TRAUMA SCORING

SYSTEM
Edi Mustamsir
 Severity of trauma
• Characterization of injury severity :
important in scientific study of trauma
• Accurate method for quantitatively
summarizing injury severity
• Predict outcome
• Many scoring systems, each has its
own problems & limitation
 TRAUMA SCORING
• Decision making
• Decisions for individual patients should
never be based solely on injury severity
score
• Evaluation of trauma care
• Trauma care research
 Trauma scoring
• Trauma outcome prediction : multivariate
problem
• Outcome prediction will never be perfect
– Injury severity is difficult to quantify
– Patient’s response to trauma is complex and
difficult to model adequately
• Multiple scoring system
TRAUMA SCORING
• Physiologic Scores
• Anatomic Scores
• Combined Scores
Physiologic Score
• Revised Trauma Score
• Acute Physiology and
Chronic Health Evaluation
 Revised Trauma Score
• Physiologic injury severity scoring
• Prehospital setting : triage tool
• 3 physiologic parameters :
– Glasgow Coma Scale (GCS)
– Systemic Blood Pressure (SBP)
– Respiratory Rate (RR)
Revised Trauma Score
Coded
GCS SBP RR
Value
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
 Revised Trauma Score
• 2 forms :
– For field triage
– For quality assurance & outcome
prediction (coded form)
• Field triage :
– RTS is determined by adding coded values
together
– RTS ranges 0 - 12
 Revised Trauma Score
• Coded form
– More complicated to compute
– Is heavily weighted towards GCS

– RTS = 0,9368 GCS + 0,7326 SBP + 0,2908 RR

– Value for RTS : 0 - 7,8408
– Threshold of RTS < 4 : patients who should be
treated in trauma centre
– RTS correlates well with the probability of survival
RTS COEFFICIENT

GCS : X 0.9368
SBP : X 0.7326
RR : X 0.2908
 Example
Mr.A
GCS 10, SBP 80 mmHg dan RR 14/min

Coded value :
GCS 3, SBP 3, RR 4
RTS= 3 X 0.9368 + 3 X 0.7326 + 4 X 0.2908
= 6.1714
 Revised Trauma Score
Limitations
• Related to GCS
• Inability to accurately score patients
who are intubated and mechanically
ventilated (difficult in determining GCS
and RR)
• Patients who are pharmacologically
paralyzed or under alcohol influence
Acute Physiology and Chronic
Health Evaluation (APACHE)
• Used widely for assessment of illness
severity in ICU.
• Has 2 components :
– Chronic Health Evaluation, which
incorporates the influence of comorbid
conditions (DM, cirrhosis etc)
– Acute Physiology Score (APS)
Acute Physiology and Chronic
Health Evaluation (APACHE)
• Version :
– Apache I (1981)
– Apache II (1985)
– Apache III (1991)
• Acute Physiologic Score consists of
variables physiologic systems
• Absence of anatomic component
poor performance
 Anatomic Scores
• Injury Severity Score (ISS)
• Anatomic Profile (AP)
• International Classification of
Disease (ICD)
 Injury Severity Score (ISS)
• Anatomical scoring system that provide
overall score for patients with multiple injuries
• Each injury is assigned an Abbreviated Injury
Scale (AIS) score and is allocated to one of
six body areas
• AIS : anatomically based, ranging from 1
(minor injury) to 6 (lethal)
• Only the highest AIS score in each body
region is used
• The 3 most severily injured body regions
squared and added together ISS
 REGIO AIS Score
Face Minor 1
Head/neck Moderate 2
Thorax Severe not LT 3
Abdomen Severe LT 4
Extremities Critical 5
External Maximum Injury 6
 Injury Severity Score (ISS)
Injury Square
Region AIS
Description Top Three
Head & Neck Cerebral contusion 3 9

Face No injury 0

Chest Flail chest 4 16

Minor liver contusion 2
Abdomen
Complex spleen rupt 5 25
Extremity Fractured femur 3

Exteral No injury 0

Injury Severity Score 50

 Injury Severity Score (ISS)

• Value : 0 - 75
• If an injury is assigned as AIS of 6
(unsurvivable), the ISS : 75
• Simple, numerical method for grading and
comparing injuries by severity
• Classic use : predict mortality from trauma
• Consistent risk factor predictor for postinjury
MOF
 Injury Severity Score (ISS)
Weakness :
• Error in AIS scoring : ISS error
• Inability to account for multiple injuries to the
same body region.
• ISS weights injury to each body region
equally, ignoring the importance of head
injuries in mortality rate
Osler et al :
• Modified ISS (NISS)
• Based on 3 most severe injuries regardless of
body region
 Anatomic Profile
• Limitation of ISS AP is developed
• All serious injuries in body regions
• Appropriately weights head and torso
injuries
• Mathematical complexity & only modest
improvement in redictive performance
failed to gain support
 International Classification
of Disease (ICD-9)
• ICD-9 Injury Severity Score (ICISS)
• Survival Risk Ratios (SRRs) calculated
for each ICD-9 discharge diagnosis
• Includes all injuries, readily available
and not require special training
• Better predictive power to ISS
 Combined Scores
• Trauma & Injury Severity Score
(TRISS)
• A Severity Charavterization of
Trauma (ASCOT)
 Trauma and Injury Severity
Score (TRISS)
• Combine anatomic and physiologic
measures of injury severities (ISS &
RTS) and patient age to predict survival
from trauma
• Recognize the difference between blunt
and penetrating trauma
• Determine the probablity of survival
A Severity Characterization
of Trauma (ASCOT)
• Champion et al : improvement of TRISS
• Uses AP instead of ISS
• Predictive performance : not better than
ISS
• Not widely accepted
 Conclusion
• There is no ideal scoring system
• Still important
• Prediction for trauma outcome
• Use the scoring system with caution
?