Emergency Medicine (1999) 11, 155–166

Review Article

Trauma scoring systems explained

Mohammed Hassan Fani-Salek,1 Vicken Y Totten1 and Stephanie A Terezakis2
1Academic Emergency Medicine, Catholic Medical Center of Brooklyn and Queens, Jamaica,

New York and 2Yale University, New Haven, Connecticut, United States of America

Abstract
Objective: To list, describe and classify the extant trauma scoring systems found in the English
language literature from the vantage of utility to emergency medicine. Each system is
illustrated by a table and a hypothetical case study.
Data Sources: Medline citations provided the data. The systems are classified as physiological,
anatomical and combined trauma scoring systems.
Results: We reviewed the Glasgow Coma Scale, the Paediatric Glasgow Coma Scale, the Trauma
Score and Revised Trauma Score, the Circulation, Respiration, Abdominal/Thoracic,
Motor and Speech Scale, the Acute Physiology and Chronic Health Evaluation System,
Abbreviated Injury Scale, the Injury Severity Score, the Anatomical Profile, A Severity
Characterization of Trauma, Revised Trauma Score and Injury Severity Score and its
revisions, the Paediatric Trauma Score and the Drug-Rock Injury Severity Score.
Conclusions: This compendium should help emergency physicians become familiar with trauma
scoring systems which evaluate the extent and severity of injuries, facilitate inter-
institutional comparisons and facilitate trauma research.
Key words: injury, trauma, trauma scoring.

Introduction designated trauma centres are required to report their

Trauma scoring systems have played a pivotal role in
the evolution of trauma care over the past 20 years, yet
they remain poorly understood by many emergency
physicians.1–5 Trauma documentation facilitates com-
parisons of patient care and outcomes from different
centres and even across national borders. Trauma
scores also quantify the severity and extent of an
injury and, thus, help predict the probability of
survival and subsequent morbidity.1,6–10 In the USA, all
data to their State database. Some States require the
original data, others request the calculated scores.
Trauma scores are mathematical models, useful in
predicting the probability of survival of a cohort;
however, most are not as effective at predicting the
quality of life for survivors.11–13 Surgeons use trauma
scores to refine trauma care and public health officials
use the data to improve prehospital systems.2,5,14,15
None of the extant systems includes a mechanism of
injury among the predictors of survival. Public health

