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Trauma scoring systems

The document reviews various trauma scoring systems used in medical practice to assess the severity of injuries and predict outcomes, highlighting key systems such as the Revised Trauma Score (RTS), Acute Physiology and Chronic Health Evaluation II (APACHE II), Injury Severity Score (ISS), and organ injury scales. It discusses their methodologies, limitations, and applications in clinical settings, including predicting trauma mortality, guiding decision-making, and enhancing research capabilities. Additionally, it introduces newer indices like the Modified Injury Severity Score (NISS) and Anatomic Profile that aim to overcome some limitations of traditional scoring systems.

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TRAUMA SCORING SYSTEMS MOHAMMAD VAZIRI MD THORACIC SURGEON IRAN UNIVERSITY OF MEDICAL SCIENCES Member of The New York Academy of Sciences International Association for the Study of Lung Cancer European Society of Medical Oncology
TRAUMA SCORING SYSTEMS Applications Physiologic Scores Revised Trauma Score Acute Physiology and Chronic Health Evaluation Anatomic Scores Abbreviated Injury Scale Injury Severity Score Anatomic Profile International Classification of Diseases Organ Injury Scaling Combination Scores Trauma and Injury Severity Score
➢Scoring systems Abbreviated Injury Scale Organ Injury Scales Injury Severity Score Glasgow Coma Score Glasgow Paediatric Coma Score Revised Trauma Score TRISS ➢Outcome Scores Glasgow Outcome Score
Applications of Trauma Severity Scores To predict outcome from trauma (mortality) is perhaps the most fundamental use End-of-life decision-making Pre-hospital triage decisions Quality assurance Trauma care research( stratifying patients into comparable groups)
Physiologic Scores ➢ Revised Trauma Score It uses 3 physiologic parameters: (1) Glasgow Coma Scale (GCS) (2) Systemic blood pressure (SBP) (3) Respiratory rate (RR). Practitioners code parameters from 0-4 based on the magnitude of the physiologic derangement.
Revised Trauma Score The RTS has 2 forms depending on its use: When used for field triage, the RTS is determined by adding each of the coded values together. Thus, the RTS ranges from 0-12 An RTS of less than 11 is used to indicate the need for transport to a designated trauma center
Revised Trauma Score The RTS has 2 forms depending on its use: The coded form of the RTS is used more frequently for quality assurance and outcome prediction. The coded RTS is calculated as follows: RTSc = 0.7326 SBPc + 0.2908 RRc + 0.9368 GCSc
GlasgowComaScale (GCS) SystolicBloodPressure (SBP) RespiratoryRate (RR) CodedValue 13-15 >89 10-29 4 9-12 76-89 >29 3 6-8 50-75 6-9 2 4-5 1-49 1-5 1 3 0 0 0
The RTS has several limitations 1-The inability to accurately score patients who are intubated: Determining the verbal component of the GCS and the respiratory rate are difficult in these patients. 2-Patients who are pharmacologically paralyzed or under the influence of alcohol or illicit drugs also are difficult to score. 3-Research has shown that substitution of the best motor response for the GCS results in no loss of predictive capability. the best motor response predicts trauma mortality as well as or better than other scores.
Physiologic Scores Acute Physiology and Chronic Health Evaluation Assessment of illness severity in ICU. This system has 2 components: 1-The chronic health evaluation: the influence of comorbid conditions (eg, diabetes mellitus, cirrhosis) 2- The Acute Physiology Score (APS).
Physiologic Scores Acute Physiology and Chronic Health Evaluation The APS consists of weighted variables representing the major physiologic systems, including: neurologic, cardiovascular, respiratory, renal, gastrointestinal, metabolic, and hematologic variables. Researchers use data that are the most abnormal during the first 24 hours.
In 1985, the APACHE system was revised (ie, APACHE II) by Reducing the number of APS variables from 34 to12 Restricting the comorbid conditions Deriving coefficients for specific diseases. APACHE II is the most widely applied APACHE system
APACHE system has several limitations. 1-Being a relatively younger population, co-morbidity is unusual in these patients 2-By using only ICU data and not accounting for prior treatment, APACHE II underestimates mortality in patients who are transferred to the ICU after relative stabilization. 3-Patients with trauma frequently are resuscitated in the emergency department or operating room prior to admission to the ICU.
APACHE system has several limitations. 4-Patients with trauma comprise only 8% of the population used to develop APACHE II. 5-85% of trauma fatalities were related to traumatic brain injury. 6-Poor performance was related largely to the absence of an anatomic component in the APACHE system.
The most recent version, APACHE III, was published in 1991 The most important modifications were limiting comorbid conditions to those affecting immune function Disease-specific equations Including multiple trauma Distinguishing between head and nonhead trauma Practitioners do not widely accept APACHE III, partially because its accuracy needs to be convincingly validated in patients with trauma
Anatomic Scores ➢Abbreviated Injury Scale (AIS) First introduced in 1969. The latest incarnation of the AIS score is the 1990 revision. The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine.
