The Abbreviated Injury Scale and its Correlation withPreventable Traumatic Accidental Deaths: A study fromSouth Delhi

R RAUTJI, MBBS DHHM MD (Forensic Med)Associate Professor, Department of Forensic Medicine, Armed Forces Medical College, Pune, India

D N BHARDWAJ, MBBS MD (Forensic Med)Additional Professor, Department of Forensic Medicine and Toxicology, AIIMS, New Delhi, India

T D DOGRA, MBBS MD (Forensic Med)Professor and Head, Department of Forensic Medicine and Toxicology, AIIMS, New Delhi, India

Correspondence: Dr (Lt Col) Ravi Rautji, Department of Forensic Medicine AFMC, Sholapur Road,Pune, 411040, India. E-mail: rautjiravi@hotmail.com

ABSTRACTAnatomic trauma scoring systems are fundamentalto trauma research. The Abbreviated Injury Scale(AIS) and its derivative, the Injury Severity Score(ISS), are the most frequently used scales.

In a prospective study, 400 autopsies of roadtraffic accident victims performed between January2002 and December 2003were coded according to theAIS and ISS methods. All the cases were classifiedinto different injury groups according to the InjurySeverity Scale. Fifty-eight cases (14.5%) wereassigned an ISS value of

Any injury coded as AIS 6 (which is consideredincompatible with life, such as penetratingbrain stem injury) automatically gives an ISSmaximum score of 75.

Interpretation of trauma deaths by autopsyremains profoundly important to trauma re-search and particularly to continuous qualityimprovement. Quality of care audits usingautopsy and clinical data have indicated that,in the United States, up to 35% of traumadeaths were preventable. (Pollock et al., 1993)Similar studies in England found that about30% of deaths were preventable. (RoyalCollege of Surgeons of England, 1988) Theresults of these studies led to the implementa-tion of trauma care systems and traumacentres. Such studies demonstrate the vitalrole of autopsy as a tool in the continuingefforts to improve the quality of traumatreatment. The regular use of trauma scoresin forensic medicine may provide a standard-ized database of autopsy findings, which wouldbe a tremendous contribution to the quality oftrauma treatment and the assessment ofpreventable death.

This paper aims to assess the use of traumascoring systems, i.e. the AIS and its derivative,the ISS, in autopsies of road traffic fatalitiesbrought to AIIMS, New Delhi and to correlateincidences of preventable death.

MATERIALS AND METHODSThe All India Institute of Medical Sciences isthe hospital where the medico-legal autopsiesof South Delhi, India, are conducted. Thepresent study was carried out on the dead

bodies of victims of road traffic fatalitiesbrought to the mortuary of AIIMS, New Delhi.These consisted of cases mainly fromDelhi anda few from the surrounding states. Cases forthe present study include only the prospectiveautopsies from January 2002 to December2003. A total of 400 cases of death due to roadtraffic accidents were studied during theabove-mentioned period. Decomposed bodies,cases with a doubtful history and cases inwhich the victim had undergone surgery butthe operative notes could not be recoveredwere excluded from the study.

Detailed information regarding the natureof the accident, the time of accident, type ofvehicle involved, category of victims, mode oftransportation to the hospital (in cases otherthan instant death), were noted down. Theinjuries reported at each autopsy wereanalyzed to determine the Abbreviated InjuryScale (AIS) score of each injured body region,and the Injury Severity Score (ISS) wascalculated using the Association for Advance-ment of Automotive Medicine (AAAM), 1990protocol. The cases were divided into groupsbased on their ISS, where the group with lessserious injuries (ISS

53.5% (n=214) of the deaths. Among thefemales the highest number of deaths wasobserved in the 31-50 years (n=24, 6%) agegroup (Figure 1).

Accident victimsPedestrians were involved in 176 (44%) cases,followed by riders of two-wheelers, totalling128 (32%) cases. Cyclists were next on the list,accounting for 32 (8%) cases, while car occu-pants accounted for 28 (7%) cases (Figure 2).

