DIFFERENT SCORING

SYSTEMS IN TRAUMA

Sharmin Jahan Quader (PGY 2)

Shahul Hameed (Mentor)
Venugopalan P P (HOD)
Emergency Medicine, MIMS, Calicut
 Objectives

ƒ Trauma scoring overview

ƒ Introduction to different trauma scoring

ƒ Limitations & advantages of systems

 Trauma Score - Overview

ƒ >50 scoring systems

ƒ Convert the severity of an injury into a

number

ƒ Common language
 Trauma Score - Overview

Three main groups of trauma scores

ƒ Anatomical

ƒ Physiological

ƒ Combined
 Anatomical

ƒ Abbreviated Injury Scale (AIS)

ƒ Injury Severity Score (ISS)

ƒ New Injury Severity Score (NISS)

ƒ Anatomic Profile (AP)

 Physiological

ƒ Revised Trauma Score (RTS)

ƒ Glasgow Coma Score (GCS)

ƒ Acute Physiology and Chronic Health

Evaluation- (APACHE)
 Combined

ƒ Trauma and Injury Severity Score - (TRISS)

ƒ International Classification of Diseases-

based ISS - (ICISS)
 Trauma Score - Overview

ƒ Limitations and advantages

ƒ No universally accepted scoring system

available
Abbreviated Injury Scale - (AIS)

ƒ Stratify victims of motor vehicle crashes

ƒ Six revisions since 1971

ƒ Injury severity values range from 1 to 6

Abbreviated Injury Scale - (AIS)

Injury - AIS score

1 - Minor 4 - Severe
2 - Moderate 5 - Critical
3 - Serious 6 - Unsurvivable
 AIS – Limitations

ƒ No comprehensive measure of severity

ƒ No linear scale

ƒ Not predicting patient outcomes or

mortality
 Injury Severity Score - ISS

ƒ Patients with multiple injuries

ƒ Each injury is assigned an Abbreviated Injury

Scale (AIS) score

*Baker et al 1974
Injury Severity Score …

ƒ Six body regions

ƒ Head, Face, Chest, Abdomen (including

Pelvis), Extremities, External

ƒ Highest AIS score - body region

 Injury Severity Score …

ƒ 3 most severely injured body regions - score

squared and added

ƒ Values - 0 to 75

ƒ Correlates mortality, morbidity, hospital stay

and other measures of severity
 Example - Injury Severity Score
Square
Region Injury Description AIS
Top 3

Head & Neck Cerebral Contusion 3 9

Face No Injury 0
Chest Flail Chest 4 16

Minor Contusion of Liver 2

Abdomen
Complex Rupture Spleen 5 25

Extremity Fractured femur 3

External No Injury 0
Injury Severity Score: 50
Limitations of Injury Severity Score

ƒ Error in AIS scoring increases ISS error

ƒ Limits total number of injuries to 3 regions

ƒ Description of patient injuries unknown

ƒ Not a triage tool

New Injury Severity Score - NISS

ƒ Modified in 1997 from ISS

ƒ “The sum of the squares of the AIS of each

of the patient’s three most severe AIS
injuries, regardless of the body region in
which they occur”

*Osler et al 1997
New Injury Severity Score …

ƒ Scores >ISS values indicate multiple injuries

ƒ Predicts survival

ƒ Easier to calculate than ISS

Limitations of New Injury Severity
Score

ƒ More accurate for penetrating injury

ƒ No account for physiological variables

 Anatomic Profile - (AP)

ƒ Anatomic scoring system

ƒ Includes all the serious injuries

ƒ Weights head and torso injuries more

Anatomic Profile…

Four categories:

ƒ A - Head and spinal cord

ƒ B - Thorax and anterior neck
ƒ C - All remaining serious injuries
ƒ D - All non-serious injuries
Anatomic Profile…

ƒ Square root of the sum of squares of the

AIS scores of all serious injuries in each
region

ƒ No injury - Zero
 Anatomic Profile – Limitations

ƒ Mathematical complexity

ƒ Modestly improves predictive performance

 Revised Trauma Score - (RTS)

ƒ Physiologic injury severity score

Components
• Glasgow Coma Scale (GCS)
• Systolic Blood Pressure (SBP)
• Respiratory Rate (RR)

*Champion 1989
Revised Trauma Score…

ƒ GCS, SBP and RR are given a coded value

ƒ Sum of the coded values

GCS + SBP + RR RTS

 RTS as triage tool – Triage Sort

12 – priority 3

11 – priority 2

10 or less – priority 1
 Revised Trauma Score

Systolic
Glasgow Respiratory
blood Coded value
coma scale rate
pressure
13- 15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
Revised Trauma Score …