Anatomic Scores ➢Abbreviated Injury Scale (AIS) Injuries are ranked on a scale of 1 to 6, with 1 being minor, and 6 an un-survivable injury. This represents the 'threat to life' associated with an injury There are many similarities between the AIS scale and the Organ Injury Scales of the American Association for the Surgery of Trauma.
AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable
Injury Severity Score The AIS forms the foundation for the ISS. Baker et al introduced the ISS in 1974 The ISS is defined as the sum of squares of the highest AIS grade in the 3 most severely injured body regions.
Injury Severity Score Six body regions are defined, as follows: The thorax, abdomen and visceral pelvis, head and neck, face, bony pelvis and extremities, and external structures. Only one injury per body region is allowed. The ISS ranges from 1-75, and an ISS of 75 is assigned to anyone with an AIS of 6.
Region Injury Description AIS Square Top Three Head & Neck Cerebral Contusion 3 9 Face No Injury 0 Chest Flail Chest 4 16 Abdomen Minor Contusion of Liver Complex Rupture Spleen 2 5 25 Extremity Fractured femur 3 External No Injury 0 Injury Severity Score: 50
The ISS has several limitations. 1-The most obvious limitation is its inability to account for multiple injuries to the same body region. 2-It limits the total number of contributing injuries to only 3. This seriously impairs the usefulness of the ISS in penetrating injuries, in which multiple injuries are common.
The ISS limitations. 3-The ISS weights injuries to each body region equally, ignoring the importance of head injuries in mortality from trauma 4- Mortality is not strictly an increasing function of the ISS. The mortality rate for an ISS of 16 may higher than the mortality rate for an ISS of 17 because of the different combinations of AIS scores
The ISS limitations. 5-Many ISS values cannot occur, while other ISS values can result from multiple different combinations of AIS scores. 6-This makes the ISS a heterogeneous score and reduces its predictive ability.
The ISS limitations. 7-Any error in AIS scoring increases the ISS error 8-Many different injury patterns can yield the same ISS score 9-As a full description of patient injuries is not known prior to full investigation & operation, the ISS (along with other anatomical scoring systems) is not useful as a triage tool ➢The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay
the ISS also has been noted to be a consistent risk factor predictor for postinjury multiple-organ failure (MOF). Recently, Osler et al reported a modified ISS (new ISS or NISS) based on the 3 most severe injuries regardless of body region. The Preliminary studies suggest that the NISS is a more accurate predictor of trauma mortality than the ISS, particularly in penetrating trauma. The NISS is superior to the ISS as a measure of tissue injury in predictive models of postinjury MOF
Anatomic Scores ➢Anatomic Profile In response to the limitations of the ISS, researchers developed the AP. Unlike the ISS, the AP includes all serious injuries in a body region. The AP appropriately weights head and torso injuries more heavily than other body regions.
Anatomic Scores ➢ Anatomic Profile This index summarizes all serious injuries (AIS greater >3) into 3 categories. Category A : head and spinal cord. Category B : thorax and anterior neck. Category C : all remaining serious injuries. A fourth category, category D, summarizes all nonserious injuries.
Anatomic Scores ➢ Anatomic Profile Practitioners calculate each component as the square root of the sum of squares of the AIS scores of all serious injuries within each region. A region with no injury receives a score of zero. Using logistic regression, these AP component values are used to calculate a probability of survival. The AP performs better than the ISS in discriminating survivors from non-survivors
ICD-9 Injury Severity Score (ICISS) Anatomic injury scoring based on the International Classification of Disease, Ninth Edition (ICD-9) codes Uses survival risk ratios (SRRs) calculated for each ICD-9 discharge diagnosis. SRRs are derived by dividing the number of survivors in each ICD-9 code by the total number of patients with the same ICD-9 code. ICISS is calculated as the simple product of the SRRs for each of the patient's injuries
ICISS advantages 1- it represents a true continuous variable that takes on values between 0 and 1. 2- it includes all injuries. 3- ICD-9 codes are readily available 4-ICD-9 has better predictive power when compared to the ISS. 5- ICISS has the potential to better account for the effects of co-morbidity on outcome
Organ Injury Scaling Originally convened in 1987 by the American Association for the Surgery of Trauma. The scale is graded 1 through 6 for each organ 1 being least severe and 5 the most severe injury from which the patient may survive. Grade 6 injuries are by definition not salvageable
Organ Injury Scaling Spleen Grade Injury Description AIS- 90 I Haematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1cm parenchymal depth 2 II Haematoma Subcapsular, 10-50% surface area Intraparenchymal, <5cm diameter 2 Laceration 1-3cm parenchymal depth not involving a parenchymal vessel 2 III Haematoma Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma. Intraparencymal haematoma >5cm 3 Laceration >3cm parenchymal depth or involving trabecular vessels 3 IV Laceration Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen) 4 V Laceration Completely shattered spleen 5 Vascular Hilar vascular injury which devascularized spleen 5 Advance one grade for multiple injuries to same organ up to Grade III
Organ Injury Scaling Liver Grade Injury Description AIS- 90 I Haematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1cm parenchymal depth 2 II Haematoma Subcapsular, 10-50% surface area 2 Intraparenchymal, <10cm diameter 2 Laceration 1-3cm parenchymal depth, <10cm length 2 III Haematoma Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma 3 Intraparencymal haematoma >10cm or expanding 3 Laceration >3cm parenchymal depth 3 IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Coinaud's segments in a single lobe 4 V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Coinaud's segments within a single lobe 5 Vascular Juxtahepatic venous injuries ie. retrohepatic vena cava/central major hepatic veins 5 VI Vascular Hepatic Avulsion 6 Advance one grade for multiple injuries to same organ up to Grade III
Organ Injury Scaling Lung Grade Injury Description AIS- 90 I Contusion Unilateral, <1 lobe 3 II Contusion Unilateral, single lobe 3 Laceration Simple pneumothorax 3 III Contusion Unilateral, >1 lobe 3 Laceration Persistent (>72 hrs), airleak from distal airway. 3-4 Haematoma Nonexpanding intraparenchymal 3-4 IV Laceration Major (segmental or lobar) airway leak. 4-5 Haematoma Expanding intraparenchymal 4-5 Vascular Primary branch intrapulmonary vessel disrupion 3-5 V Vascular Hilar vessel disruption 4 VI Vascular Total, uncontained transection of pulmonary hilum 4 Advance one grade for bilateral injuries. Haemothorax is graded by thoracic vascular OIS.
