Development Of A Scoring System For The

Veterinary Trauma Patient

Richard A. Rockar, VMD Frances S. Shofer, PhD
Kenneth S. Drobatz, DVM Department of Emergency Medicine
Department of Clinical Studies University of Pennsylvania School of Medicine
University of Pennsylvania Philadelphia, PA 19104
School of Veterinary Medicine
5900 Delancey Street Address reprint requests to:
Philadelphia, PA 19104 Richard A. Rockar, VMD
VCA Veterinary Care Animal Hospital
9901 Montgomery NE
Albuquerque, NM 87111
Phone: (505) 292-5553

An animal trauma triage (ATT) scoring system w'as devised to provi’de stratification of ve en’nary trau-
ma patient populations based upon severity ofinJury. A retrospective population o,f 1O1 trauma patients and
a prospective population of 88 patients were used to evaluate the predictive power of the ATT scoring system
for suwival seven days acer initial presentation to the emergency service. In both groups, the mean ATT
score for suwivors was signffcantly low'er than the mean ATT score for non-survivors. In a logistic regres-
sion model, the ATT score w'asfound to be a signffcant predictor of the likelihood ofsurvival seven days acer
initial presentation for both populations. Each poi’nt increase in the ATT score resulted in a 2.5-2.6 times
decreased likelihood of survival. The ATT scoring system is a usefiil o@ective classffcation scheme for pre-
dicn’ng the likelihood to suwive a traumatic incident and can serve as a prototype for severity ofi’ny’ury scor-
ing systems for the veterinary trauma patient.

Key words: trauma, trauma scoring systems, animal trauma triage scoring system

Introduction
A trauma score is a numerical characterization of
the injuries sustained by a patient from a traumatic
incident. It provides an objective means of classifi-
cation for a very heterogenous patient population. A
trauma scoring system can be used for stratification
of patient populations for clinical research and inter-
nal hospital review, or for the triage and prediction of
outcome for individual trauma patients.
Scoring systems for the human trauma patient
have been developed and refined over the last three
decades.' ' To our knowledge, a comprehensive scor-
ing system for the veterinary trauma patient has not
been described. Shores• has described the Small
Animal Coma Scale (SACS) for the grading of neuro-
logical function following cranio-cerebral trauma.
However, statistical evaluation of the SACS as a
prognostic tool has been limited to a small patient
population.• Kirby' 0 and Brasmer" have indepen-
dently recommended the triage of trauma patients
into categories of mild, moderate, severe, and cata-

THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE ° VOL. 4, NO. 2 • PAGE 77
strophic injuries. Neither has provided statistical
validation of their respective classification schemes.
The purpose of this study was to create an ani-
maI trauma triage (ATT) scoring system for compre-
hensive assessment of the veterinary trauma patient.
Using retrospective and prospective study popula-
tions generated from trauma patients at the
Veterinary Hospital of the University of
Pennsylvania, we evaluated the predictive power of
the ATT scoring system for survival 7 days beyond
presentation for emergency care following a traumat-
ic incident.
Materials and Methods
The Animal Trauma Triage Scoring System
The animal trauma triage scoring system (see
Appendix) was developed from the trauma triage
guidelines published in the veterinary literature'° "
and from the consensus recommendations of the
experienced emergency clinicians on staff. Six cate-
gories (perfusion, cardiac, respiratory, eye/ muscle/
integument, skeletal, and neurologic) are scored on a
0-3 scale (0 indicates slight or no injury, 3 indicates
severe injuries) by use of predetermined criteria list-
ed on the ATT scoring chart. If physical examination
findings met the criteria for more than one grade, the
highest of the grades was assigned. The six scores
were added together to give a total ATT score. The
highest possible ATT score was 18.
Retrospective Study
The medical records of animals presenting to the
Emergency Service of the Veterinary Hospital of the
University of Pennsylvania following a witnessed or
suspected traumatic incident for the period of
September and October 1992 were selected for
review. For inclusion in the retrospective study, the
case record had to contain a complete description of
the physical examination findings upon presenta-
tion. One author (RAR) assigned an Animal Trauma
Triage score for each patient from the recorded initial
physical examination findings. The signalment and
nature of trauma (motor vehicle, projectile, animal
interaction, fall from height, undetermined blunt
trauma, undetermined sharp trauma, or
unknown/inapparent) were recorded for each case.
Survival information (alive or died/euthanized) for
the patient seven days after presentation to the
PAGE 78 • THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE • VOL. 4, NO. 2
Emergency Service was recorded from the medical
record when known or from telephone contact with
the owner. Cases were excluded from statistical
analysis if the animal presented dead on arrival or if
information on survival was unavailable.
Prospective Study
During a five week period of August and
September 1993, all cases presenting to the
Emergency Service of the Veterinary Hospital of the
University of Pennsylvania following witnessed or
suspected traumatic incidents were included in the
prospective study and were assigned an ATT score
by the primary clinician for the case. Scores were
assigned prior to therapy, based upon physical
examination findings. The signalment and nature of
trauma were recorded for each case. Survival infor-
mation for the patient seven days after presentation
to the Emergency Service was recorded from the
medical record when known or from telephone con-
tact with the owner. Cases were excluded from sta-
tistical analysis if the animal presented dead on
arrival, if an ATT score was not assigned by the pri-
mary clinician, or if survival information was
unavailable.
Statistical Analysis
Statistical analysis was performed by one author
(FSS). ATT scores for the survivor and non-survivor
groups are expressed as the mean z the standard
error (SE). Differences in ATT scores between sur-
vivors and non-survivors were evaluated by
Student's t-test. A multiple logistic regression model
as described by Walker and Duncan' 2 and imple-
mented by the SAS LOGISTIC'° procedure was used
to identify factors independently associated with a
decreased chance of survival. Prognostic factors
evaluated included ATT score, species, age, and
weight. For all models created, both forward and
backward selection procedures were employed.
Statistical significance was defined as p < .05.
Results
Retrospective Study
Seventy-six dogs and twenty-rave cats fulfilled
the criteria for inclusion in the retrospective study.
Motor vehicle trauma was the most frequent source
of injury in dogs (n=38), followed by animal interac-
 TABLE 1
Typamof trauma suffered sy the 101 patients in the ratrospectiva study popumlation.

Species Animal Vertical Motor Projectile Other Other Unkown Total

Interaction Fall Vehicle Blunt Sharp

Ganine 15 4 38 4 12 3 0 76
feline 5 1 3 0 11 1 4 25

Prognostic Factor Regression Coefficient Probability TABLE 2

b0gi5ti0 RfigfeSS!00 /tfItl'/5I5*
Intercept -5.379 <0.0001 f0F.th9 f tf0S 0CtlV9 StUd}/. §O#-
elation of 101 patients.
ATT Score 0.966 0.0002
j\gt 0.2984 *Statistics for best fit model:
Sex 0.1782 108.4 = -2 log-likelihood (2LL)
for the model containing the
Species 0.0801
intercept only; 52.7 = 2LL for
Weight 0.5661 the final model containing the
variable ATT score.

Arr score A IT ScoYE

Figure 1 Figure 2
Frequency distribution of ATT scores for the retrospective and The observed and predicted survival rate for the retrospective
prospective study populations. and prospective study populations at 7 days after initial pre-
sentation.

THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE • VOL. 4, NO. 2 • PAGE 79
tion (n=l5) and undetermined blunt trauma (n=12)
(Tdble 1). Cats presented most often with signs of
undetermined blunt trauma (n=11). The ATT scores
for the retrospective population ranged from 0-12
(Figure 1).
The overall survival rate for the retrospective
group was 77.2%. The mean ATT score of the sur-
vivors (2.58 z 0.18) was significantly (p < 0.0001)
lower than the mean score for the non-survivors
(7.17 + 0.b4 . Of the parameters tested in a logistic
regression model, species showed a trend toward
significance, but only the ATT score was a significant
predictor of the likelihood of survival (Tdble 2). For
each increase of one point in the ATT score, the like-
lihood of surviving the traumatic incident decreased
2.6 times (Figure 2).
Prospective Study
Sixty-two dogs and twenty-six cats fulfilled the
criteria for inclusion in the prospective study. This
population was similar to the retrospective popula-
tion with regards to the distribution of type of trau-
ma (Tdble 3). ATT scores ranged from 0-14 (Figure
1 j.
Overall survival rate for the prospective popula—
tion was 85.2°ñ. Survivors of trauma had a signifi-
cantly lower mean ATT score than the non-survivors
(2.h1 0.25 vs. 8.77 z 0.98, p < 0.0001). On logis-
tic regression analysis, ATT score was again the only
significant predictor of surviving a traumatic incident
(Thble 4). Each increase of one in the ATT score
resulted in a 2.3 times decreased likelihood of sur-
viving the incident (Figure 2). The plot generated
from the prospective study for the predicted likeli-
hood to survive is shifted right of the curve generat-
ed in the retrospective study, indicating a higher sur-
vival rate for a given ATT score in the prospective
population.
discussion
The data generated from our retrospective and
prospective study populations support our hypothe-
sis that the ATT scoring system is a good predictor of
the likelihood of surviving seven days beyond pre-
sentation for emergency care following a traumatic
incident. Furthermore, an increase in ATT score cor-
responds to a decreased survival rate in both popu-
lations. In our experience, the ATT scoring system
PAGE 80 • THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE • VOL. 4, NO. 2
was a useful screening tool for the early identifica-
tion of those patients likely to die or to be euthanized
due to a poor prognosis for complete recovery. The
ATT scoring system can serve as a prototype for
severity of injury scoring systems for the veterinary
trauma patient.
The ATT scoring system was designed to utilize
information gathered from the physical examination
performed at presentation for emergency care, prior
to extensive diagnostic and therapeutic intervention.
Clinical laboratory analysis may provide more objec-
tive information about prognosis", but it may not be
immediately available to the veterinary emergency
clinician. Further investigations are warranted to see
if the predictive power of the ATT scoring system can
be increased by the addition of information generat-
ed from very specific diagnostic tests. Investigations
should be limited to those tests that are inexpensive
and rapidly performed to avoid delay in the genera-
tion of a prognostic ATT score. We attempted to limit
the subjectivity of the physical examination findings
by defining the criteria for scoring for each of the six
regions of interest. In addition, we condensed the
information into a grid that was supplied with the
admissions paperwork for easy access by the exam-
ining clinician. The clinicians found the system easy
and quick to apply once they became familiar with
the scoring criteria.
Comparing the prospective and retrospective
populations, we found a consistent trend in the
prospective population toward a higher survival rate
for a given ATT score. The author scoring the retro-
spective population (RAR) may have been conserva-
tive in the estimation of injuries from the medical
record information and derived lower ATT scores for
similar injuries than the clinicians in the prospective
study, or important physical examination informa-
tion relevant to the score may have been absent from
the record. Bias introduced by the clinician generat-
ing the score could be tested in a prospective study
by having two or more clinicians generate ATT
scores for the same patient in a blinded fashion and
evaluating for statistical differences.
For this study, we elected to include all eutha-
nized animals in our non-survivor group. We recog-
nize that this artificia1ly inflated our mortality rate
because some of these animals may have survived if
provided aggressive medical and surgical therapy.
For meaningful statistical conclusions, exclusion cri-
teria based upon an owner's reason for euthanasia or
 T/{Ie Ot tI'ZUM6 SUff8I'6€l bg ll10 gg gdti0fltS ift tht t0Sg6CtiV8 StUd}/ g0{Itlldti0fj.

