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Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting
outcomes of blunt trauma abdomen

Article in Polish Journal of Surgery · February 2021

DOI: 10.5604/01.3001.0014.7394

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 original article

Evaluation of ISS, RTS, CASS and TRISS scoring systems

for predicting outcomes of blunt trauma abdomen
Ewaluacja skal ISS, RTS, CASS i TRISS w ocenie rokowania u pacjentów
po urazie tępym jamy brzusznej
Arshad Alam, Arun Kumar Gupta, Nikhil Gupta, Raghav Yelamanchi, Lalit Kumar Bansal, C K Durga
Department of Surgery, Atal Bihari Vajpayee Institute of Medical Sciences and Dr. Ram Manohar Lohia Hospital, New Delhi, India

Article history: Received: 05.10.2020 Accepted: 10.02.2021 Published: 11.02.2021

ABSTRACT: Introduction: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes
one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior
mobilization of resources in anticipation.
Aim: The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen.
 aterials and methods: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised
M
trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity
Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative
complications and mortality.
Results: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as
per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and
TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative
complications. All scores except CASS significantly predicted mortality.
Conclusions: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good
accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and
TRISS predicted mortality with good accuracy but the superiority of one score over the other could not be proved.
KEYWORDS: blunt trauma abdomen, Clinical Abdominal Scoring System, Injury Severity Score, Revised Trauma Score, Trauma and Injury
Severity Score

STRESZCZENIE: Wstęp: Urazy pozostają główną przyczyną zgonów u osób poniżej 45. r.ż. Jedną czwartą wszystkich urazów stanowią urazy
jamy brzusznej. Skale kliniczne stosowane w urazach są niezbędne dla oceny ich ciężkości i wcześniejszego zorganizowania
środków w oczekiwaniu na przyjazd chorego.
Cel: Celem badania była ocena zastosowania skal RTS, ISS, CASS i TRISS w urazach tępych jamy brzusznej.
 ateriały i metody: Przeprowadzono prospektywne jednoośrodkowe badanie kliniczne na 43 pacjentach z urazem tępym jamy
M
brzusznej. Obliczono wyniki w: skali oceny ciężkości urazów (RTS), skali oceny ciężkości mnogich obrażeń ciała (ISS), klinicznej
skali oceny jamy brzusznej (CASS) oraz w skali ciężkości urazu i obrażeń (TRISS), a także porównano je z punktami końcowymi,
takimi jak: potrzeba leczenia zabiegowego, powikłania pooperacyjne i zgon.
Wyniki: W niniejszym badaniu większość stanowili mężczyźni (83,7%). Uraz jamy brzusznej był głównie wynikiem wypadku
komunikacyjnego (72,1%). Najczęściej dochodziło do urazu śledziony. Wyniki CASS i TRISS były istotne w przewidywaniu
potrzeby interwencji zabiegowej. Jedynie dla ISS wykazano istotność w przewidywaniu powikłań pooperacyjnych. Wszystkie
skale, z wyjątkiem CASS, istotnie przewidywały ryzyko zgonu.
Wnioski: Spośród przeanalizowanych skal, CASS i TRISS przewidywały konieczność interwencji zabiegowej z dobrą
dokładnością. W przypadku ryzyka powikłań pooperacyjnych jedynie wynik w skali ISS wykazywał istotność statystyczną.
Skale ISS, RTS i TRISS przewidywały zgon z dużą dokładnością, bez przewagi jednej ze skal nad pozostałymi.
SŁOWA KLUCZOWE: Clinical Abdominal Scoring System, Injury Severity Score, Revised Trauma Score, Trauma and Injury Severity Score, uraz tępy jamy
brzusznej

ABBREVIATIONS CECT – contrast enhanced computerized tomography

FAST – Focused Assessment with Sonography for Trauma
AAST – American Association for the Surgery of Trauma GCS – Glasgow Coma Scale
AIS – Abbreviated Injury Scale ISS – Injury Severity Score
ATLS – Advanced Trauma Life Support ROC – eceiver operating characteristic
AUC – area under the ROC curve RTS – Revised Trauma Score
CASS – Clinical Abdominal Scoring System TRISS – Trauma And Injury Severity Score
POL PRZEGL CHIR 2021: 93 (2): 9-14 DOI: 10.5604/01.3001.0014.7394 9
 original article