Organ Injury Scaling Chest Wall Grade Injury Description AIS-90 I Contusion Any size 1 Laceration Skin and subcutaneous 1 Fracture <3 ribs, closed 1-2 nondisplaced clavicle,closed 2 II Laceration Skin, subcutaneous and muscle 1 Fracture =>3 adjacent ribs, closed 2-3 Open or displaced clavicle 2 Nondisplaced sternum, closed 2 Scapular body 2 III Laceration Full thickness including pleura 2 Fracture Open, displaced or flail sternum 2 Unilateral flail segment <3 ribs 3-4 IV Laceration Avulsion of chest wall tissues with underlying rib fractures 4 Fracture Unilateral flail chest => 3 ribs 3-4 V Fracture Bilateral flail chest 5 Advance one grade for bilateral injuries
Organ InjuryScaling Diaphragm Grade Injury Description AIS-90 I Contusion 2 II Laceration <= 2cm 3 III Laceration 2 - 10cm 3 IV Laceration >10cm with tissue loss <= 25sq cm 3 V Laceration with tissue loss >25sq cm 3 Advance one grade for bilateral injuries.
Organ Injury Scaling Abdominal Vasculature Grade Injury Description AIS-90 I Non-named superior mesenteric artery or vein branches - Non-named inferior mesenteric artery or vein branches - Phrenic artery/vein - Lumbar artery/vein - Gonadal artery/vein - Ovarian artery/vein - Other non-named arterial or venous structure requiring ligation - II Right, left or common hepatic artery 3 Splenic artery/vein 3 Right or left gastric arteries 3 Gastroduodenal artery 3 Inferior mesenteric artery or vein 3 Primary named branches of mesenteric artery or vein 3 Other named abdominal vessels requiring ligation 3 III Superior mesenteric vein 3 Renal artery/vein 3 Iliac artery/vein 3 Hypogastric artery/vein 3 Infra renal vena cava 3 IV Superior mesenteric artery 3 Coeliac axis 3 Suprarenal, infrahepatic vena cava 3 Infrarenal aorta 3 V Portal vein 3 Extra-parenchymal hepatic vein 3-5 Retro or suprahepatic vena cava 5 Suprarenal, subdiaphragmatic aorta 5
Organ Injury Scaling Thoracic Vasculature Grade Injury Description AIS-90 I Intercostal artery/vein 2-3 Internal mammary artery/vein 2-3 Bronchial artery/vein 2-3 Oesophageal artery/vein 2-3 Hemiazygous vein 2-3 Unnamed artery/vein 2-3 II Azygous vein 2-3 Internal jugular vein 2-3 Subclavian vein 3-4 Innominate vein 3-4 III Carotid artery 3-5 Innominate artery 3-4 Subclavian artery 3-4 IV Thoracic aorta, descending 4-5 Inferior vena cava (intrathoracic) 3-4 Pulmonary artery, primary intraparenchymal branch 3 Pulmonary vein, primary intraparenchymal branch 3 V Thoracic aorta, ascending and arch 5 Superior vena cava 3-4 Pulmonary artery, main trunk 4 Pulmonary vein, main trunk 4 VI Uncontained total transection of thoracic aorta 5 Uncontained total transection of pulmonary hilum 4 Advance one grade for multiple grade III or IV if >50% circumference. Decrease one grade for grade IV & V if <25% circumference.