Animal Vertical Motor Projectile Other Other Unkown Total

Interaction Fall Vehicle Blunt Sharp

Canine 9 6 21 3 11 10 2 62
Feline 9 4 3 0 6 2 2 26

Prognostic Factor Regression Coefficient Probability

TABLE 4
Logistic Rg resslon Analysis’
ROI th4 §£08{Ig6tiY6 StUd\ [t0gU-
Intercept -6.008 0.0001 lation of 88 patients.
ATT Score 0.8133 0.0007
Age 0.1637 *Statistics for best fit model:
Sex 0.4015 73.7 = -2 log-likelihood (2LL)
Species 0.2170 for the model containing the
intercept only; 33.3 = 2LL for
Weight 0.2048
the final model containing the
variable ATT score.

withholding of treatment would have to be applied to
the survivor as well as the non-survivor population.
This information could be gathered from a uniform
owner survey offered at the time of the animal's pre-
sentation. However, we question the practicality of
offering such a survey in the already tense emer-
gency room environment. Instead, we recommend
the judicious application of the findings of this and
future investigations.
As presented, the ATT scoring system can pro-
vide uniform initial triage of the veterinary trauma
patient. definitive outcome prediction with the ATT
scoring system will require the generation of a large
multi-institutional database for rigorous statistical
analysis. Using logistic regression analysis, weight-
ed coefficients could be applied to the six categories
of the ATR scoring system reflecting the importance
of the category for that particular outcome.
Prognostic scoring systems in human trauma medi-
cine typically focus on mortality alone' '. The veteri-
narian is often required to predict many other out-
comes as well, including permanent disability, length
of intensive care hospitalization, length of overall
hospitalization, and cost of care to the client and the
hospital. Predictive equations for each outcome of
interest could be generated from the logistic regres-
sion analysis of the proposed multi-institutional
database s .
The derived ATT score was intended to reflect
severity of injury independent of the nature of the
traumatic incident. In our limited experience, we
found the ATT scoring system to be applicable to all
forms of trauma, but a larger database is needed to
verify our experiences. Factors such as pre-existing
medical conditions, elapsed time from trauma to
emergency room presentation, and the administra-
tion of medical care prior to presentation have been
found to affect outcome in human trauma patients' 5, l6
and are worthy of further investigation in the veteri-
nary population.
In this investigation, we focused our efforts on
the creation of a veterinary trauma scoring system
that could be applied to future multi-institutional
trauma surveys. We wanted to statistically validate
the Animal Trauma Triage scoring system with a lim-
ited patient population before committing the per-
sonnel and resources required of a more exhaustive
survey of veterinary trauma populations. From our
experiences, we would like to propose recommenda-
tions for the implementation of the ATT scoring sys-

THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE • VOL. 4, NO. 2 • PAGE 81
tern in a long term multi-institutional survey. First,
we would recommend that data collection be the
shared responsibility of several collaborators at each
institution. The around-the-clock nature of trauma
presentations would place inordinate demands upon
a single investigator attempting to identify
record the information from all patients eligible for
inclusion in a long term survey. Secondly, we would
recommend the incorporation of the ATT scoring sys-
tem into the hospital record keeping software. This
would facilitate data retrieval and analysis for trau-
ma patients, as well as make use of information (sig-
nalment, time and date of presentation, attending
clinician) already recorded for each patient.
Furthermore, other outcomes such as length of hos-
pitalization and client costs would be readily avail-
able for analysis.
In conclusion, we propose the ATT scoring sys-
tem for the stratification of the veterinary population
with regard to comprehensive traumatic injury.
nauma patient stratification can be applied to clini-
cal research design, internal hospital review, and
identification of individual patients that may benefit
from aggressive medical and surgical therapy". In
clinical research, a trauma scoring system can con-
trol for the severity of injury and may highlight
patient subsets that most benefit from a novel thera-
peutic approach. Unexpected outcomes generated
from trauma scoring can serve as the focus for inter-
nal review of emergency room performance.
Documentation of the severity of patient injuries can
guide the allocation of resources and personnel to
optimize the delivery of emergency care. For the
individual patient, trauma scoring can promptly
identify those who need immediate and intensive
attention. Response to therapy can be evaluated by
monitoring for a change in the ATT score.
Trauma scoring systems can lead to inaccurate
predictions if the limitations of the system are
ignored". Predictions are reliable only if the popula-
tion under study is similar to that used to develop
and validate the scoring system. Furthermore, pop-
ulation statistics must be applied judiciously to the
individual patient' . A high ATT score suggests that
survival is improbable but not impossible. Likewise
we should not become lackadaisical in the monitor-
ing of the patient with a low ATT score upon presen-
tation.
PAGE 82 • THE JOURNAL OF VETERINARY EMERGENCY AND CRITICAL CARE • VOL. 4, NO. 2
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 Appendix
The animal trauma triage scoring system