Correspondence: Dr Vicken Y Totten, Academic Emergency Medicine 3F, Catholic Medical Center of Brooklyn and Queens, 88–25 153d
Street, Jamaica, New York 11432, United States of America. Email: <totten@erols.com>
MH Fani-Salek, MD, Gynaecology Resident; VY Totten, MD, MS, Director for Education and Research in Emergency Medicine; SA Terezakis,
Medical Student.
 MH Fani-Salek et al.
List of abbreviations:
AIS Abbreviated Injury Scale
AP Anatomical Profile
APACHE Acute Physiology and Chronic Health Evaluation
ASCOT A Severity Characterization of Trauma
CRAMS Circulation, Respiratory, Abdominal/Thoracic,
Motor and Speech Scale
DRISS Drug-Rock Injury Severity Score
ED Emergency Department
EM Emergency Medicine
EMS Emergency Medical Service
GCS Glasgow Coma Scale
officials and emergency physicians who are interested
in injury reduction would find this added datum very
useful for guiding injury-prevention efforts. Emergency
medicine now has the opportunity to begin to collect
that data in an easily retrievable form through the
e-code system. Emergency medicine could make an
important contribution to trauma prevention by
making capture of the mechanism of injury routine,
‘e-coding’ the data and submitting it to extant trauma
databases.
This paper reviews existing trauma scoring
systems for the use of the emergency physician. Each
system is presented as a table or figure for easy
reference. After reviewing extant trauma scoring
systems, we score an illustrative Case Example.
Background
The first trauma systems were developed for battlefield
triage, primarily for victims of penetrating trauma. As
more sophisticated trauma systems were introduced
into civilian life in the late 1960s, they were used to
predict outcomes for victims of blunt trauma. By the
early 1970s, pooled data from various trauma severity
scores, coupled with outcomes data, argued for the
stratification of trauma receiving centres.4,16 Currently,
all US trauma centres submit their patient data to a
sizeable database located at the Trauma Registry
Center in Atlanta, Georgia, USA; this allows for the
comparison and study of trauma patients from
different settings.4 These data have helped policy
makers identify the problems associated with various
trauma systems.
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ISS Injury Severity Score
LOC Level of Consciousness
PGCS Paediatric Glasgow Coma Scale
Ps Probability of Survival
PTS Paediatric Trauma Score
RR Respiratory Rate
RTS Revised Trauma Score
SBP Systolic Blood Pressure
SICU Surgical Intensive Care Unit
TRISS Revised Trauma Score and Injury Severity Score
Trauma systems classifications
Trauma scoring systems can be classified into
physiological, anatomical and combined systems.5
Physiological scoring systems measure the physical
changes induced by trauma. They tend to focus on
neurological, haematological and respiratory
abnormalities, and are strong predictors of mortality.
Most physiological scoring systems fail to recognize
the importance of site-of-injury on subsequent
disability.17 These scoring systems provide the most
accurate data on functional status and functional
outcome, and are especially valuable in triaging a
patient to the appropriate level of care.2,7,16,18,19
Anatomical scoring systems characterize the degree
of anatomical disruption weighted by the importance
of the site of injury. They clearly delineate anatomical
damage but fail to elucidate organ system
derangements.
The combined systems attempt to overcome the
limitations of the pure anatomical or physiological
systems by incorporating elements from both.
Combined systems are superior to either anatomical or
physiological systems as predictors of survival.
However, combined systems are more comprehensive
and thus are also more cumbersome. Therefore,
combined systems are usually scored in an in-patient
setting, after initial stabilization and treatment of the
trauma patient.1,20,21
Physiological trauma severity scoring systems
The physiological trauma severity scoring systems
found by searching the English language literature
were: (i) the Glasgow Coma Scale (GCS); (ii) the Trauma
 Trauma scoring systems

Score and Revised Trauma Score (RTS); (iii) the
Circulation, Respiration, Abdominal/Thoracic, Motor
and Speech Scale (CRAMS); and the various
incarnations of (iv) the Acute Physiology and Chronic
Health Evaluation (APACHE) scale.
Glasgow Coma Scale
The Glasgow Coma Scale (GCS) (Table 1) was
developed to standardize assessments of a patient’s
level of consciousness (LOC). The GCS has virtually
eliminated discrepant descriptions of LOC. Only three
behavioural elements are evaluated: (i) motor;
(ii) verbal; and (iii) eye opening. This makes GCS easy
to use, even in the prehospital setting. The GCS can
assess the depth and predict the duration of coma. The
GCS can be used to follow changes to LOC over
time.22,23 Although the introduction of the GCS was an
improvement over previous measurements of LOC, the
GCS has limited predictive power for mortality.24 The
GCS has been modified for use with children,
producing the Paediatric Glasgow Coma Scale (PGCS)
for use with preverbal children (Table 2). Only the
verbal response subscale is different.
Since its introduction in 1974, the GCS has
undergone only one minor change.5 In 1976, the scale’s
original developers increased the motor response
portion of the scale from five to six categories. This
increased the total possible number of points from 14
to 15. A higher score indicates a better prognosis. The
minimum score is 3 (deep coma or death) and the
maximum score is 15 (no neurological deficit).
One significant limitation of the GCS is that it is
ordinal but not interval. On an ordinal scale, the
difference between unit values is not consistent and
only compares better with worse. Because the GCS is
ordinal, it is difficult to compare a group with a score of
10 with a group with a score of 12.25
The GCS is simple to apply. It is used by most
emergency medical services systems in the field, by a
great number of emergency department (ED) triage
nurses to determine urgency of care, by emergency
physicians to document serial neurological
examinations and has been incorporated into the
American College of Surgeon’s Advanced Trauma Life
Support (ATLS) course. Additionally, a number of
other scoring systems have incorporated the GCS or a
mathematical transformation of the GCS score in their
trauma scoring systems. As such, one could argue that
the GCS is the most useful of the trauma scoring
systems.
The Trauma Score and the Revised Trauma Score
In 1981, in response to the limitations of the GCS, four
additional elements were added to the GCS to create the
Trauma Score.26 Of the initial four elements
(respiratory rate, RR; systolic blood pressure, SBP;

