Trauma Scoring Systems

Author: Derek Moore

Topic updated on 02/12/13 4:54pm

Glasgow Coma Scale

Score calculated by adding score for Eye Opening, Best Motor Response, and Verbal Response
- Best Motor Response
  - 6 - Obeys command
  - 5 - Localizes pain
  - 4 - Normal withdrawal (flexion)
  - 3 - Abnormal withdrawal (flexion): decorticate
  - 2 - Abnormal withdrawal (extension): decerebrate
  - 1 - None (flaccid)
- Verbal Response
  - 5 - Oriented
  - 4 - Confused conversation
  - 3 - Inappropriate words
  - 2 - Incomprehensible sounds
  - 1 - None
- Eye Opening
  - 4 - Spontaneous
  - 3 - To speach
  - 2 - To pain
  - 1 - None

Systemic Inflammatory Response Syndrome (SIRS)

A generalized response to trauma characterized by
- an increase in cytokines
- an increase in complement
- an increase in hormones
A marker for an individual's generalized response to trauma that likely has a genetic predisposition
Associated with conditions such as
- disseminated intravascular coagulopathy (DIC)
- acute respiratory distess syndrome (ARDS)
- renal failure
- multisystem organ failure
- shock
Diagnosed criteria
- diagnosed when a patient has two or more of the following criteria:
  - Heart rate > 90 beats/min
  - WBC count <4000 cells/mm³ OR >12,000 cells/mm³
  - Respiratory rate > 20 or PaCO2 < 32mm (4.3kPa)
  - Temperature less than 36 degrees or greater than 38 degrees

Injury Severity Scale (ISS)

Introduction
- used to define injury severity of injury for research purposes
- based on anatomic and severity indices
Calculation
- ISS = sum of squares for the highest AIS (abbreviated injury scale) grades in the three most severely injured ISS body regions
  - ISS = A² + B² + C²
  - where A, B, C are the AIS scores of the three most severely injured ISS body regions
- AIS grades
- minor
  1. moderate
  2. serious
  3. severe
  4. critical
  5. maximal (currently untreatable, unsurvivable)
Scores range from 1 to 75
- if any region scores 6, the score is automatically set to 75
Based on scores of 9 anatomic regions
1. Head
2. Face
3. Neck
4. Thorax
5. Abdominal and Pelvic Contents
6. Spine
7. Upper Extremity
8. Lower Extremity
9. External

Modified Injury Severity Scale (MISS)

Introduction
- similar to ISS but for pediatric trauma.
MISS categorizes injuries into 5 body areas:
1. neurologic
2. face & neck
3. chest
4. abdomen & pelvic contents
5. extremities & pelvic girdle.
Each category is scored 1-5 with:
1. being minor
2. being moderate
3. being severe but not life threatening
4. being severe with probable survival
5. being critical with uncertain survival.
The total score for the MISS is the sum of the squares for the highest injury score grades in the three most severely injured body regions.
- e.g., A pediatric trauma patient has the following MISS scores: neurologic is 1, chest is 2, abdomen/pelvis is 3, extremity is 3.
- MISS score = (2x2) + (3x3) + (3x3) = 22.
  - neurologic is excluded because it is the least severe

Mangled extremity severity score (MESS)

Has high specificity, low sensitivity for predicting amputation
Score determined by adding scores of components in four categories
1. Skeletal and Soft Tissue Injury
2. Limb Ischemia (this score is doubled for ischemia time > 6 hr)
3. Shock
4. Age

Sickness Impact Profile

When evaluating patients after severe lower extremity injuries, the psychosocial subscale of the Sickness Impact Profile does not improve with time

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Qbank (5 Questions)

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(OBQ09.205) A patient sustains a severe lower extremity injury. What can be said about his outcome at 2 years if he chooses reconstruction over amputation? Topic

Review Topic

1. He has a higher risk of rehospitalization
2. He has a higher chance of returning to work
3. He will have a higher overall SIP (Sickness Impact Profile) score
4. His psychosocial SIP score will improve with time
5. He will have a better SIP score if he did not complete high school

PREFERRED RESPONSE ▶

DISCUSSION: Severe lower extremity injury patients undergoing reconstruction have a higher rate of rehospitalization at 2 years. This question is based on data published by the LEAP study group, a multi-centered study of severe extremity injuries treated with either amputation or reconstruction.