INTRODUCTION Tab. I. D
 emographic details of the population and the etiologies of blunt trauma
abdomen.
Trauma is the leading cause of mortality in people below the age GENDER PROPORTION
of 45 years who constitute the most productive population of so-
Male 83.7%
ciety [1]. Apart from mortality, trauma will be the leading cause
of years of productive life lost by the end of this decade as per Female 16.3%
the World Health Organization estimates [2]. Abdominal trauma AGE GROUP (years)
constitutes one-fourth of the trauma burden and blunt trauma
to the abdomen is the most common mechanism of injury [2, 3]. ≤ 20 27.9%
Blunt trauma most commonly leads to solid organ injury rather 21–30 27.9%
than hollow viscus injury. All trauma patients should undergo re-
suscitation as per a standardized protocol as it has been shown 31 27.9%
to reduce mortality by 15% in patients with severe trauma [4, 5]. 40 9.3%
Advanced Trauma Life Support (ATLS) is one of the most com-
51–60 2.3%
monly followed trauma systems worldwide designed initially by dr.
James Styner after the tragic private jet crash involving his family 61–70 4.6%
[6]. Apart from trauma management systems, many scoring sys- ETIOLOGY
tems have been designed for trauma for prediction of outcomes.
Road traffic accident 72.1%
Revised Trauma Score (RTS) is a physiological scoring system and Fall from height 18.6%
is based on Glasgow Coma Scale (GCS), systolic blood pressure and
Fall of heavy object 4.64%
respiratory rate [7, 8]. RTS ranges from 0 to 7.8408. Injury Severity
Score (ISS) is an anatomical scoring system based on the degree Physical assault 2.32%
of injuries in six different body regions. Each region is assigned an
Railway accident 2.32%
Abbreviated Injury Scale (AIS). The AIS of the three most severely
injured body regions is squared and added to derive the score [7].
Tab. II. O
 rgans injured and outcomes.
Clinical Abdominal Scoring System (CASS) was initially designed ORGAN FREQUENCY PROPORTION
as a predictor of the need for laparotomy in blunt trauma abdo-
men patients [9]. The various parameters considered in CASS are Spleen 9 20.95%
the time of presentation after trauma, pulse rate, systolic blood Liver 14 32.56%
pressure, GCS and abdominal clinical findings [9]. Trauma And
Kidney 3 6.98%
Injury Severity Score (TRISS) is based on ISS and RTS along with
the inclusion of age as a parameter [7, 10]. It estimates the prob- Pancreas 1 2.32%
ability of survival of a trauma patient. It is hypothesized as a bet- Bladder 2 4.64%
ter scoring system as it includes an anatomical score as well as
a physiological score. Mesentery and gastrointestinal tract 6 13.95%
Multiple organ injuries 8 18.6%
Scoring systems in trauma are necessary for grading the severity of
OUTCOMES
the injury and prior mobilization of resources in anticipation. Scor-
ing systems can also be used to objectively convey the prognosis to Uneventful conservative 20 46.5%
the patients’ relatives. The aim of this study was to evaluate RTS, management
ISS, CASS and TRISS scoring systems in blunt trauma abdomen. Operative management 13 30.2%
Authors hypothesized that the above scoring systems significant- without complications
ly predicted the outcomes of patients of blunt trauma abdomen. Operative management with 8 18.6%
complications
Death 2 4.7%
MATERIALS AND METHODS
Institutional ethics committee approval was taken prior to the com- surgical department of our hospital during the study period, sat-
mencement of the study. All patients were enrolled in the study isfying the inclusion and exclusion criteria, were included in the
after taking written informed consent. study (consecutive sampling). All patients belonged to a single
cohort as per the protocol and were followed up prospectively till
discharge or death.
STUDY DESIGN AND POPULATION
A prospective single-center study was conducted in our institu- INCLUSION CRITERIA
tion which is a tertiary care and academic center located in India
from November 2017 to March 2019. Forty-three patients of blunt All adult patients of blunt trauma abdomen who presented to the
trauma abdomen were included in the study on accrual. All adult surgical department of our hospital during the study period were
patients who were diagnosed with blunt trauma abdomen in the included in the study.

10 WWW.PPCH.PL
 original article

EXCLUSION CRITERIA Tab. III. S ummary of significance of scores in predicting outcomes.