Table 2. Paediatric Glasgow Coma Scale

Table 1. Glasgow Coma Scale
Variable Score
Variable Score
1. Eye opening
1. Eye opening Spontaneous 4
Spontaneous 4 To voice 3
To voice 3 To pain 2
To pain 2 None 1
None 1 2. Verbal response
2. Verbal response Appropriate words or social smiles, 5
Oriented 5 fixes on and follows objects
Confused 4 Cries but is consolable 4
Inappropriate words 3 Persistently irritable 3
Incomprehensible sound 2 Restless, agitated 2
None 1 Silent 1
3. Motor response 3. Motor response
Obeys commands 6 Obeys commands 6
Localizes pain 5 Localizes pain 5
Withdraw (pain) 4 Withdraw (pain) 4
Flexion (pain) 3 Flexion (pain) 3
Extension (pain) 2 Extension (pain) 2
None 1 None 1

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 MH Fani-Salek et al.

degree of respiratory expansion; capillary refill), the
latter two proved too difficult to evaluate in the field
and were removed from the Trauma Score.27 The
resultant Revised Trauma Score (RTS) (Table 3) adds
only two elements to the GCS.
The RTS is highly sensitive and a strong predictor
of survival. The RTS effectively incorporates the
severity of head injury as a predictor of mortality and
is easy to use in the field, even before full knowledge of
patients’ injured organs.12,28 The RTS’ developers claim
that an RTS of 12 suggests the need for triage to a
major trauma centre; however, others have criticized
this cut-off as overly conservative.6,13,25,27
The RTS is more cumbersome to calculate than the
GCS (which it incorporates). To begin the calculation,
the GCS is converted from a simple 3–15 summation to
a 4–0 score. Next, the physiological parameters of RR
and SBP are fitted into specified ranges (each range
has a score). Scores can range from 0 to 12, with a
higher score suggesting a more stable patient.
The RTS can be used to predict the probability of
survival. In order to calculate the probability of
survival, each subscore is multiplied by a weighting
factor, then the weighted scores are summed to produce
a cohort probability of survival (Table 3).23,27 The
weighting factors for each subgroup were derived by
regression analysis of outcome data in a major North
American database, the Major Trauma Outcome
study.14
Circulation, Respiration, Abdominal/Thoracic, Motor and Speech
Scale
The Circulation, Respiration, Abdominal/Thoracic,
Motor and Speech Scale is a simple and widely applic-
able physiological trauma scoring system (Table 4).29
The CRAMS scores five easily observable physiological
parameters (circulation, respiration, trauma to the
trunk, motor and speech) on a 0–2 scale. A score of 0
indicates severe injury or absence of the parameter; a
score of greater than 2 indicates no deficit. Thus, the
total possible score ranges from zero (for a corpse) to 10
(for an uninjured person). Incorporating zero as the
score for death makes CRAMS more intuitive than the
GCS, in which even a corpse can score greater than 3. A
CRAMS score of 8 or less indicates major trauma, while
a score of 9 or 10 indicates minor trauma. The CRAMS
distinguishes between major and minor trauma and can
be used to prevent over-triage to trauma centres.
Although reliable for field triage, CRAMS is limited in
its ability to predict the need for surgery.30
Acute Physiology and Chronic Health Evaluation System
The Acute Physiology and Chronic Health Evaluation
(Table 5) was developed in 1981 to measure injury

