Assessing the severity of trauma and the quality of trauma care

Abstract

Despite major technological and therapeutic advances, in developed countries trauma remains the leading cause of death in patients younger than 30 years of age [1]. In these subjects, mortality shows a trimodal distribution: roughly 50% of patients die within 1 h after the accident due to injuries incompatible with life; preventive measures (i.e., implementation of speed limits, airbags etc.) appear to be the only way to reduce this burden. Another 30% of subjects die within 3–4 h after the trauma: it is likely that the outcome of many of them could have been different with a better triage or a more rapid transfer to specialized centers (so-called regionalization). The remaining patients die in the Intensive Care Units (ICU) days or weeks after the trauma, mainly due to the consequences of head injuries, infection or multiple organ dysfunction syndrome (MODS). Independent of the clinical course, the final outcome of patients in the two latter groups is likely influenced by two different, interacting categories of factors. The first is represented by direct consequences of the injuries, which can be heavily influenced, in various ways, by the quality of care either in the prehospital or in the hospital phase. Good example of the potential effects of trauma care are the reduction of the incidence and severity of secondary brain injury [2], or the early achievement of proposed resuscitation goals [3]. Conversely, the second category of factors cannot be affected by the quality of care, and includes the victim’s age and the presence of coexisting disease [4]. Thus, since outcome relies upon multiple factors acting in different time frames, it appears that: a) any consideration of the probability of survival and/or of the quality of care must be based on careful assessment of the trauma-induced anatomic and physiologic alterations and the preexisting organ functional reserve; b) the quality of treatment must be assessed using a methodologic approach aimed at reducing as much as possible any subjective bias of judgement.