Organ Injury Scaling Cardiac Grade Injury Description AIS- 90 I Blunt cardiac injury with minor ECG abnormality (nonspecific ST or T wave changes, premature atrial or ventricular contraction or persistent sinus tachycardia) 3 Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade or cardiac herniation 3 II Blunt cardiac injury with heart block or ischaemic changes without cardiac failure 3 Penetrating tangential cardiac wound up to but not extending through endocardium, without tamponade 3-4 III Blunt cardiac injury with sustained or multifocal ventricular contractions 3-4 Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion without cardiac failure 3-4 Blunt pericardial laceration with cardiac herniation 3-4 Blunt cardiac injury with cardiac failure 3-4 Penetrating tangential myocardial wound up to but not through endocardium, with tamponade 3 IV Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion producing cardiac failure 3 Blunt or penetrating cardiac injury with aortic or mitral incompetence 3 Blunt or penetrating cardiac injury of the right ventricle, right or left atrium 5 V Blunt or penetating cardiac injury with proximal coronary artery occlusion 5 Blunt or penetrating left ventricular perforation 5 Stellate injuries <50% tissue loss of the right ventricle, right or left atrium 5 VI Blunt avulsion of the heart 6 Penetrating would producing >50% tissue loss of a chamber 6 Advance one grade multiple penetrating wounds to a single chamber or multiple chamber involvement.
Organ Injury Scaling Kidney Grade Injury Description AIS- 90 I Contusion Microscopic or gross haematuria, urological studies normal 2 Haematoma Subcapsular, nonexapnding without parenchymal laceration 2 II Haematoma Nonexpanding perirenal haematoma confined to renal retroperitoneum 2 Laceration <1cm parenchymal depth of renal cortex without urinary extravasation 2 III Laceration >1cm depth of renal cortex, without collecting system rupture or urinary extravasation 3 IV Laceration Parenchymal laceration extending through the renal cortex, medulla and collecting system 4 Vascular Main renal artery or vein injury with contained haemorrhage 5 V Laceration Completely shattered kidney 5 Vascular Avulsion of renal hilum which devascularizes kidney 5 Advance one grade for multiple injuries to same organ
Combination Scores ➢Trauma and Injury Severity Score This test combines both anatomic and physiologic measures of injury severity (ISS and RTS, respectively) and patient age in order to predict survival from trauma. Recognizing the difference between blunt and penetrating injury, researchers developed separate models for each mechanism.
Combination Scores Trauma and Injury Severity Score RTSc is the coded version of the RTS Patient age is categorized such that age is equal to zero if the patient is younger than 55 years and age is equal to one otherwise. The coefficients will differ for blunt and penetrating trauma.
Trauma Score - Injury Severity Score : TRISS TRISS determines the probability of survival (Ps) of a patient from the ISS and RTS using the following formulae: Where 'b' is calculated from: The coefficients b0 - b3 are derived from multiple regression analysis of the Major Trauma Outcome Study (MTOS) database. AgeIndex is 0 if the patient is below 54 years of age or 1 if 55 years and over. b0 to b3 are coefficients which are different for blunt and penetrating trauma. If the patient is less than 15, the blunt coefficients are used regardless of mechanism. Blunt Penetrating b0 -0.4499 -2.5355 b1 0.8085 0.9934 b2 -0.0835 -0.0651 b3 -1.7430 -1.1360 The TRISS calculator determines the probability of survival from the ISS, RTS and patient's age. ISS and RTS scores can be inputted independently or calculated from their base parameters
Trauma and Injury Severity Score limitations (1) It is only moderately accurate for predicting survival (2) Problems already are noted with the ISS ( inhomogeneity, inability to account for multiple injuries to the same body region)
Trauma and Injury Severity Score limitations (3) No information is incorporated related to preexisting conditions (cardiac disease, chronic obstructive pulmonary disease, cirrhosis) (4) Similar to the RTS, it cannot include intubated patients because respiratory rate and verbal responses are not obtainable
Glasgow Coma Score The GCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : Best Eye Response. (4) 1. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response. (5) 1. No verbal response 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused 5. Orientated Best Motor Response. (6) 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands. Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury
Glasgow Paediatric Coma Score Best Eye Response. (4) 1. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response. (5) 1. No vocal response 2. Inconsolable, agitated 3. Inconsistently consolable, moaning. 4. Cries but is consolable, inappropriate interactions. 5. Smiles, oriented to sounds, follows objects, interacts. Best Motor Response. (6) 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands.
Glasgow Outcome Score Score Rating Definition 5 Good Recovery Resumption of normal life despite minor deficits 4 Moderate Disability Disabled but independent. Can work in sheltered setting 3 Severe Disability Conscious but disabled. Dependent for daily support 2 Persistent vegetative Minimal responsiveness 1 Death Non survival
Trauma scoring systems

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Trauma scoring systems

  • 2.
    TRAUMA SCORING SYSTEMS MOHAMMADVAZIRI MD THORACIC SURGEON IRAN UNIVERSITY OF MEDICAL SCIENCES Member of The New York Academy of Sciences International Association for the Study of Lung Cancer European Society of Medical Oncology
  • 3.
    TRAUMA SCORING SYSTEMS Applications PhysiologicScores Revised Trauma Score Acute Physiology and Chronic Health Evaluation Anatomic Scores Abbreviated Injury Scale Injury Severity Score Anatomic Profile International Classification of Diseases Organ Injury Scaling Combination Scores Trauma and Injury Severity Score
  • 4.