Table 4. Circulation, Respiration, Abdominal/Thoracic, Motor and

Speech Scale (CRAMS)
Table 3. Revised Trauma Score*
Component Score
Score Weight
Circulation
Respiratory rate (/min) 0.2908 Normal capillary refill and BP > 100 mmHg 2
10–29 4 Delayed capillary refill or 85 < BP < 100 mmHg 1
> 29 3 No capillary refill or BP < 85 mmHg 0
6–9 2 Respiration
1–5 1 Normal 2
0 0 Abnormal (laboured or shallow) 1
Systolic blood pressure (mmHg) 0.7236 Absent 0
> 89 4 Abdomen/thorax
76–89 3 Abdomen and thorax non-tender 2
50–75 2 Abdomen and thorax tender 1
1–49 1 Abdomen rigid, flail chest, or penetrating trauma 0
0 0 Motor
Glasgow Coma Scale score 0.9368 Normal 2
13–15 4 Responds only to pain (other than decerebrate) 1
9–12 3 No response (or decerebrate) 0
6–8 2 Speech
4–5 1 Normal 2
3 0 Confused 1
*Score = value × weight. No intelligible words 0

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 Trauma scoring systems

severity in surgical intensive care unit (SICU) patients.9 can range from 0 to 71, no score above 55 has ever been
The APACHE I was designed to be scored within the reported.10
first 24 h of SICU admission and is too cumbersome for APACHE II has been validated and has an interval,
most emergency department (ED) use. However, in linear relationship between score and mortality.31
1981 it represented an advance in predicting injury out- APACHE II facilitates hospital mortality ranking by
comes because it was the first system to take pre-injury the severity of disease.32 APACHE II scores can be
health status into account.5,10,15,23 The APACHE I used to compare different treatments and their
evaluated 34 physiological elements, with ‘normal’ subsequent outcomes for similar injuries. The main
being assigned to the lowest scores. Unfortunately, limitation of the APACHE system is its lack of an
APACHE I proved too complex and was abandoned. anatomical component and, therefore, its limited
accuracy in otherwise healthy patients. APACHE is
In 1985, the APACHE II modification was publish-
poorly correlated with length of hospital stay.32
ed.31 APACHE II retained 12 of the original 34 physio-
In 1990, a comparison of the index SICU patient to
logical elements from APACHE I, scoring these
the national norm was added to APACHE II to create
physiological elements from 0 (normal) to 4 (severely APACHE III.33 The value of APACHE III, as compared
abnormal), and added two additional elements9,31 The with its predecessors, is yet to be proven.
inverse of the GCS, an additional element, serves as the
neurological subscore. The other additional element,
Anatomical scores
age, contributes one point per decade of age over
45 years, to a maximum of 6 points. Chronic health Anatomical scoring systems characterize anatomical
status can contribute a maximum of 5 points. Elective derangement, weighted by the importance of the site of
postoperative patients receive 2 points, emergency injury. Examples in the English language literature
admissions with chronic organ dysfunction are given were the Abbreviated Injury Scale (AIS), Injury
the score of 5. Although, theoretically, the total score Severity Score (ISS) and the Anatomical Profile (AP).

Table 5. Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system

The 12 physiological High abnormal Low abnormal

variables range range
+4 +3 +2 +1 0 +1 +2 +3 +4
Rectal temperature (°C) > 41 39–40.9 38.5–38.9 36–38.4 34–35.9 32–33.9 30–31.9 < 30
Mean arterial pressure (mmHg) > 160 130–159 110–129 70–109 50–69 < 50
Heart rate (/min) > 179 140–179 110–139 70–109 55–69 40–54 < 40
Respiratory rate (/min) > 49 35–49 25–34 12–24 10–11 16–9 <6
Oxygenation:
A: a DO 2 if FiO 2 > 50% > 499 350–499 200–349 < 200 PaO 2 PaO 2 PaO 2 PaO 2
PaO 2 if Fio 2 < 50% > 70 61–70 55–60 < 55
Arterial pH 7.25–7.32 7.15–7.24 < 7.15
Serum sodium (mmol/L) > 179 160–179 155–159 150–154 130–149 120–129 111–119 < 111
Serum potassium (mmol/L) >7 6–6.9 5.5–5.9 3.5–5.4 3–3.4 2.5–2.9 < 2.5
Serum creatinine (mg/100 mL)* > 3.4 2–3.4 1.5–1.9 0.6–1.4 < 0.6
Haematocrit (%) > 59.9 50–59.9 46–49.9 30–45.9 20–29.9 < 20
White blood count (total/mm3) × 103 > 39.9 20–39.9 15–19.9 3–14.9 1–2.9 <1
Serum bicarbonate (mmol/L) > 51.9 41–51.9 32–31.9 18–21.9 15–17.9 < 15

Points 0 2 3 5 6
Age score < 45 45–54 55–64 65–74 > 74 = –––––––––––
Neurological score .................................................................................................................................................................................................................... 15 GCS = –––––––––––
Chronic health score .................................................................................................................................................................................................................................... = –––––––––––
Physiological score (see above) ....................................................................................................................................................................................................... = –––––––––––

*Double points for renal failure.

