  •  

No response

1
GCS scoring criteria

(Paediatric Glasgow Coma Scale)

 

Trauma Score (TS)

This system assesses 5 physiological parameters (respiratory rate, systolic blood pressure, GCS, respiratory expansion and capillary refill), which are weighted to give a score of 1-16. However, this system has been effectively superseded by the Revised Trauma Score (RTS) that uses 3 parameters (respiratory rate, GCS and systolic BP) and a multiplication or weighting factor. Survival probabilities have been calculated for each whole number RTS (Champion et al 1989). 

Unweighted versions of this system exist for rapid use in triage (Triage Revised Trauma Score and Paediatric Trauma Score (Greaves et al 2001).

 

Combined Scoring Systems

 

Trauma Score – Injury Severity Score (TRISS)

This system utilises RTS, ISS and the patient’s age, applying different weightings for blunt and penetrating trauma. Unfortunately, the system is not validated for children and because it relies on the ISS, injures to more than one limb etc are grouped together, and the score counts only the most serious injury in any body region, discounting others that may exist.

 

A Severity Characterisation of Trauma (ASCOT)

ASCOT was described by Champion et al (1990) as an improvement on TRISS, and was found to perform more reliably as a severity indicator. Like TRISS, however, it relies on the construction of a reasonably complex formula, and is probably more suited to audit study use, rather than a practical scoring system that is capable of being widely used on the ground (like GCS, for example).

 

 

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