    ➢Scoring systems Abbreviated InjuryScale Organ Injury Scales Injury Severity Score Glasgow Coma Score Glasgow Paediatric Coma Score Revised Trauma Score TRISS ➢Outcome Scores Glasgow Outcome Score
  • 5.
    Applications of TraumaSeverity Scores To predict outcome from trauma (mortality) is perhaps the most fundamental use End-of-life decision-making Pre-hospital triage decisions Quality assurance Trauma care research( stratifying patients into comparable groups)
  • 6.
    Physiologic Scores ➢ RevisedTrauma Score It uses 3 physiologic parameters: (1) Glasgow Coma Scale (GCS) (2) Systemic blood pressure (SBP) (3) Respiratory rate (RR). Practitioners code parameters from 0-4 based on the magnitude of the physiologic derangement.
  • 7.
    Revised Trauma Score TheRTS has 2 forms depending on its use: When used for field triage, the RTS is determined by adding each of the coded values together. Thus, the RTS ranges from 0-12 An RTS of less than 11 is used to indicate the need for transport to a designated trauma center
  • 8.
    Revised Trauma Score TheRTS has 2 forms depending on its use: The coded form of the RTS is used more frequently for quality assurance and outcome prediction. The coded RTS is calculated as follows: RTSc = 0.7326 SBPc + 0.2908 RRc + 0.9368 GCSc
  • 9.
  • 10.
    The RTS hasseveral limitations 1-The inability to accurately score patients who are intubated: Determining the verbal component of the GCS and the respiratory rate are difficult in these patients. 2-Patients who are pharmacologically paralyzed or under the influence of alcohol or illicit drugs also are difficult to score. 3-Research has shown that substitution of the best motor response for the GCS results in no loss of predictive capability. the best motor response predicts trauma mortality as well as or better than other scores.
  • 11.
    Physiologic Scores Acute Physiologyand Chronic Health Evaluation Assessment of illness severity in ICU. This system has 2 components: 1-The chronic health evaluation: the influence of comorbid conditions (eg, diabetes mellitus, cirrhosis) 2- The Acute Physiology Score (APS).
  • 12.
    Physiologic Scores Acute Physiologyand Chronic Health Evaluation The APS consists of weighted variables representing the major physiologic systems, including: neurologic, cardiovascular, respiratory, renal, gastrointestinal, metabolic, and hematologic variables. Researchers use data that are the most abnormal during the first 24 hours.
  • 13.
    In 1985, theAPACHE system was revised (ie, APACHE II) by Reducing the number of APS variables from 34 to12 Restricting the comorbid conditions Deriving coefficients for specific diseases. APACHE II is the most widely applied APACHE system
  • 14.
    APACHE system hasseveral limitations. 1-Being a relatively younger population, co-morbidity is unusual in these patients 2-By using only ICU data and not accounting for prior treatment, APACHE II underestimates mortality in patients who are transferred to the ICU after relative stabilization. 3-Patients with trauma frequently are resuscitated in the emergency department or operating room prior to admission to the ICU.
  • 15.
    APACHE system hasseveral limitations. 4-Patients with trauma comprise only 8% of the population used to develop APACHE II. 5-85% of trauma fatalities were related to traumatic brain injury. 6-Poor performance was related largely to the absence of an anatomic component in the APACHE system.
  • 16.
    The most recentversion, APACHE III, was published in 1991 The most important modifications were limiting comorbid conditions to those affecting immune function Disease-specific equations Including multiple trauma Distinguishing between head and nonhead trauma Practitioners do not widely accept APACHE III, partially because its accuracy needs to be convincingly validated in patients with trauma
  • 17.
    Anatomic Scores ➢Abbreviated InjuryScale (AIS) First introduced in 1969. The latest incarnation of the AIS score is the 1990 revision. The AIS is monitored by a scaling committee of the Association for the Advancement of Automotive Medicine.
  • 18.
    Anatomic Scores ➢Abbreviated InjuryScale (AIS) Injuries are ranked on a scale of 1 to 6, with 1 being minor, and 6 an un-survivable injury. This represents the 'threat to life' associated with an injury There are many similarities between the AIS scale and the Organ Injury Scales of the American Association for the Surgery of Trauma.
  • 19.
    AIS Score Injury 1Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable
  • 20.
    Injury Severity Score TheAIS forms the foundation for the ISS. Baker et al introduced the ISS in 1974 The ISS is defined as the sum of squares of the highest AIS grade in the 3 most severely injured body regions.
  • 21.
    Injury Severity Score Sixbody regions are defined, as follows: The thorax, abdomen and visceral pelvis, head and neck, face, bony pelvis and extremities, and external structures. Only one injury per body region is allowed. The ISS ranges from 1-75, and an ISS of 75 is assigned to anyone with an AIS of 6.
  • 22.
    Region Injury Description AIS Square TopThree Head & Neck Cerebral Contusion 3 9 Face No Injury 0 Chest Flail Chest 4 16 Abdomen Minor Contusion of Liver Complex Rupture Spleen 2 5 25 Extremity Fractured femur 3 External No Injury 0 Injury Severity Score: 50
  • 23.