MANAGEMENT
Patients of blunt trauma abdomen with other significant comor-
bidities which may adversely affect outcomes such as uncontrolled Scores
diabetes mellitus, coronary artery disease with cardiac dysfunc- Conservative Surgical P-value
tion, uncontrolled hypertension, etc. were excluded from the study. (n = 21) (n = 22)
RTS 7.78 ± 0.89 7.56 ± 0.62 0.3051
ISS 19.95 ± 9.32 24.50 ± 6.75 0.051
MANAGEMENT
CASS* 9.29 ± 1.68 11.36 ± 1.09 <0.0011
All patients with a history of blunt trauma abdomen who present- TRISS* 95.31 ± 12.03 94.70 ± 9.53 0.0101
ed to the emergency initially underwent a primary survey as per
POST-OPERATIVE COMPLICATIONS
the ATLS protocol. The vital parameters of patients were moni-
tored continuously. RTS, ISS, CASS and TRIS scores were calcu- Scores
lated for all patients. Present Absent P-value
(n = 9) (n = 14)
All patients underwent Focused Assessment with Sonography for RTS 7.41 ± 0.88 7.83 ± 0.70 0.5961
Trauma (FAST). All hemodynamically stable patients with positive
ISS* 27.78 ± 6.48 21.36 ± 6.78 0.0381
FAST underwent contrast enhanced computerized tomography
(CECT) of the abdomen for further assessment of the injury. Pa- CASS 11.56 ± 1.13 11.07 ± 1.21 0.3181
tients also underwent other investigations like non-contrast com- TRISS 91.69 ± 14.60 96.96 ± 2.30 0.2691
puterized tomography of the head and relevant X-rays based on
MORTALITY
the clinical history and examination findings. Based on the clinical
and radiological findings further management of the patient was Scores
decided by the trauma team. The indications for operative inter-
Present Absent
vention in a case of blunt trauma abdomen were: P-value
(n = 2) (n = 41)
RTS* 5.44 ± 1.32 7.78 ± 0.55 0.0011
• blunt trauma abdomen with hemodynamic instability with
positive FAST, ISS* 37.50 ± 4.95 21.54 ± 7.76 0.0321
• free intraperitoneal air or retroperitoneal air on imaging, CASS 12.50 ± 2.12 10.24 ± 1.68 0.1341
• abdominal CECT suggestive of perforated gastrointestinal
TRISS* 48.65 ± 6.29 97.26 ± 2.56 0.0191
tract, intraperitoneal bladder rupture, renal pedicle
injury or severe solid organ injury as per the American *Significant at P < 0.05, 1: Wilcoxon-Mann-Whitney U Test
Association for the Surgery of Trauma (AAST) grading,
• clinical features suggestive of peritonitis. Statistics, International Business Machines Corporation, New
York). Data was not normally distributed. Hence, non-parametric
Patients with the above indications were shifted to the operation the- test such as the Wilcoxon-Mann-Whitney U Test was used to test
atre and underwent all necessary procedures. Bleeding from solid statistical significance. Association between the scores and the out-
organs was controlled by pressure, packing and by applying local comes was tested using receiver operating characteristic (ROC)
haemostatic agents. Splenectomy was required in 2 cases in view curves and the cut-off values were calculated. The area under the
of severe splenic injury in our study. Mesenteric and bowel injuries ROC curve (AUC) of scores was compared using the De Long’s test.
were repaired primarily if the vascularity of the bowel was preserved.
If the vascularity of the bowel was not maintained, resection and
anastomosis was performed. Urinary bladder injury was repaired RESULTS
primarily. In the post-operative period patients received routine
post-operative care and were closely monitored for any complica- The majority of the study subjects were males (83.7%). Females ac-
tions such as wound infection, wound dehiscence, intraabdominal counted for only 16.3% of patients (Tab. I.). The mean ± standard
collections, respiratory complications, sepsis, etc. The scores calcu- deviation of age of the population was 31.18 ± 12.564 years. The
lated were evaluated for predicting the following outcomes: age distribution of patients is shown in Tab. I. The most common
etiology for blunt trauma abdomen as per this study was road traf-
• need for surgical intervention, fic accident (72.1%) followed by fall from height (18.6%) (Tab. I.).
• post-operative complications, Other etiologies included fall of heavy objects (4.64%), physical
• mortality. assault (2.32%) and railway accidents (2.32%) (Tab. I.).