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 MH Fani-Salek et al.

Abbreviated Injury Scale Injury Severity Score

The AIS (Table 6) was developed in 1971 to evaluate The ISS (Fig. 1) is the most widely used anatomical
blunt trauma.20,23,24 Using AIS, each separate injury scoring system in the world.23 It was first introduced in
suffered by the patient is assigned a value from 1 1974 as a method of comparing outcomes of patients
(minor) to 5 (critical).20,24 The weights are found in the with multiple injuries.12,35 Like the AIS, the ISS is not a
AIS Dictionary Manual, which is a compendium of quick score to calculate, because each injury must be
over 1200 injuries.19 A score of > 5 is reserved for fatal coded by the AIS system. However, the subsequent
injuries. The AIS is cumbersome to use during the calculations are simple.36 The ISS correlates well with
initial management of a trauma victim, because each mortality and outcome.12
individual injury must be looked up in the AIS The ISS score consists of the squared and summed
Dictionary Manual. AIS scores of the most severe injury in three of six
Since its introduction, the AIS has been revised six body regions (Fig. 1). The maximum possible score is
times20,34 and the current version includes a wider 25 + 25 + 25 = 75 and all fatal injuries are accorded a
range of injuries and has become more specific than score of 75. Patients with ISS scores of 16 or greater
earlier versions.34 Values for penetrating injuries have should be cared for in a major trauma centre.23
been added. The AIS correlates well with the degree of The ISS is comprehensive and has good predictive
injury, however, it suffers as a prognostic tool because power. Its disadvantages are that, at an early point in
it does not take physiological derangements or chronic the care of the trauma victim, the nature of some
health status into account.5 injuries has not yet been determined fully. Also, the ISS
does not account for patient age or chronic medical
status. Multiple injuries to the same body area are not
weighted higher than a single injury to that area; for
example, a patient with a combination of massive liver,
spleen and bowel injuries is scored the same as if that
Table 6. Abbreviated Injury Scale patient had any one of these injuries alone.
Furthermore, the severity of head injuries is under-
Type of injury Score
weighted, compared with other somatic injuries.5
Minor 1
Moderate 2 The Anatomical Profile
Severe but not life-threatening 3 The AP (Fig. 2) was developed in response to the
Severe, life-threatening, survival probable 4 limitations of the ISS.35,37 The AP classifies injuries by
Critical, survival uncertain 5 regional anatomical values into only four categories,
Not survivable 6 but assesses every region separately. This increases the

ISS body regions

1. Head and neck
2. Face
3. Chest
4. Abdominal and pelvic contents
5. Extremities and pelvis
6. General/skin
Computational formula:
ISS score = Σ of:
(AIS score of most severe injury in ISS any region)2 +
(AIS score of next most severe injury in another ISS region)2 +
(AIS score of most severe injury in any remaining ISS region)2 +

ISS score =

Where ISS region is defined as above.

Figure 1. Injury Severity Score (ISS).

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 Trauma scoring systems

Body region and classification

Head/brain and spinal cord ......................................................................... A
Thorax and front of the neck ..................................................................... B
All body regions other than A or B ..................................................... C
All non-serious injuries .................................................................................... D
Calculation formula
AP score = Σ of
Square root of [Region A (injury 1)2 + (injury 2 … n)2 ] +
Square root of [Region B (injury 1)2 + (injury 2 … n)2 ] +
Square root of [Region C (injury 1)2 + (injury 2 … n)2 ] +

AP score =

Where injury n is the AIS score for each injury in that region.
Figure 2. Anatomical Profile (AP).

