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Updated: Jun 24 2021

Trauma Scoring Systems

Images
https://upload.orthobullets.com/topic/1055/images/trauma.jpg
https://upload.orthobullets.com/topic/1055/images/tss.jpg
https://upload.orthobullets.com/topic/1055/images/classifications of trauma scores.jpg
https://upload.orthobullets.com/topic/1055/images/gcs.jpg
https://upload.orthobullets.com/topic/1055/images/revised trauma score.jpg
  • 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)
        • Ganga Hospital Open Injury Score (GHOIS)
  • 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 is 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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