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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 Patients 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


GCS 13-15 9-12 6-8 4-5 3 SBP > 89 76-89 50-75 1-49 0 RR 10-29 > 29 6-9 1-5 0

Coded Value
4 3 2 1 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 Face Head/neck Minor

AIS Score 1 2

Moderate

Thorax
Abdomen

Severe not LT
Severe LT

3
4

Extremities
External

Critical
Maximum Injury

5
6

Injury Severity Score (ISS)


Region
Head & Neck
Face Chest Abdomen Extremity

Injury Description
Cerebral contusion
No injury Flail chest Minor liver contusion Complex spleen rupt Fractured femur

AIS
3
0 4 2 5 3

Square Top Three


9

16

25

Exteral

No injury
Injury Severity Score

0
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

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