Trauma Scores

Introduction
Correct triage is essential to the effective functioning
of regional trauma systems. Overtriage can inundate
trauma centers with minimally injured patients and
delay care for severely injured patients. On the other
hand, undertriage can produce inadequate initial
care and cause preventable morbidity and mortality.
Unfortunately, the perfect triage tool does not exist.
For this reason, most experts now advocate use of
Revised Trauma Score
the Guidelines for Field Triage of Injured Patients:
Recommendations of the National Expert Panel on Experience with adult trauma scoring systems illus-
Field Triage, 20111 in lieu of trauma scores, per se. trates the problem of their imprecision by the multi-
However, since many emergency medical services plicity of scoring systems that have been proposed over
(EMS) systems still rely on trauma scores as tools for the past two decades. None of these currently existing
field triage, the two most commonly used trauma trauma scores is universally accepted as a completely
scores are described below. effective triage tool. At present, however, many adult
trauma surgeons still utilize the Revised Trauma
Score (RTS) as a triage tool and the weighted variation
Centers for Disease Control and Prevention. Guidelines for Field Triage of
1
of this score as a predictor of potential mortality. This
Injured Patients: Recommendations of the National Expert Panel on Field
Triage, 2011. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6101a1.htm. score is based totally on physiologic derangement on
Accessed September 7, 2012. initial evaluation and entails a categorization of blood
pressure, respiratory rate, and the Glasgow Coma
Scale (See Table 1).

Pediatric Trauma Score

Application of the three components of the RTS to the

pediatric population remains difficult and inconsist-
ent. Respiratory rate is often inaccurately measured
in the field and does not necessarily reflect respiratory
insufficiency in the injured child. Although the Glas-
gow Coma Scale is an extremely effective neurologic
assessment tool, it requires some revision for applica-
tion to the preverbal child. These problems, in asso-
ciation with the lack of any identification of anatomic
injury or quantification of patient size, undermine the
applicability of the RTS to effective triage of injured
children. For these reasons, the Pediatric Trauma
Score (PTS) was developed. The PTS is the sum of the
severity grade of each category and has been demon-
strated to predict potential for death and severe dis-
ability reliably (Table 2).

1
2 Trauma Scores

Table 1 Revised Trauma Score

ASSESSMENT COMPONENT VARIABLES SCORE START OF TRANSPORT END OF TRANSPORT

A. Respiratory Rate 1029 4

(breaths/minute) > 29 3
69 2
15 1 _____________________ ___________________
0 0

B. Systolic Blood Pressure > 89 4

(mm Hg) 7689 3
5075 2
149 1 _____________________ ___________________
0 0

C. Glasgow Coma Scale Score Conversion 1315 4

C = D + E1 + F (adult) 912 3
C = D + E2 + F (pediatric) 68 2
45 1 _____________________ ___________________
<4 0

D. Eye Opening Spontaneous 4

To voice 3
To pain 2 _____________________ ___________________
None 1

E-1. Verbal Response, Adult Oriented 5

Confused 4
Inappropriate words 3
Incomprehensible words 2 _____________________ ___________________
None 1

E-2. Verbal Response, Pediatric Appropriate 5

Cries, consolable 4
Persistently irritable 3
Restless, agitated 2 _____________________ ___________________
None 1

F. Motor Response Obeys commands 6

Localizes pain 5
Withdraws (pain) 4
Flexion (pain) 3
Extension (pain) 2 _____________________ ___________________
None 1

Glasgow Coma Scale Score

(Total = D + E1 or E2 + F) _____________________ ___________________

Revised Trauma Score

(Total = A + B + C)

Adapted with permission from Champion HR, Sacco WJ, Copes WS, et al: A revision of the Trauma Score. Journal of Trauma 1989;29(5):624.

SIZE evolving shock may occur (50 to 90 mm Hg systolic

Size is a major consideration for the infant-toddler
group, in which mortality from injury is the highest.
Airway is assessednot just as a function, but also as a
descriptor of what care is required to provide adequate
management. Systolic blood pressure assessment pri-
marily identifies those children in whom preventable
blood pressure [+l]). Regardless of size, a child whose
systolic blood pressure is below 50 mm Hg (l) is in
obvious jeopardy. On the other hand, a child whose
systolic pressure exceeds 90 mm Hg (+2) probably
falls into a better outcome category than a child with
even a slight degree of hypotension.
 Trauma Scores 3

Table 2 Pediatric Trauma Score

ASSESSMENT SCORE
COMPONENT
+2 +1 1

Weight > 20 kg (> 44 lb) 1020 kg (2244 lb) < 10 kg (< 22 lb)

Airway Normal Oral or nasal airway, oxygen Intubated, cricothyroidotomy, or

tracheostomy

Systolic Blood Pressure > 90 mm Hg; good peripheral 5090 mm Hg; carotid/femoral < 50 mm Hg; weak or no pulses
pulses and perfusion pulses palpable

Level of Consciousness Awake Obtunded or any loss of Coma, unresponsive

consciousness

Fracture None seen or suspected Single, closed Open or multiple

Cutaneous None visible Contusion, abrasion, laceration Tissue loss, any gunshot wound
< 7 cm not through fascia or stab wound through fascia

Totals:

Adapted with permission from Tepas JJ, Mollitt DL, Talbert JL, et al: The pediatric trauma score as a predictor of injury severity in the injured child. Journal of
Pediatric Surgery. 1987;22(1)15.

LEVEL OF CONSCIOUSNESS other than pediatric trauma units. As a predictor of

Level of consciousness is the most important factor in
initially assessing the central nervous system. Because
children frequently lose consciousness transiently dur-
ing injury, the obtunded (+l) grade is given to any
child who loses consciousness, no matter how fleeting
the loss. This grade identifies a patient who may have
sustained a head injury with potentially fatalbut of-
ten treatableintracranial sequelae.
MUSCULOSKELETAL INJURY
Skeletal injury is a component of the PTS because of
its high incidence in the pediatric population and its
potential contribution to mortality. Finally, cutaneous
injury, both as an adjunct to common pediatric injury
patterns and as an injury category that includes pen-
etrating wounds, is considered in the computed PTS.
USE OF THE PTS
The PTS serves as a simple checklist, ensuring that all
components critical to the initial assessment of the in-
jured child have been considered. It is useful for para-
medics in the field, as well as for doctors in facilities
injury, the PTS has a statistically significant inverse
relationship with the Injury Severity Score (ISS) and
mortality. Analysis of this relationship has identified a
threshold PTS of 8, above which injured children should
have a mortality rate of 0%. All injured children with a
PTS of less than 8 should be triaged to an appropriate
pediatric trauma center, because they have the highest
potential for preventable mortality, morbidity, and dis-
ability. According to National Pediatric Trauma Regis-
try statistics, this group represents approximately 25%
of all pediatric trauma victims, clearly requiring the
most aggressive monitoring and observation.
Studies comparing the PTS with the RTS have
identified similar performances of both scores in pre-
dicting potential for mortality. Unfortunately, the RTS
produces what most experts believe to be unacceptable
levels of undertriage, which is an inadequate trade-off
for its greater simplicity. Perhaps more important,
however, the PTSs function as an initial assessment
checklist requires that each of the factors that may
contribute to death or disability is considered during
initial evaluation, and becomes a source of concern for
those individuals responsible for the initial assessment
and management of the injured child.