    The ISS hasseveral limitations. 1-The most obvious limitation is its inability to account for multiple injuries to the same body region. 2-It limits the total number of contributing injuries to only 3. This seriously impairs the usefulness of the ISS in penetrating injuries, in which multiple injuries are common.
  • 24.
    The ISS limitations. 3-TheISS weights injuries to each body region equally, ignoring the importance of head injuries in mortality from trauma 4- Mortality is not strictly an increasing function of the ISS. The mortality rate for an ISS of 16 may higher than the mortality rate for an ISS of 17 because of the different combinations of AIS scores
  • 25.
    The ISS limitations. 5-ManyISS values cannot occur, while other ISS values can result from multiple different combinations of AIS scores. 6-This makes the ISS a heterogeneous score and reduces its predictive ability.
  • 26.
    The ISS limitations. 7-Anyerror in AIS scoring increases the ISS error 8-Many different injury patterns can yield the same ISS score 9-As a full description of patient injuries is not known prior to full investigation & operation, the ISS (along with other anatomical scoring systems) is not useful as a triage tool ➢The ISS score is virtually the only anatomical scoring system in use and correlates linearly with mortality, morbidity, hospital stay
  • 27.
    the ISS alsohas been noted to be a consistent risk factor predictor for postinjury multiple-organ failure (MOF). Recently, Osler et al reported a modified ISS (new ISS or NISS) based on the 3 most severe injuries regardless of body region. The Preliminary studies suggest that the NISS is a more accurate predictor of trauma mortality than the ISS, particularly in penetrating trauma. The NISS is superior to the ISS as a measure of tissue injury in predictive models of postinjury MOF
  • 28.
    Anatomic Scores ➢Anatomic Profile Inresponse to the limitations of the ISS, researchers developed the AP. Unlike the ISS, the AP includes all serious injuries in a body region. The AP appropriately weights head and torso injuries more heavily than other body regions.
  • 29.
    Anatomic Scores ➢ AnatomicProfile This index summarizes all serious injuries (AIS greater >3) into 3 categories. Category A : head and spinal cord. Category B : thorax and anterior neck. Category C : all remaining serious injuries. A fourth category, category D, summarizes all nonserious injuries.
  • 30.
    Anatomic Scores ➢ AnatomicProfile Practitioners calculate each component as the square root of the sum of squares of the AIS scores of all serious injuries within each region. A region with no injury receives a score of zero. Using logistic regression, these AP component values are used to calculate a probability of survival. The AP performs better than the ISS in discriminating survivors from non-survivors
  • 31.
    ICD-9 Injury SeverityScore (ICISS) Anatomic injury scoring based on the International Classification of Disease, Ninth Edition (ICD-9) codes Uses survival risk ratios (SRRs) calculated for each ICD-9 discharge diagnosis. SRRs are derived by dividing the number of survivors in each ICD-9 code by the total number of patients with the same ICD-9 code. ICISS is calculated as the simple product of the SRRs for each of the patient's injuries
  • 32.
    ICISS advantages 1- itrepresents a true continuous variable that takes on values between 0 and 1. 2- it includes all injuries. 3- ICD-9 codes are readily available 4-ICD-9 has better predictive power when compared to the ISS. 5- ICISS has the potential to better account for the effects of co-morbidity on outcome
  • 33.
    Organ Injury Scaling Originallyconvened in 1987 by the American Association for the Surgery of Trauma. The scale is graded 1 through 6 for each organ 1 being least severe and 5 the most severe injury from which the patient may survive. Grade 6 injuries are by definition not salvageable
  • 34.
    Organ Injury Scaling Spleen GradeInjury Description AIS- 90 I Haematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1cm parenchymal depth 2 II Haematoma Subcapsular, 10-50% surface area Intraparenchymal, <5cm diameter 2 Laceration 1-3cm parenchymal depth not involving a parenchymal vessel 2 III Haematoma Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma. Intraparencymal haematoma >5cm 3 Laceration >3cm parenchymal depth or involving trabecular vessels 3 IV Laceration Laceration of segmental or hilar vessels producing major devascularization (>25% of spleen) 4 V Laceration Completely shattered spleen 5 Vascular Hilar vascular injury which devascularized spleen 5 Advance one grade for multiple injuries to same organ up to Grade III
  • 35.
    Organ Injury Scaling Liver GradeInjury Description AIS- 90 I Haematoma Subcapsular, <10% surface area 2 Laceration Capsular tear, <1cm parenchymal depth 2 II Haematoma Subcapsular, 10-50% surface area 2 Intraparenchymal, <10cm diameter 2 Laceration 1-3cm parenchymal depth, <10cm length 2 III Haematoma Subcapsular, >50% surface area or expanding. Ruptured subcapsular or parenchymal haematoma 3 Intraparencymal haematoma >10cm or expanding 3 Laceration >3cm parenchymal depth 3 IV Laceration Parenchymal disruption involving 25-75% of hepatic lobe or 1-3 Coinaud's segments in a single lobe 4 V Laceration Parenchymal disruption involving >75% of hepatic lobe or >3 Coinaud's segments within a single lobe 5 Vascular Juxtahepatic venous injuries ie. retrohepatic vena cava/central major hepatic veins 5 VI Vascular Hepatic Avulsion 6 Advance one grade for multiple injuries to same organ up to Grade III
  • 36.