accuracy of assessment and helps to predict the A Severity Characterization of Trauma

outcomes of survival and length of hospital stay. The ASCOT is a comprehensive anatomical/physio-
All serious injuries (defined as an AIS score of > 2) logical scoring system that combines elements of the
are grouped in anatomical regions A, B or C. All minor AP and the RTS (Fig. 3).14,38 Injuries are classified as
injuries (defined as AIS scores of 1 or 2), regardless of blunt or penetrating. Patient age is broadened into five
their anatomical location, are classified as D.37 The categories. The probability of survival is calculated
total AP score is the sum of the square roots of the according to a formula (Fig. 3). Both ASCOT and
sum of squares of the AIS for all individual injuries TRISS are designed for in-patient use. Their value is
within a region (Fig. 2 provides a mathematical greatest when calculated for patients at trauma centres
representation of this formula). For example, if a when those patients require more than 24 h of
patient has two injuries in region A and the scores for hospitalization.
those two injuries are 5 and 4, respectively, that patient The coefficients for the ASCOT were obtained from
will receive a total score of 6.40 for region A. If there a different set of trauma patients than were the
are no other serious injuries to other regions, the score weights of the RTS.7 The ASCOT estimates the
for those regions will be zero (B = 0, C = 0, D = 0). As probability of survival (Ps), which is an estimate of the
with most of the more accurate trauma scoring percentage of persons with a like score who would
systems, this system is most useful in an in-patient survive. For example, a population based probability of
setting. survival value of 30% indicates that only 30 of
100 persons with similar injuries could be expected to
Anatomical/physiological scoring systems survive (Fig. 4).
In general, the ASCOT Ps value is the same as the
The combined anatomical/physiological systems have TRISS Ps among survivors, but differs for non-
an improved accuracy of both the injuries and the survivors. Among non-survivors, the ASCOT score is
physiological derangements caused either by the usually lower than the TRISS. The fact that the
patient’s injuries or by the patient’s underlying chronic ASCOT uses a more reliable AP system than the ISS
health state, compared with the pure anatomical or for its anatomical evaluation of injury severity, is one
physiological systems. This makes the combined explanation offered for this observation.7
systems better predictors of the probability of
survival. Each must balance ease of use against Revised Trauma Score and Injury Severity Score
accuracy and predictive value. The combined systems The Revised Trauma Score and Injury Severity Score
in the English language literature are A Severity (TRISS) was introduced in 1981.6 It incorporates the
Characterization of Trauma (ASCOT), Revised Trauma physiological elements of the RTS and the anatomical
Score and Injury Severity Score (commonly elements of the ISS.37 Additionally, patient age is
abbreviated as TRISS) and the Paediatric Trauma included for a more precise assessment of the
Score (PTS). probability of survival. While TRISS values are good

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 MH Fani-Salek et al.

predictors of survival, these values are not good system in the world for outcome assessment and
predictors of the length of hospital stay. As a result, quality assurance in trauma care.36,39
TRISS is now the most widely used combined scoring The TRISS is not easy to compute because it uses a
complex logistic regression formula to calculate Ps. The
TRISS coefficients were derived from the database of
ASCOT computational formula patients in the Major Trauma Outcome Study, and were
Ps = 1/(1 + e–k) where: subsequently recalculated with a larger database.14
k = k1 + k2G + k3S + k4R + k5A + k6B + k7C + k8Age
and where: Paediatric Trauma Score
G = Glasgow Coma Scale The PTS was developed to predict the survival of
S = Systolic blood pressure injured children.28 Specifically designed for children,
R = Respiratory rate PTS incorporates elements similar to those evaluated
Age = ASCOT age value for adult trauma victims.40 The PTS evaluates only
A, B, C are components of the AP three anatomical and three physiological components,
e = 2.7183 (natural log base) making it simple and quick to use. Since trauma is the
ASCOT patient age values leading cause of death and disability among children,
Age (years) Age value it is surprising that the PGCS is the only other injury
0–54 0 assessment system meant specifically for use with
55–64 1 children.40,41
65–74 2 The six variables of the PTS are: (i) weight;
75–84 3 (ii) airway; (iii) SBP; (iv) LOC; (v) open wounds; and
> = 85 4 (vi) skeletal injuries. Each element is scored from + 2
(normal) to – 1 (the most severe injuries). A higher
ASCOT regression coefficients by type of trauma
score on the PTS indicates a less injured patient.
Variable Blunt trauma Penetrating trauma
k1(constant) –1.1570 –1.1350
Patients scoring 8 or below are optimally treated at a
G 0.7705 1.0626 level 1 paediatric trauma unit.42
S 0.6583 0.3638 Unfortunately, studies have concluded that PTS is
R 0.2810 0.3332 no more effective than the RTS.41 Critics have also
A – 0.3002 – 0.3702 pointed out that the PTS suffers from scoring
B – 0.1961 – 0.3702 ambiguity.40 For example, the term ‘obtunded’, when
C – 0.2086 – 0.3188 used to describe a child, could be interpreted in a
Age – 0.6355 – 0.8365 number of ways (Table 7).40 Such ambiguity lends
itself to misinterpretation and inaccurate scoring.
Figure 3. A Severity Characterization of Trauma (ASCOT).