Bosse et al found that at 2 years the SIP score and return to work were not statistically signficantly different between amputation and reconstruction groups. Reconstruction patients had a higher risk of rehospitalization. The psychosocial subscale of SIP did not improve with time. Risk factors for poorer SIP score were: rehospitalization for a major complication, a low educational level, nonwhite race, poverty, lack of private health insurance, poor social-support network, low self-efficacy (the patient's confidence in being able to resume life activities), smoking, and involvement in disability-compensation litigation.

MacKenize et al evaluated factors influential in returning to work (RTW) after severe lower extremity injury. Characteristics that correlated with higher rates of RTW included younger age, higher education, higher income, the presence of strong social support, and employment in a white-collar job that was not physically demanding. Receipt of disability compensation had a strong negative effect on RTW.

REFERENCES:

1. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002;347:1924-1931 PMID:12477942 (Link to Abstract)

2. MacKenzie EJ, Morris JA Jr, Jurkovich GJ, et al: Return to work following injury: The role of economic, social, and job-related factors. Am J Public Health 1998;88:1630-1637 PMID:9807528 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Michael Hughes MD,

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(OBQ07.106) A child in a MVA has a Glasgow Coma Scale score of 14. His injuries have been graded as severe but not life-threatening injury to the chest (3 points), moderate injury to the abdomen (2 points), and severe injuries but with probable survival injury to the the face or neck (4 points) using the criteria for the Modified Injury Severity Score (MISS). There are no injuries to extremities/pelvis . Based on this information, what is the child’s total MISS score? Topic

Review Topic

1. 7
2. 9
3. 25
4. 29
5. 30

PREFERRED RESPONSE ▶

DISCUSSION: The MISS for children categorizes injuries into five body areas: 1) neurologic, 2) face & neck, 3) chest, 4) abdomen & pelvic contents, 5) extremities & pelvic girdle. Each of these are scored 1-5 with 1 being minor, 2 moderate, 3 severe but not life threatening, 4 severe with probable survival, and 5 critical with uncertain survival. The total score for the MISS, like the Injury Severity Score (ISS), is the sum of the squares for the highest injury score grades in the three most severely injured body regions. Therefore, in this case: chest (3x3) + abdomen (2x2) + face/neck (4x4) = 9+4+16 = 29. The Glasgow coma scale would be 1, which is less than the scores of 3 of the other areas so it is excluded. Loder in 1987 showed that in 78 polytrauma pediatric patients, no deaths were seen when the MISS is <40. Mortality was 50% for scores >40 and 75% for scores >50. The Mayer article is a good overview of the MISS.

REFERENCES:

1. Wilber JH, Thompson GH, Son-Hing J: The multiply injured child, in Skeletal Trauma Chidren, ed 4. 2009, pp62-63

2. Mayer T, Matlak ME, Johnson DG, Walker ML: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 1980;15:719-726 PMID:7463271 (Link to Abstract)

3. Loder RT, Pediatric polytrauma: orthopaedic care and hospital course. J Orthop Trauma. 1987;1(1):48-54. PMID:3506585 (Link to Abstract)

Question Authors:

Doug Nowak MD,

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(OBQ05.121) The mangled extremity severity score (MESS) utilizes all of the following variables EXCEPT: Topic

Review Topic

1. Limb ischemia
2. Shock
3. Patient age
4. Skeletal and soft tissue injury
5. Time from admission to surgery

PREFERRED RESPONSE ▶

DISCUSSION: The MESS is a tool utilized to help predict limb salvage success versus primary amputation at the time of presentation. As a screening tool for amputation, this scoring system has a high specificity but low sensitivity, as scores lower than 7 may also ultimately need amputation. All of the variables except choice #5 are part of the scoring system.

The scoring system is as follows: 1. Skeletal / soft-tissue injury: Low energy = 1; Medium energy = 2; High energy = 3; very high energy = 4; 2. Limb ischemia: Pulse reduced or absent but perfusion normal = 1; Pulseless = 2; Cool, paralyzed, insensate = 3; 3. Shock: normotensive = 0; transient hypotension = 1; persistent hypotension = 2; 4. Age: < 30 = 0; 30-50 = 1; >50 = 2. Limb category scores are doubled for ischemia > 6 hours. The system's original designers reported a cutoff of 7 as predicting amputation.

The referenced study by Ly et al found that the scoring system did not predict functional outcomes at 6 or 24 months. They also found that the Limb Salvage Index; the Predictive Salvage Index; the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score; and the Hannover Fracture Scale-98 all did not predict outcomes at 6 or 24 months.