    Organ Injury Scaling Lung GradeInjury Description AIS- 90 I Contusion Unilateral, <1 lobe 3 II Contusion Unilateral, single lobe 3 Laceration Simple pneumothorax 3 III Contusion Unilateral, >1 lobe 3 Laceration Persistent (>72 hrs), airleak from distal airway. 3-4 Haematoma Nonexpanding intraparenchymal 3-4 IV Laceration Major (segmental or lobar) airway leak. 4-5 Haematoma Expanding intraparenchymal 4-5 Vascular Primary branch intrapulmonary vessel disrupion 3-5 V Vascular Hilar vessel disruption 4 VI Vascular Total, uncontained transection of pulmonary hilum 4 Advance one grade for bilateral injuries. Haemothorax is graded by thoracic vascular OIS.
  • 37.
    Organ Injury Scaling ChestWall Grade Injury Description AIS-90 I Contusion Any size 1 Laceration Skin and subcutaneous 1 Fracture <3 ribs, closed 1-2 nondisplaced clavicle,closed 2 II Laceration Skin, subcutaneous and muscle 1 Fracture =>3 adjacent ribs, closed 2-3 Open or displaced clavicle 2 Nondisplaced sternum, closed 2 Scapular body 2 III Laceration Full thickness including pleura 2 Fracture Open, displaced or flail sternum 2 Unilateral flail segment <3 ribs 3-4 IV Laceration Avulsion of chest wall tissues with underlying rib fractures 4 Fracture Unilateral flail chest => 3 ribs 3-4 V Fracture Bilateral flail chest 5 Advance one grade for bilateral injuries
  • 38.
    Organ InjuryScaling Diaphragm Grade InjuryDescription AIS-90 I Contusion 2 II Laceration <= 2cm 3 III Laceration 2 - 10cm 3 IV Laceration >10cm with tissue loss <= 25sq cm 3 V Laceration with tissue loss >25sq cm 3 Advance one grade for bilateral injuries.
  • 39.
    Organ Injury Scaling AbdominalVasculature Grade Injury Description AIS-90 I Non-named superior mesenteric artery or vein branches - Non-named inferior mesenteric artery or vein branches - Phrenic artery/vein - Lumbar artery/vein - Gonadal artery/vein - Ovarian artery/vein - Other non-named arterial or venous structure requiring ligation - II Right, left or common hepatic artery 3 Splenic artery/vein 3 Right or left gastric arteries 3 Gastroduodenal artery 3 Inferior mesenteric artery or vein 3 Primary named branches of mesenteric artery or vein 3 Other named abdominal vessels requiring ligation 3 III Superior mesenteric vein 3 Renal artery/vein 3 Iliac artery/vein 3 Hypogastric artery/vein 3 Infra renal vena cava 3 IV Superior mesenteric artery 3 Coeliac axis 3 Suprarenal, infrahepatic vena cava 3 Infrarenal aorta 3 V Portal vein 3 Extra-parenchymal hepatic vein 3-5 Retro or suprahepatic vena cava 5 Suprarenal, subdiaphragmatic aorta 5
  • 40.
    Organ Injury Scaling ThoracicVasculature Grade Injury Description AIS-90 I Intercostal artery/vein 2-3 Internal mammary artery/vein 2-3 Bronchial artery/vein 2-3 Oesophageal artery/vein 2-3 Hemiazygous vein 2-3 Unnamed artery/vein 2-3 II Azygous vein 2-3 Internal jugular vein 2-3 Subclavian vein 3-4 Innominate vein 3-4 III Carotid artery 3-5 Innominate artery 3-4 Subclavian artery 3-4 IV Thoracic aorta, descending 4-5 Inferior vena cava (intrathoracic) 3-4 Pulmonary artery, primary intraparenchymal branch 3 Pulmonary vein, primary intraparenchymal branch 3 V Thoracic aorta, ascending and arch 5 Superior vena cava 3-4 Pulmonary artery, main trunk 4 Pulmonary vein, main trunk 4 VI Uncontained total transection of thoracic aorta 5 Uncontained total transection of pulmonary hilum 4 Advance one grade for multiple grade III or IV if >50% circumference. Decrease one grade for grade IV & V if <25% circumference.
  • 41.
