Updated: 6/25/2018

Trauma Scoring Systems

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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)
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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Questions (6)
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(OBQ12.79) At long term follow-up, a male who sustains multiple traumatic injuries compared with a premenopausal female, who sustained similar polytrauma, is most likely to have which of the following? Review Topic

QID: 4439
1

Higher quality-of-life scores than females

57%

(2741/4824)

2

Increased rates of complex regional pain syndrome

3%

(150/4824)

3

Require more psychiatric counseling and pharmacologic management than females

11%

(534/4824)

4

Take more absentee days at work as a result of illness than females

26%

(1275/4824)

5

Decreased incidence of lower extremity amputation

2%

(95/4824)

ML 4

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 767
1

7

2%

(17/757)

2

9

16%

(123/757)

3

25

20%

(153/757)

4

29

59%

(450/757)

5

30

1%

(7/757)

ML 3

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PREFERRED RESPONSE 4

(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) Review Topic

QID: 1061
1

11

4%

(14/379)

2

13

11%

(40/379)

3

41

69%

(260/379)

4

45

11%

(40/379)

5

46

5%

(19/379)

ML 2

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 3018
1

He has a higher risk of rehospitalization

76%

(1923/2521)

2

He has a higher chance of returning to work

4%

(92/2521)

3

He will have a higher overall SIP (Sickness Impact Profile) score

13%

(328/2521)

4

His psychosocial SIP score will improve with time

6%

(148/2521)

5

He will have a better SIP score if he did not complete high school

1%

(26/2521)

ML 2

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PREFERRED RESPONSE 1

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

QID: 1007
1

Limb ischemia

0%

(2/512)

2

Shock

6%

(32/512)

3

Patient age

17%

(87/512)

4

Skeletal and soft tissue injury

2%

(11/512)

5

Time from admission to surgery

74%

(377/512)

ML 3

Select Answer to see Preferred Response

PREFERRED RESPONSE 5
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