Solid organs were more commonly injured when compared to hol-

STATISTICAL ANALYSIS
The sample size was 43 patients on accrual. The data acquired was
coded and recorded in the MS Excel spreadsheet (Microsoft Of-
fice, Microsoft, Washington). Data was analyzed using Statistical
Package for Social Sciences (SPSS) version 23.0 (IBM SPSS
POL PRZEGL CHIR 2021: 93 (2): 9-14
low viscus (Tab. II.). The distribution of injuries of various organs
is shown in Tab. II. Multiple organ injuries occurred in 13.95% of
cases (Tab. II.). Conservative management was carried out in 21
cases and operative intervention was performed in 22 patients.
Post-operative complications occurred in 8 patients. The mortal-
ity rate as per this study was 4.7% (Tab. II.).
11
 original article

Tab. IV. Comparison of the diagnostic performance of various scores in predicting the need for surgical intervention, post-operative complications and mortality.

PREDICTOR CUT-OFF AUROC 95% CI P-VALUE SN SP PPV NPV DA

SURGICAL INTERVENTION

RTS 7.108 0.566 0.443–0.689 0.305 23% 95% 83% 54% 58%
ISS 16 0.675 0.507–0.844 0.049 100% 43% 65% 100% 72%
CASS 11 0.877 0.759–0.994 < 0.001 82% 86% 86% 82% 84%
TRISS 99% 0.729 0.571–0.887 0.010 100% 43% 65% 100% 72%
POST-OPERATIVE COMPLICATIONS

RTS 6.37 0.556 0.358–0.753 0.596 22% 100% 100% 67% 70%
ISS 19 0.762 0.558–0.966 0.038 89% 57% 57% 89% 70%
CASS 11 0.623 0.398–0.848 0.318 89% 29% 44% 80% 52%
TRISS 97% 0.643 0.402–0.884 0.269 67% 64% 54% 75% 65%
MORTALITY

RTS 6.37 0.988 0.954–1 0.001 100% 98% 67% 100% 98%
ISS 34 0.957 0.864–1 0.032 100% 90% 33% 100% 91%
CASS 11 0.817 0.498–1 0.134 100% 54% 10% 100% 56%
TRISS 53.1% 1.000 1–1 0.019 100% 100% 100% 100% 100%

AUROC – Area under ROC curve; CI – Confidence interval – Sn – Sensitivity; Sp – Specificity; PPV – Positive predictive value; NPV – Negative predictive
value; DA – Diagnostic accuracy

On calculating the significance of the scores in predicting the need
for operative intervention in patients of blunt trauma abdomen,
only CASS and TRISS scores had significant P-values. The P-values
of RTS and ISS scores did not reach significance (Tab. III.). On cal-
culating the significance of the scores in predicting post-operative
complications only the ISS score had a significant P-value while
the P-values of RTS, CASS and TRISS scores were not significant
(Tab. III.). On calculating the significance of the scores in predict-
ing mortality, all scores except CASS significantly predicted mor-
tality as evident by P-values of less than 0.05 (Tab. III.).
The scores were compared with the outcome parameters by ROC
analysis. The ROC curve between the scores and prediction of the
need for surgical intervention revealed CASS to have greater AUC
than other scores (Fig. 1A.). There was no significant difference in
the diagnostic performance of CASS and TRISS (De Long's Test P
= 0.086). The diagnostic performance of CASS (AUC = 0.877) was
significantly better than that of ISS (AUC = 0.675) (De Long's Test
P = 0.027). The diagnostic performance of CASS (AUC = 0.877)
was significantly better than that of RTS (AUC = 0.566) (De Long's
Test P =< 0.001). There was no significant difference in the diag-
nostic performance of TRISS and ISS (De Long's Test P = 0.218).
There was no significant difference in the diagnostic performance
of TRISS and RTS (De Long's Test P = 0.060). There was no sig-
nificant difference in the diagnostic performance of ISS and RTS
(De Long's Test P = 0.280) (Tab. IV.).
The ROC curve between the scores and the prediction of post-op-
erative complications revealed ISS to have greater AUC than other
scores (Fig. 1B.). There was no significant difference in the diag-
nostic performance of ISS and TRISS (De Long's Test P = 0.370).
There was no significant difference in the diagnostic performance
of ISS and CASS (De Long's Test P = 0.318). There was no sig-
nificant difference in the diagnostic performance of ISS and RTS
(De Long's Test P = 0.178). There was no significant difference in
the diagnostic performance of TRISS and CASS (De Long's Test
P = 0.889). There was no significant difference in the diagnostic
performance of TRISS and RTS (De Long's Test P = 0.384). There
was no significant difference in the diagnostic performance of
CASS and RTS (De Long's Test P = 0.629) (Tab. IV.).
The ROC curve between the scores and the prediction of mortal-
ity revealed that TRISS has greater AUC and diagnostic accuracy
than other scores (Fig. 1C.). There was no significant difference
in the diagnostic performance of TRISS and RTS (De Long's Test
P = 0.480). There was no significant difference in the diagnostic
performance of TRISS and ISS (De Long's Test P = 0.371). There
was no significant difference in the diagnostic performance of
TRISS and CASS (DeLong's Test p = 0.261). There was no signifi-
cant difference in the diagnostic performance of RTS and ISS (De
Long's Test P = 0.439). There was no significant difference in the
diagnostic performance of RTS and CASS (De Long's Test P =
0.255). There was no significant difference in the diagnostic per-
formance of ISS and CASS (De Long's Test P = 0.251) (Tab. IV.).
DISCUSSION
Males constituted the majority of trauma victims in this study
as in many other previous studies [2, 7, 11]. Road traffic accident
was the most common cause of blunt trauma abdomen as per this
study and also in previous studies [2, 3, 7, 9]. Solid organs were
more commonly injured when compared to hollow viscus in this
study. Spleen was the most commonly injured organ followed by
the liver as in previous studies [2].
Among the scoring systems, the need for surgical intervention was
predicted by CASS and TRISS. The AUC and diagnostic accuracy