TRISS calculation formula

Ps = 1/1 + eb where
b = b0 + b1(RTS) + b2(ISS) + b3(age)
and where
RTS = Revised Trauma Score value
ISS = Injury Severity Score value
Age = age < 55 = 0 or age > 55 = 1
e = 2.7183 (natural log base)

Regression coefficients (from 1987 MTOS)

Injury b0 b1 b2 b3
Blunt trauma –1.2470 0.9544 – 0.0768 – 1.9052
Penetrating trauma – 0.6029 1.1430 – 0.1516 – 2.6676 Figure 4. Revised Trauma Score and Injury
Severity Score (TRISS).

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Table 7. Trauma scoring in the Paediatric Trauma Score (PTS) Table 8. Drug-Rock Injury Severity Score (DRISS)

Value +2 +1 –1 Mnemonic Meaning Assigned value

Weight > 20 kg 10–20 kg < 10 kg
Airway Normal Maintained Not maintained
Systolic BP > 90 mmHg 50–90 mmHg < 50 mmHg
CNS Awake Obtunded Comatose
Open wound(s) None Minor Major
Skeletal fracture(s) None Closed Open or
multiple
BP, blood pressure; CNS, central nervous system.
Drug-Rock Injury Severity Score
The Drug-Rock Injury Severity Score (DRISS) (Table 8)
is a new, combined system developed specifically to
more accurately and efficiently triage persons injured
during a rock concert.43 The DRISS can be used to
compare medical resource use at different events. The
DRISS incorporates values for intoxicants because of
the high incidence of drug/alcohol use at rock concerts.
Although not yet validated, DRISS may be useful for
classifying patients into the groups of those needing
additional care and those who may be safely treated
and released. The DRISS was developed by emergency
physicians and illustrates how trauma severity scores
can be developed or modified for new, specific
situations.
Case example
The following illustrative Case Example may be used
to review the extant trauma scoring systems (scoring
systems’ calculations for the Case Example are shown
in Fig. 5):
A 78-year-old pedestrian is struck by an automobile.
He sustains head, abdominal and leg injuries. On
arrival in ED his GCS is 9, respiratory rate (RR)
35 /min and SBP is 80 mmHg. Computed tomography
(CT) scan shows a small subdural haematoma with
left parietal lobe swelling. There is a major laceration
to the liver but no other intra-abdominal injuries.
Radiographs of the lower limbs show a displaced
fracture of the upper left tibia.
International classification of diseases
The International Classification of Diseases (ICD-9) is
the ninth revision of the international classification of
disease. Although not an injury severity scoring
system, it must be mentioned briefly here since it is the
(points)
D Drugs abused (including ethanol) 1/drug
R Respiratory rate < 12 or > 20 /min and/or 1
heart rate < 60 or > 100 /min 1
U Unstable: BP systolic < 90 or diastolic > 100 1
G Gastro-intestinal symptoms 1
R Restraints required/combative 1
O Oxygen required/Ocular: pinpoint or dilated* 1
C Cardiac monitor/Coma cocktail 1
(D50 & naloxone)*
K Knocked-out (depressed level of 1
consciousness)
I Injury/trauma; Intravenous Infusion* 1
S Seizures or Syncope, Skin diaphoretic 1
or pallorous*
S Seen in first-aid station 1
*Score one unit each.
standard for classifying disease or trauma.5 Each ICD-
9 code describes a disease or injury for the purpose of
reimbursement. Each injury is assigned a specific code,
regardless of its severity. The ICD-9 has proved its
usefulness for research and clinical evaluation and is
widely used in emergency departments.
The e-code modifiers of the ICD-9 describe the
mechanism of injury;44 e-codes are recognized for their
value in national and international injury surveil-
lance.45,46 Because e-codes are still under development
their use may be prone to coding ambiguities.47
Unfortunately, EDs do not routinely provide e-code
information.47 If the mechanism of injury was
included in a major trauma coding system using e-code
descriptors, this information would be available
through the national trauma databases and invaluable
for public health purposes.
Conclusion
There is a multitude of trauma scoring systems,
designed for various purposes. Trauma care has been
improved in the USA since the Vietnam War by
standardizing patient assessment and reporting data
into national data banks.
At their current stage of development, trauma
scores cannot accurately predict the outcome of any
individual patient. Nor are trauma scores successful in

