Injury, Int. J.

Care Injured 43 (2012) 127128

Contents lists available at SciVerse ScienceDirect

Injury
journal homepage: www.elsevier.com/locate/injury

Editorial

Classication of patients with multiple injuriesIs the polytrauma patient dened

adequately in 2012?

The face of trauma in Europe continues to be mainly

represented by patients with blunt injuries. Even in 2012,
multiply injured patients are usually younger and male gender
is prevailing. Scoring of these patients is an important factor for
clinicians and for reimbursement of care. Anatomic scoring
systems continue to be used as gold standard. Despite well
described shortcomings, the abbreviated injury scale and the
injury severity score continue to be the most relevant scales to
assess injury severity. However, since the initial descriptions of
the AIS/ISS, there have been signicant developments in trauma
management techniques, both in the preventive and acute-care
phases of trauma management.1 Since the development of the
score, mortality rates dropped from 30% and more to less than
15%. Regardless, major trauma is still dened using an Injury
Severity Score (ISS) threshold of 16.2,3
The requirements to dene severe injuries have been described
before and are still valid:
Like scoring systems, they should full accuracy, reliability and
specicity. Then, these scoring systems serve various useful
purposes as follows (modied according to 4):
 The ability to predict outcome from trauma: mortality prediction
is perhaps the most fundamental use of injury severity scoring,
followed by other outcome measures.
 Comparison of therapeutic modalities.
 Pre and inter hospital triage tool.
 Tool for quality improvement and prevention programme.
 Tool for trauma research.
AIS has been modied 6 times the most notable being 1985 (AIS
85) and 1990 revisions (AIS-90). Likewise, ISS has been the
standard for injury scoring for many years with some challenges
and modications.
AIS/ISS does not reect the physiological course after injury,
which can be very dynamic in nature and it is capable to inuence
the outcome profoundly. The TRISS methodology was widely used
but is not adequate for the denition of polytrauma. This
methodology provided improvement in the ability to predict
outcome, mortality in particular after a trauma, and gained
popularity. However, certain limitations apply as well. Some
authors have addressed the issue that underscoring occurs for
extreme injuries.35 The development of the NISS was thought to
represent a major improvement. Lavoie described that the NISS is a

00201383/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.12.014

better choice for case mix control in trauma research than the ISS
for predicting ICU admission and LOS, particularly among patients
with moderate to severe head injuries but has not become routine
use.57
Then, the American College of Surgeon Committee on Trauma
proposed ASCOT (A Severity Characterisation of Trauma) to predict
outcome. It incorporates AIS injury descriptions, age, and
physiologic data into a single score. This method appeared to be
too complex for routine clinical use.
Others proposed to use the International Classication of
Diseases, and found it to address some of the deciencies of the ISS
but no widespread use occurred either.
The latest addition to the existing scoring systems-The HARM
(Harborview Assessment of Risk of Mortality) was proposed by
AlWest et al. in 2000. This system is also based on ICD-9 CM codes
making utilisation of already available hospital data for this
purpose.
Depending on the system, reimbursement for trauma has
changed in many ways. When diagnosis related groups are applied
only, the DRG thought to be relevant for multiple injured patients
in fact does not apply at all times. This is particularly true for many
patients are graded in DRGs associated with long term ventilation
rather than those developed for multiple injuries.8,9 Therefore,
several practical reasons exist to revisit the idea of a denition of
polytrauma. It will be a multinational challenge to address this
issue.

References
1. Pfeifer R, Tarkin IS, Rocos B, Pape HC. Patterns of mortality and causes of death in
polytrauma patientshas anything changed? Injury 2009;40(9):90711.
2. Tamim H, Al Hazzouri AZ, Mahfoud Z, Atoui M, El-Chemaly S. The injury
severity score or the new injury severity score for predicting mortality,
intensive care unit admission and length of hospital stay: experience from
a university hospital in a developing country. Injury 2008;39(1):11520
[Epub 2007 Sep 18].
3. Harwood PJ, Giannoudis PV, Probst C, Van Griensven M, Krettek C, Pape HC.
Polytrauma study group of the german trauma society. Which AIS based scoring
system is the best predictor of outcome in orthopaedic blunt trauma patients? J
Trauma 2006;60(2):33440.
4. Chawda MN, Hildebrand F, Pape HC, Giannoudis PV. Predicting outcome after
multiple trauma: which scoring system? Injury 2004;35(4):34758.
5. Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The injury severity score or
the new injury severity score for predicting intensive care unit admission and
hospital length of stay? Injury 2005;36(April (4)):83477.
6. Butcher N, Balogh ZJ. AIS>2 in at least two body regions: a potential new
anatomical denition of polytrauma. Injury 2011;(July).

128

Editorial / Injury, Int. J. Care Injured 43 (2012) 127128

7. Butcher N, Balogh ZJ. The denition of polytrauma: the need for international
consensus. Injury 2009;40(November S1222 (Suppl 4).
8. Flohe S, Buschmann C, Nabring J, Merguet P, Luetkes P, Lefering R, Nast-Kolb D,
Ruchholtz S. Denition of polytrauma in the German DRG system 2006. Up to
30% incorrect classications. Unfallchirurg 2007;110(7):6518.
9. Qvick B, Buehren V, Woltmann A. Is polytrauma affordable these days?: G-DRG
system vs per diem charge based on 1,030 patients with multiple injuries.
Unfallchirurg 2011;(February).

H.C. Pape*
University of Aachen Medical Center, Department of Orthopaedic
Trauma, 30 Pauwels street, 52074 Aachen, Germany
*Tel.: +49 241 8089350; fax: +49 241 8082415
E-mail address: hpape@ukaachen.de (H.C. Pape)