12 WWW.PPCH.PL

A B
Sensitivity
Sensitivity
1 - Specificity 1 - Specificity
RTS
ISS
CASS
TRISS
Fig. 1. R
 eceiver operating characteristic (ROC) curves comparing scores with outcome parameters. (A) ROC curves of scores and prediction of operative intervention; (B) ROC curves
of scores and prediction of post-operative complications; (C) ROC curves of scores and prediction of mortality.
of CASS were higher when compared to TRISS but the difference
was not statistically significant. The CASS score was originally
designed to predict the need for laparotomy in blunt trauma pa-
tients. Even though the diagnostic accuracy of the CASS score
in this study was lower when compared to the previous study by
Erfantalab-Avini P et al. and Afifi RY (94%), it is still the highest
among the scores compared [9, 12]. Historically, the decision of
laparotomy when based only on clinical findings was associated
with an accuracy of only 16–45% [13]. The cut-off value of CASS
was ≥ 11 in this study which was close to other studies where
a score of > 12 was used as a criterion for laparotomy [12]. CASS
has also avoided auxiliary investigations in a significant propor-
tion of cases in the study by Afifi RY [12].
Among the scores studied, a significant association was seen only
with ISS in predicting post-operative complications. In a system-
atic review by Feldhaus I. et al., both ISS and RTS could be used to
predict post-operative complications [14]. The feasibility of the ISS
score is questionable as in many studies it was underestimated due
to the lack of proper adjunct imaging modalities to accurately assess
the severity of injury [14]. However, ISS is one of the commonly
used scoring systems in low and middle income countries [14].
As per the study, all scores except CASS predicted mortality
significantly. This can be explained as CASS was designed for
predicting the need for laparotomy in trauma rather than to
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original article
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Word count: 3713 Page count: 6 Table: 4 Figures: 1 References: 17

DOI: 10.5604/01.3001.0014.7394 Table of content: https://ppch.pl/issue/13669

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Corresponding author: Dr. Raghav Yelamanchi (ORCID: 0000-0001-6786-8056); Department of Surgery, Ward 17, Atal Bihari Vajpayee Institute of
Medical Sciences and Dr. Ram Manohar Lohia Hospital; New Delhi, 110001, India; E-mail: raghavyelamanchi@gmail.com

Cite this article as: Alam A., Kumar Gupta A., Gupta N., Yelamanchi R., Kumar Bansal L., Durga C.K.: Evaluation of ISS, RTS, CASS and TRISS
scoring systems for predicting outcomes of blunt trauma abdomen; Pol Przegl Chir 2021: 93 (2): 9-14

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