163
 MH Fani-Salek et al.

Revised Trauma Score total (RTS) = 5.8806 calculation:

GCS = 9; coded value 3; weight = 0.9368; value × wt = 2.8104
RR = 35; coded value 3; weight = 0.2908; value × wt = 0.8724
SBP = 80; coded value 3; weight = 0.7326; value × wt = 2.1978

Abbreviated Injury Score (AIS) = 14 Injury Severity Score (ISS) = 41

Region Injury
A Small subdural haematoma 4 ISS = (1st Region Injury)2
[Parietal lobe swelling] [3] + (2nd Region Injury)2
B Liver laceration 4 + (3rd Region Injury)2
C Upper left tibial fracture +3
ISS = 42 + 42 + 32 = 41
14

Calculated probability of survival (Ps) Ps = 1/1 + e–0.7353 = 0.6759 or 68%

Computation:
b = – 1.2470 + (0.9544)(5.8806) + (– 0.0768)(41) + (– 1.9052)(1) = – 0.7353
using coefficients from the MTOS for blunt trauma.

Anatomical Profile
Region A Subdural haematoma AIS = 4
Parietal lobe swelling AIS = 3
Region B No injury
Region C Liver laceration AIS = 4
Upper left tibial fracture AIS = 3

Calculated probability of survival with ASCOT: Ps = 1/1 + e–1.7502 = 0.8522, or 85%

using coefficients for blunt trauma, K = – 1.157 + (0.7705)(2.8104) + (0.2810)(0.8724) + Figure 5. Trauma scoring
(0.6583) (2.1978) + (– 0.3002)(5) + (– 0.1961) (0) + (– 0.2086)(5) + (– 0.6355)(3) = – 1.7502 systems calculations for the
presented Case Example.

predicting the quality of life for survivors. The GCS,
which evaluates neurological injury, is the only scoring
system that measures a degree of disability. No current
system accurately predicts the level of disability from
musculoskeletal injuries in trauma patients.
Trauma scoring systems have promoted reliable
interinstitutional comparisons of trauma patients and
model the aggregate probability of survival. Trauma
databases are invaluable for conducting patient-
outcome research and for policy development. The
results of public health policies can be shown by
changes in these aggregate databases. Emergency
physicians should be familiar with extant trauma
scoring systems, even though the complexity of certain
trauma scoring systems, notably ASCOT and TRISS,
limit their usefulness in emergency medicine. The
differences among systems should be taught in
emergency medicine residencies.
Future directions for trauma scoring system
development should focus on validating tools which are
easy to score, either in the field or in the emergency
department. Tools that can predict the degree of
musculoskeletal disability should be developed. A
significant contribution which emergency medicine
could make to the trauma databases would be to
routinely document the mechanism of injury and add
the appropriate e-codes to all ICD-9 codes on trauma
charts.
Accepted 25 March 1999
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