    Organ Injury Scaling Cardiac GradeInjury Description AIS- 90 I Blunt cardiac injury with minor ECG abnormality (nonspecific ST or T wave changes, premature atrial or ventricular contraction or persistent sinus tachycardia) 3 Blunt or penetrating pericardial wound without cardiac injury, cardiac tamponade or cardiac herniation 3 II Blunt cardiac injury with heart block or ischaemic changes without cardiac failure 3 Penetrating tangential cardiac wound up to but not extending through endocardium, without tamponade 3-4 III Blunt cardiac injury with sustained or multifocal ventricular contractions 3-4 Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion without cardiac failure 3-4 Blunt pericardial laceration with cardiac herniation 3-4 Blunt cardiac injury with cardiac failure 3-4 Penetrating tangential myocardial wound up to but not through endocardium, with tamponade 3 IV Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid incompetence, papillary muscle dysfunction or distal coronary artery occlusion producing cardiac failure 3 Blunt or penetrating cardiac injury with aortic or mitral incompetence 3 Blunt or penetrating cardiac injury of the right ventricle, right or left atrium 5 V Blunt or penetating cardiac injury with proximal coronary artery occlusion 5 Blunt or penetrating left ventricular perforation 5 Stellate injuries <50% tissue loss of the right ventricle, right or left atrium 5 VI Blunt avulsion of the heart 6 Penetrating would producing >50% tissue loss of a chamber 6 Advance one grade multiple penetrating wounds to a single chamber or multiple chamber involvement.
  • 42.
    Organ Injury Scaling Kidney GradeInjury Description AIS- 90 I Contusion Microscopic or gross haematuria, urological studies normal 2 Haematoma Subcapsular, nonexapnding without parenchymal laceration 2 II Haematoma Nonexpanding perirenal haematoma confined to renal retroperitoneum 2 Laceration <1cm parenchymal depth of renal cortex without urinary extravasation 2 III Laceration >1cm depth of renal cortex, without collecting system rupture or urinary extravasation 3 IV Laceration Parenchymal laceration extending through the renal cortex, medulla and collecting system 4 Vascular Main renal artery or vein injury with contained haemorrhage 5 V Laceration Completely shattered kidney 5 Vascular Avulsion of renal hilum which devascularizes kidney 5 Advance one grade for multiple injuries to same organ
  • 43.
    Combination Scores ➢Trauma andInjury Severity Score This test combines both anatomic and physiologic measures of injury severity (ISS and RTS, respectively) and patient age in order to predict survival from trauma. Recognizing the difference between blunt and penetrating injury, researchers developed separate models for each mechanism.
  • 44.
    Combination Scores Trauma andInjury Severity Score RTSc is the coded version of the RTS Patient age is categorized such that age is equal to zero if the patient is younger than 55 years and age is equal to one otherwise. The coefficients will differ for blunt and penetrating trauma.
  • 45.
    Trauma Score -Injury Severity Score : TRISS TRISS determines the probability of survival (Ps) of a patient from the ISS and RTS using the following formulae: Where 'b' is calculated from: The coefficients b0 - b3 are derived from multiple regression analysis of the Major Trauma Outcome Study (MTOS) database. AgeIndex is 0 if the patient is below 54 years of age or 1 if 55 years and over. b0 to b3 are coefficients which are different for blunt and penetrating trauma. If the patient is less than 15, the blunt coefficients are used regardless of mechanism. Blunt Penetrating b0 -0.4499 -2.5355 b1 0.8085 0.9934 b2 -0.0835 -0.0651 b3 -1.7430 -1.1360 The TRISS calculator determines the probability of survival from the ISS, RTS and patient's age. ISS and RTS scores can be inputted independently or calculated from their base parameters
  • 46.
    Trauma and InjurySeverity Score limitations (1) It is only moderately accurate for predicting survival (2) Problems already are noted with the ISS ( inhomogeneity, inability to account for multiple injuries to the same body region)
  • 47.
    Trauma and InjurySeverity Score limitations (3) No information is incorporated related to preexisting conditions (cardiac disease, chronic obstructive pulmonary disease, cirrhosis) (4) Similar to the RTS, it cannot include intubated patients because respiratory rate and verbal responses are not obtainable
  • 48.
    Glasgow Coma Score TheGCS is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of three parameters : Best Eye Response, Best Verbal Response, Best Motor Response, as given below : Best Eye Response. (4) 1. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response. (5) 1. No verbal response 2. Incomprehensible sounds. 3. Inappropriate words. 4. Confused 5. Orientated Best Motor Response. (6) 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands. Note that the phrase 'GCS of 11' is essentially meaningless, and it is important to break the figure down into its components, such as E3V3M5 = GCS 11. A Coma Score of 13 or higher correlates with a mild brain injury, 9 to 12 is a moderate injury and 8 or less a severe brain injury
  • 49.
    Glasgow Paediatric ComaScore Best Eye Response. (4) 1. No eye opening. 2. Eye opening to pain. 3. Eye opening to verbal command. 4. Eyes open spontaneously. Best Verbal Response. (5) 1. No vocal response 2. Inconsolable, agitated 3. Inconsistently consolable, moaning. 4. Cries but is consolable, inappropriate interactions. 5. Smiles, oriented to sounds, follows objects, interacts. Best Motor Response. (6) 1. No motor response. 2. Extension to pain. 3. Flexion to pain. 4. Withdrawal from pain. 5. Localising pain. 6. Obeys Commands.
  • 50.
    Glasgow Outcome Score ScoreRating Definition 5 Good Recovery Resumption of normal life despite minor deficits 4 Moderate Disability Disabled but independent. Can work in sheltered setting 3 Severe Disability Conscious but disabled. Dependent for daily support 2 Persistent vegetative Minimal responsiveness 1 Death Non survival