REFERENCES:

1. Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am. 2008 Aug;90(8):1738-43. PMID:18676906 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Jan Szatkowski MD, Edward Perez M.D.,

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(OBQ05.175) What is the Injury Severity Score (ISS) for a patient with an open chest wound (Abbreviated Injury Scale, AIS=4), colon transection (AIS=4), femoral fracture (AIS=3), shoulder dislocation (AIS=2), and a thyroid gland contusion (AIS=1) Topic

Review Topic

1. 11
2. 13
3. 41
4. 45
5. 46

PREFERRED RESPONSE ▶

DISCUSSION: Injury Severity Score (ISS) scores are used to define injury severity for research purposes. The score is based on anatomic and severity indicies. Injury severity is based upon the AIS (abbreviated injury scale). AIS scores range from 1-6 where 1 is a minor laceration or contusion and 6 is a unsurvivable severe injury. An example of a 6 is a crushed head or brain whereas a 5 is a crushed larynx. Open pelvic fracture and femoral shaft fracture come in at 3 and large joint dislocations are a level 2 injury. ISS is the sum of the squares for the highest AIS grades in the three most severely injured ISS body regions. An ISS greater than 18 reflects multiply injured patients and that a transfer to a trauma center is indicated. So in this case, it would be (4x4)+(4x4)+(3x3)= 16+16+9=41. The AIS table can be found in Miller 5th ed p571. Recently, the New Injury Severity Score (NISS) has been developed and found by some authors (Lavoie et al & Balogh et al) to be more reliable indicator of length of stay and ICU stay. The NISS differs from the ISS in that the NISS sums the squares of the 3 most significant injuries (even if they occur in the same anatomic area). The ISS sums the 3 most significant injuries in 3 separate anatomic areas.

REFERENCES:

1. Van Natta TL, Morris JA: Injury scoring and trauma outcomes, In Mattox KL, Feliciano DV, Moore EE (EDS): Trauma. New York, NY, McGraw Hill, 2000, p69-80

2. Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The Injury Severity Score or the New Injury Severity Score for predicting intensive care unit admission and hospital length of stay? Injury. 2005 Apr;36(4):477-83. Epub 2005 Jan 22. PMID:15755427 (Link to Abstract)

3. Balogh ZJ, Varga E, Tomka J, Süveges G, Tóth L, Simonka JA. The new injury severity score is a better predictor of extended hospitalization and intensive care unit admission than the injury severity score in patients with multiple orthopaedic injuries. J Orthop Trauma. 2003 Aug;17(7):508-12. PMID:12902789 (Link to Abstract)

Question Authors:

Doug Nowak MD,

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ABOS II: Trauma Scoring Systems

General - Oral Boards Review

7/29/2011

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Evidence & References Show References

Level of Evidence 2 (Prospective Cohort Study)

Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation of leg-threatening injuries. N Engl J Med 2002;347:1924-1931 PMID:12477942 (Link to Abstract)
MacKenzie EJ, Morris JA Jr, Jurkovich GJ, et al: Return to work following injury: The role of economic, social, and job-related factors. Am J Public Health 1998;88:1630-1637 PMID:9807528 (Link to Abstract)

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Ly TV, Travison TG, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group. Ability of lower-extremity injury severity scores to predict functional outcome after limb salvage. J Bone Joint Surg Am. 2008 Aug;90(8):1738-43. PMID:18676906 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Wilber JH, Thompson GH, Son-Hing J: The multiply injured child, in Skeletal Trauma Chidren, ed 4. 2009, pp62-63
Mayer T, Matlak ME, Johnson DG, Walker ML: The modified injury severity scale in pediatric multiple trauma patients. J Pediatr Surg 1980;15:719-726 PMID:7463271 (Link to Abstract)
Loder RT, Pediatric polytrauma: orthopaedic care and hospital course. J Orthop Trauma. 1987;1(1):48-54. PMID:3506585 (Link to Abstract)
Van Natta TL, Morris JA: Injury scoring and trauma outcomes, In Mattox KL, Feliciano DV, Moore EE (EDS): Trauma. New York, NY, McGraw Hill, 2000, p69-80
Lavoie A, Moore L, LeSage N, Liberman M, Sampalis JS. The Injury Severity Score or the New Injury Severity Score for predicting intensive care unit admission and hospital length of stay? Injury. 2005 Apr;36(4):477-83. Epub 2005 Jan 22. PMID:15755427 (Link to Abstract)
Balogh ZJ, Varga E, Tomka J, Süveges G, Tóth L, Simonka JA. The new injury severity score is a better predictor of extended hospitalization and intensive care unit admission than the injury severity score in patients with multiple orthopaedic injuries. J Orthop Trauma. 2003 Aug;17(7):508-12. PMID:12902789 (Link to Abstract)

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