Grade Perf\IStOI\ Cardiac Respiratory Eye/Muscle/ Skeletal Neurological

Integument
mm pink & moist Hn: C - 60-140 regular resp rate with no abrasion. laceration: weight bearing in 3 or 4 central: conscious, alert
CRT - 2 sec F - 120-2tO stridor none partial bmbs, no palpable fracture —+sl dull; interest in
thickness or joint laxity surroundings
0 rectal temp Z 37.8’C nomial sinus rhythm no abdominal component
t1tD’D to resp eye: no floorescein periph: normal spinal
ptake reflexes; purposeful
femoral pulses stzong or movement and
bounding nociception in all limbs
mini hyperemic py HR: C - 140-180 mildly † resp rate & abrasion, laceration: closed appendicular/rib fx central: conscious but
pale pink: mm tacicy F - 2tXI-260 effol some abdominal full thickness, no or any mandibular fx dull, depressed,
cofaponent 4eep tissue withdrawn
THE

CRT 0-2 sec nomial sinus rhythm or involvement single joint lanityfluxation
vPC’s < 2O/min mildly † uptcr airway inci. sacroiliac joint peripb: abnormal spinal
rect emp?37.8’C sounds eye: corneal reflexes with purposeful
(ix’p laceration/ulcer, not pelvic fx with unilateral movement md
JOUORFNAL

perforated intact SI-ilium-acetab nociception intact in all 4

femoral pulses fair limbs
single limb openfclosed fx
at or below carpusftarsus
HR: C - >180 moderntely † resp effort abrasion. laceration: multiple Grade 1 conditions central: unconscious but
v tacky P - >260 with abdom component, full thickness, deep (see above) responds to noxious
VETERINARY EMERAGNEDNCY

elbow abduction tissue involvement, stimuli

2 CRT 2-3 sec consisknt arrhythmia and arteries, nerves,
moderntely † upper muscles intact single long bone open fx pcriph: abeent purposeful
rectal Amp < 37.8"C airway sounds above carpus/tarsus with movement with intact
(lQj"Fj eye: corneal cortical bone preserved nociception in 2 or more
perforation. punctured limbs py nociGeption
detectable but poor globe or proptosis absent o ynl in 1 limb;
femoral pulses non-mandibular skull fx
kIId) dTtd/OF I&i1 tOf\0

penetration to vertebral body central: nonresponsive to

CRITICCAAL•RE

HR: C - 560 marked respiratory effort thoracic/abdo cavity fracture/luxation except ali stimuli;
F - 1t20 py coccygeal refractory seizures
CRT>3sx gasping/agonal respiration abrasion, lacerafion:
3 erratic arrhythmia or irregularly umed effort full thickness, deep multiple long bone open fx periph: absent nociception
rectal temp < 37.8"C tissue involvement, above tarsusfcarpus in 2 or more limbs; absent
VO4L,. NO

(100”Fj little or no detectable and artery, nerve, or tail or perianal

air passage muscle compromised single long bone open fx nociception
femoral pulse not above tarsusfcarpus with
deteced
2. •

loss of cortical bone

PAGE