ƒ Ranges 0-12

ƒ Score < 11 - transfer to trauma centre

ƒ Quality assurance and outcome prediction

Limitations of Revised Trauma Score

ƒ Not practical in field

ƒ Problems :
Intubated patients
Influence of alcohol
Drugs
The Glasgow Coma Scale - (GCS)

Sum of three coded values

ƒ Motor (1–6)
ƒ Verbal (1–5)
ƒ Eye (1–4)

*Teasdale and Jennett 1974

Glasgow Coma Scale…

Scored between 3 and 15

ƒ Worst - 3
ƒ Best - 15
 Glasgow Coma Scale

Best Eye Response Best Verbal Response Best Motor Response

1 No eye opening 1 No verbal response 1 No motor response

2 Incomprehensible
2 Eye opening to pain 2 Extension to pain
sounds

3 Eye opening to verbal

3 Inappropriate words 3 Flexion to pain
command
4 Eyes open
4 Confused 4 Withdrawal from pain
spontaneously
5 Orientated 5 Localising pain
6 Obeys Commands
Glasgow Coma Scale…

'GCS of 11' - meaningless

Break down into E3V3M5 = GCS 11

Traumatic brain injury

13 or Higher - Mild
9 to 12 - Moderate
8 or Less - Severe
Glasgow Coma Score…

ƒ Best motor component – most powerful

predictor of outcome
 Limitations of GCS

Motor response unreliable in:

ƒ Pharmacologic paralysis
ƒ Traumatic paralysis (spinal cord injuries)
 Trauma and Injury Severity
Score - (TRISS)

Anatomical and physiological measures of

injury severity:

ƒ ISS
ƒ RTS
ƒ Patient age
 TRISS – Limitations

ƒ Multiple injuries to same body region

cannot measure

ƒ Limitations of RTS , Intubated patients are

excluded
 TRISS – Limitations

ƒ Physiological data, unreliable or unavailable

ƒ Affected by degree of resuscitation

ƒ No account of pre-existing medical conditions

 International Classification of
Diseases-based ISS - (ICISS)

ƒ Anatomical injury score based on the ICD-9

codes

ƒ Uses survival risk ratios (SRRs) calculated

for each ICD-9 discharge diagnosis
 International Classification of
Diseases-based ISS

Some advantages over ISS

ƒ Allows all injuries in predictions

ƒ Injuries more accurately modeled
ƒ Information about all injuries
 ICISS – Limitations

ƒ ICD-9 code varies from hospital to hospital

ƒ Ignores physiological data

 ICISS – Limitations

ƒ Computational software is needed for

calculations and predictions

ƒ Claimed improvement of ICISS over ISS is

not unique
PEDIATRICS
A Very Special Population…….
 Glasgow Paediatric Coma Score
Best Eye Response Best Verbal Response Best Motor Response
1.No eye opening. 1.No vocal response 1.No motor response
2. Eye opening to 2.Inconsolable, agitated 2.Extension to pain
pain
3. Eye opening to 3.Inconsistently 3.Flexion to pain
verbal command consolable, moaning.
4. Eyes open 4.Cries but is consolable, 4.Withdrawal from pain
spontaneously inappropriate
interactions.
5.Smiles, oriented to 5.Localising pain
sounds, follows objects,
interacts
6.Obeys Commands
 Glasgow Infant Coma Score
Best Eye Response Best Verbal Response Best Motor Response

1.No eye opening. 1.Coos, babbles 1.No motor response

2. Eye opening to 2.Irritable cry, consolable 2.Extension to pain
pain
3. Eye opening to 3.Cries persistently to 3.Flexion to pain
verbal command pain
4. Eyes open 4.Moans to pain 4.Withdrawal from
spontaneously pain

5.No response 5.Localising pain

6.Obeys Commands
 Pediatric Trauma Score
+2 +1 -1
Size >20 10-20 <10
(Kg)
• Score +12 to -4
SBP >90 50-90 <50 • 0% mortality ≥ 8
• 45% = 2
Airway Normal Maintainable Unmaintainable
• 100% = 0
CNS Awake Obtunded Comatose • Transfer to
pediatric trauma
Open None Minor Major
Wound center if PTS <8
Skeletal None Closed Open
In MIMS ED………..
 Conclusion

ƒ Despite imperfections, trauma scoring

remains important

ƒ Existing severity scores are being used for

which they are not intended
 Conclusion

ƒ Scoring systems in ICU not useful for

individual patient

ƒ Continued research will improve

methodology and accurate prediction on
individual patient basis
 References

• http.//www.ATLS.org
• http.//www.ITLS.org
• http://www.jhsph.edu/Research/Centers/CIRP/ The Johns
Hopkins Center for Injury Research & Policy
• http://www.trauma.org/A British web-based trauma
resource center
• http://www.trauma.org/scores/rtscalc.html/Revised