Offending vehiclesBuses/minibuses were the most commonoffending vehicles, being responsible for102 (25.5%) deaths, followed by unknownvehicles (n=76, 19%), trucks (n=74, 18.5%),cars (n=54, 13.5%) and two-wheelers (n=52,13%) (Figure 3).

Time of accidentsThe majority of accidents (n=120, 30%)occurred between 18.00hrs to 24.00hrs, fol-lowed by 28.5%, (n=114) between 12.00hrs to18.00hrs, 25% (n=100) between 06.00hrs to12.00hrs and 16.5% (n=66) cases were reportedbetween 24.00hrs to 06.00hrs.

AlcoholBlood was analyzed for the qualitative pre-sence of alcohol in 292 cases. Alcohol wasdetected in 52 (17.8%) cases.

Mode of transportationIn 140 cases (35%) the injured were trans-ported to the nearest hospital by taxi, in 44cases (11%) they were transferred by private

vehicle, in 200 cases (50%) by PCR (PoliceControl Room) vans and in 16 cases (4%) byambulance.

Time taken during transportationOut of the 298 cases transported by variousmeans to the hospitals, only 32 cases (10.74%)were able to reach the hospital in less than 15minutes; 116 cases (38.93%) took less than 30minutes, and 126 cases (42.28%) arrived in lessthan 60 minutes.

Transportation time by different vehiclesThe average time taken by a PCR van was33.86 minutes, followed by an ambulance(37 minutes) and private vehicles/taxi (45.53minutes).

Survival timeOf the total 400 cases, 102 (25.5%) died at thesite of the accident and 102 (25.5%) werealready dead on arrival at hospital or diedwithin an hour of admission. Twenty-one percent of cases died within 24 hours of theaccident, 36 cases (9%) survived for up to threedays, 38 (9.5%) cases survived for up to oneweek and 38 cases (9.5%) survived for morethan one week. Four cases (1%) survived forthree weeks before succumbing to their in-juries.

Involvement of body regionThe head and neck were the most vulnerablebody regions, involved in 302 (75.5%) cases,followed by the chest (n=180, 45%), theextremities (n=162, 40.5%) and the abdomen(n=138, 34.5%) (Figure 4).

Figure 2. Accident victims. Figure 3. Offending vehicles.

Rautji et al.: The Abbreviated Injury Scale and its Correlation with Preventable Traumatic Accidental Deaths 159

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Multiple traumas

Sixty-six per cent of the patients sufferedmultiple traumas, i.e. two ormore body regionshad severe or critical injuries. Persons with ahigher number of injured body regions had ahigher ISS. In patients who had only a singlebody region with a severe or critical injury, theISS was low.

Cause of death

Of the 400 fatalities, the major cause of deathwas head injury in 43.5% of the cases. Twentyper cent of deaths resulted from intra-thoracicor intra-abdominal haemorrhage, 6.5% fromsepsis and 30% from a combination of factors.

AIS in different body regionsOut of 302 cases of head injury, AIS 5 andabove (severe head injury) was seen in 70.2% ofcases, whereas in cases of injury to the thorax(44.4% of cases), to the abdomen (20.29%) andto the extremities, only 6.18% of the casesreported an AIS of 5 or above. An AIS of 4 orless in the various categories was present lessfrequently (Figure 5).

ISS groupingIn the present study 58 (14.5%) cases wereassigned an ISS value of

(86.67%) were found dead at the accident sceneor were dead on arrival at the hospital. Out ofthe 38 cases with an ISS between 50-74, 34cases (89.47%) were found dead at the accidentscene or were dead on arrival at the hospital,and only four cases survived until the thirdday. Out of 244 cases with an ISS between25-49, 86 cases (35.25%) survived for morethan one day and out of 58 cases with an ISS