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http://upload.orthobullets.com/topic/1055/images/trauma.jpg
http://upload.orthobullets.com/topic/1055/images/tss.jpg
http://upload.orthobullets.com/topic/1055/images/classifications of trauma scores.jpg
http://upload.orthobullets.com/topic/1055/images/gcs.jpg
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Introduction
  •  Purpose of scoring systems
    • appropriate triage and classification of trauma patients
    • predict outcomes for patient and family counseling
    • quality assurance
    • research
      • extremely useful for the study of outcomes
    • reimbursement purposes
  • Classifications
    • physiologic
      • Revised Trauma Score (RTS)
      • Acute Physiology and Chronic Health Evaluation (APACHE)
      • Sequential Organ Failure Assessment Score (SOFA)
      • Systemic Inflammatory Response Syndrome Score (SIRS)
      • Emergency Trauma Score
    • anatomic
      • Abbreviated Injury Score (AIS)
      • Injury Severity Score (ISS)
      • New Injury Severity Score (NISS)
      • Anatomic Profile (AP)
      • Penetrating Abdominal Trauma Index (PATI)
      • ICD-based Injury Severity Score (ICISS)
      • Trauma Mortality Prediction Model (TMPM-ICD9)
    • combined
      • Trauma Score - Injury Severity Score (TRISS)
      • A Severity Characterization of Trauma (ASCOT)
      • International Classification of Diseases Injury Severity Score (ICISS)
Glasgow Coma Scale
  • Introduction
    • quantifies severity of head injury by measuring CNS function
    • used as
      • initial assessment tool
      • continual re-evaluation of head injured patients
  • Variables
    • 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)
    • Best Verbal Response
      • 5 - Oriented
      • 4 - Confused conversation
      • 3 - Inappropriate words
      • 2 - Incomprehensible sounds
      • 1 - None
    • Eye Opening
      • 4 - Spontaneous
      • 3 - To speech
      • 2 - To pain
      • 1 - None
  • Calculation
    • motor response + verbal response + eye opening
  • Interpretation
    • brain injury
      • severe <9
      • moderate 9-12
      • minor 13 and above
  • Pros
    • reliably predicts outcomes for diffuse and focal lesions
  • Cons
    • does not take into account
      • focal or lateralizing signs
      • diffuse metabolic processes
      • intoxication
Revised Trauma Score (RTS)
  • Introduction
    • most widely used prehospital field triage tool
  • Variables
    • Glasgow Coma Scale (GCS)
      • score
        • 4: 13-15
        • 3: 9-12
        • 2: 6-8
        • 1: 4-5
        • 0: 3
    • systolic blood pressure
      • score
        • 4: >90
        • 3: 76-89
        • 2: 50-75
        • 1: 1-49
        • 0: 0
    • respiratory rate
      • score
        • 4: 10-29
        • 3: >30
        • 2: 6-9
        • 1: 1-5
        • 0: 0
  • Calculation
    • Glasgow coma scale score + systolic blood pressure score + respiratory rate score
  • Interpretation
    • lower score indicates higher severity
    • RTS <4 proposed for transfer to trauma center
  • Pros
    • useful during triage to determine which patients need to be transported to a trauma center
  • Cons
    • can underestimate injury severity in patients injured in one system
Injury Severity Scale (ISS)
  • Introduction
    • first scoring system to be based on anatomic criteria
    • defines injury severity for comparative purposes
  • Variables
    • 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
  • Calculation
    • Abbreviated Injury Scale (AIS) grades
      • 0 - no injury
      • 1 - minor
      • 2 - moderate
      • 3 - severe (not life-threatening)
      • 4 - severe (life-threatening, survival probable)
      • 5 - severe (critical, survival uncertain)
      • 6 - maximal, possibly fatal
    • ISS
      • ISS = sum of squares for the highest AIS 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
        • scores range from 1 to 75
          • single score of 6 on any AIS region results in automatic score of 75
  • Interpretation
    • ISS > 15 associated with mortality of 10%
  • Pros
    • integrates anatomic areas of injury in formulating a prediction of outcomes
  • Cons
    • difficult to calculate during initial evaluation and resuscitation in emergency room
    • difficult to predict outcomes for patients with severe single body area injury
      • New Injury Severity Score (NISS) overcomes this deficit
  • Modifications
    • Modified Injury Severity Score (MISS)
      • similar to ISS but for pediatric trauma
      • categorizes body into 5 areas, instead of 9
      • sum of the squares for the highest injury score grades in the three most severely injured body regions
    • New Injury Severity Score (NISS)
      • takes three highest scores regardless of anatomic area
      • more predictive of complications and mortality than ISS
Mangled Extremity Severity Score (MESS)
  • Introduction
    • used to predict necessity of amputation after lower extremity trauma
  • Variables
    • skeletal and soft tissue injury (graded 1-4)
    • limb ischemia (graded 1-3)
    • shock (graded 0-2)
    • age (graded 0-2)
  • Calculation
    • score determined by adding scores of components in four categories
  • Interpretation
    • score of 7 or more is highly predictive of amputation
  • Pros
    • high specificity for predicting amputation
  • Cons
    • low sensitivity for predicting amputation
Sickness Impact Profile
  • Introduction
    • evaluates the impact of disease on physical and emotional functioning
  • Variables
    • 12 categories
      • sleep
      • eating
      • work
      • home management
      • recreation
      • physical dimension
        • ambulation
        • body care
        • movement
      • psychosocial dimension
        • social interaction
        • alertness behavior
        • emotional behavior
        • communication
  • Relevance to trauma
    • lower extremity injuries
      • psychosocial subscale does not improve with time
    • polytrauma
      • at 10 year follow-up after a major polytrauma, females have
        • decreased quality-of-life scores
        • increased PTSD rates
        • increased absentee sick days  when compared to males
Systemic Inflammatory Response Syndrome (SIRS)
  • Introduction
    • 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 distress syndrome (ARDS)
      • renal failure
      • multisystem organ failure
      • shock
  • Variables
    • heart rate > 90 beats/min
    • WBC count <4000cells/mm³ OR >12,000 cells/mm³
    • respiratory rate > 20 or  PaCO2 < 32mm (4.3kPa)
    • temperature less than 36 degrees or greater than 38 degrees
  • Calculation
    • each component (heart rate, WBC count, respiratory rate, temperature) is given 1 point if it meets the above criteria
  • Interpretation
    • score of 2 or more meets criteria for SIRS
 

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