[The value of subjective estimation of the severity of thoracic injuries by the emergency surgeon].
OBJECTIVE
Thorax trauma (TT) is associated with a high rate of pulmonary failure and increased mortality. To prevent these complications, the German trauma system recommends intubation and chest tube insertion at the scene of the accident, even in cases without acute respiratory dysfunction. Due to the possible life threatening complications of the therapy, the emergency surgeon should be able to correctly identify a TT at the scene. Therefore, we retrospectively compared the evaluation of chest trauma by the emergency surgeon with objective injury severity according to the Abbreviated Injury Scale (AIS).


METHODS
Data from 2,392 patients (aged 39+/-1 years, Injury Severity Score 27+/-0.3) were taken from the multiple trauma database of the German Trauma Society. The evaluation of TT (absent, light, medium, severe) by the emergency surgeon was compared with objective injury severity (AIS=0: absent, 0>AIS<3: light, AIS=3: medium, AIS>3: severe). If the difference between the subjective and objective injury severity increased or decreased two and more levels, a substantial misclassification was assumed. The influence of the estimate on outcome was tested by comparing the predicted (TRISS-method) with the observed fatalities.


RESULTS
Absence of TT was estimated correctly in 62%, light in 24%, medium in 40% and severe TT in 46% of cases. Thus a correct estimate of TT was made for 49% of the patients. The chest injury severity was substantially overrated by the emergency surgeon in 20% and substantially underestimated in 17% of cases. In patients with the correct classification at the scene, a total of 81% received a chest tube. Of these patients, only 50% received their chest tube at the scene. Of the patients with an initially overlooked TT, only 37% received a chest tube and nearly all were placed in the emergency room. The number of fatalities was lower than predicted in all groups, even in patients with correctly estimated severe TT (observed: 34%, estimated: 42+/-2%), and also in patients with initially overlooked TT (observed: 16%, estimated: 24+/-2%).


CONCLUSIONS
Due to the high rate of misclassification and possible severe complications caused by therapy, and without having any benefit in terms of outcome, intubation and chest tube insertion should not be carried out in vital, stable patients.
Aufmkolk
M
M
Klinik und Poliklinik für Unfallchirurgie, Universitätsklinik Essen, Essen. michael.aufmkolk@uni-essen.de
Ruchholtz
S
S
Hering
M
M
Waydhas
C
C
Nast-Kolb
D
D
D000328:Adult; D003937:Diagnosis, Differential; D004630:Emergencies; D004632:Emergency Medical Services; D005260:Female; D006801:Humans; D007442:Intubation, Intratracheal; D008297:Male; D009104:Multiple Trauma / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D012720:Severity of Illness Index; D013898:Thoracic Injuries / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D015599:Trauma Severity Indices; D014194:Traumatology; D016896:Treatment Outcome