Scoring systems in traumatized children

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Presented at First Pediatric Anesthesia Conference, Cairo, Egypt, www.egyptpac.org

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Scoring systems in traumatized children

  1. 1. SCORING SYSTEMS in TRAUMATIZED CHILDREN Prof. Mohamed Ezzat Moemen Founder of anaesthesia & intensive care, faculty of medicine, Zagazig university
  2. 2. Scoring systems aim to reduce large amounts of data to simple grades or numbers Aim
  3. 3. Do we need scoring systems ?
  4. 4. Trauma deaths - Immediate - Second peak - Late
  5. 5. Patient triage - Priorities - Labels - Repetition
  6. 6. Glasgow Coma Scale (adults) PointsResponseBehavior 4 3 2 1 Spontaneous To speech To pain Nil Eye opening 5 4 3 2 1 Oriented Confused conversation Inappropriate words Incomprehensive sounds Nil Verbal response 6 5 4 3 2 1 Obeys Localizes Withdraws Abnormal flexion Extends Nil Motor response
  7. 7. Modification of Glasgow Coma Scale For Children Score 5 4 3 2 1 Best Verbal Response : -Appropriate words or social smiles, fixes on and follows objects -Cries but consolable -Persistantly irritable -Restless, agitated -Silent Eye and Motor Responses: Scored as in the scale for adults
  8. 8. Pediatric Trauma Score Tubelirer et al (1990) -1+1+2Component <1010 - 20> 20Size (kg) < 5050 - 90> 90SBP (mmHg) Difficult to maintainCan be maintained NormalAirway Coma or decerebrateObtundedAwakeCNS Open or multiple fractures Closed fractureNoneSkeletal Major or penetratingMinorNoneCutaneous
  9. 9. Age-Specific Pediatric Trauma Score (Potoka et al 2001) Coded Score RRPulseSBPGCS 3NormalNormalNormal14-15 2Tachypnea (RR>mean+SD) Tachycardia (Pulse>mean+SD) Mild to moderate hypotension (SBP<mean-2SD) 10-13 1Hypoventilation (RR<mean-SD) Bradycardia (Pulse<mean-SD) Severe hypotension (SBP<mean-3SD) 4-9 00 or intubated003
  10. 10. ScoreVariableScoreVariable Capillary RefillRespiratory Rate 2 1 0 Normal Delayed (>2 s) Non 5 4 3 2 1 10 – 24 / min 25 – 35 / min >35 / min >10 / min 0 / min Glasgow Coma Scale 5 4 3 2 1 14 – 15 11 – 13 8 – 10 5 – 7 3 – 4 Respiratory Effort 1 0 Normal Shallow or retractive Systolic Blood Pressure Total Score 4 3 2 1 0 > 90 mmHg 70 – 90 mmHg 50 – 69 mmHg < 50 mmHg 0 mmHg Trauma Score (adults)
  11. 11. Revised Trauma Score (RTSc) ScoreX Weighting value Coded Factor 0.2908 4 3 2 1 0 Respiratory rate (b/min): 10 – 29 >29 6 – 9 0 – 5 0 0.7326 4 3 2 1 0 Systolic B P (mmHg): >89 76 – 89 50 – 75 1 – 49 0 0.9368 4 3 2 1 0 Glasgow coma scale : 13 – 15 9 – 12 6 – 8 4 – 5 3
  12. 12. The Abbreviated Injury Score (AIS) Division of the body into six regions: 1- Thorax 2- Abdomen and viscera 3- Head and Neck 4- Face 5- Bony pelvis and extremities 6- External structures Scoring for each region injury as: No injury (0), minor (1), moderate (2), serious (3), severe (4), critical (5), incompatible with life (6)
  13. 13. The sum of squares from the highest AIS grades in each of the three most severely injured areas. •75 points = worst outcome •AIS of any region : 6 points = worst outcome •30-40 points = 50% survival Injury Severity Score (ISS) (Baker et al 1974)
  14. 14. New Injury Severity Score (NISS) (Osler et al 1997) • The AIS is the frame. • Based on the three most severe injuries regardless the body regions. • Useful for penetrating injuries.
  15. 15. TRISS Method Chart TS x coefficient ISS x coefficient Age x coefficient
  16. 16. Score 1 2 3 4 Region affected Skin / extremity Back Chest / abdomen Head / neck Type of injury Laceration / contusion Stab Blunt Missile Cardiac vascular Hemorrhage present BP<100 HR>100 BP<80 HR>140 Pulse less CNS Drowsy Chest pain Stupor Focal exam Coma Respiratory Dyspnea / hemoptysis Aspiration Apena/ cyanosis Trauma index Kirkpatrick and Yeoman’s, (1971)
  17. 17. Variable Score Circulation Capillary refill normal BP>100 mmHg Delayed capillary refill or BP 85 – 100 mmHg No capillary refill or BP<85 mmHg 2 1 0 Respiratory Normal Labored or Shallow Absent 2 1 0 Abdomen / Thorax Abdomen & thorax non-tender Abdomen or thorax tender Abdomen rigid, flail chest, or Penetrating injury 2 1 0 Motor Normal Responds only to pain Decerebrate or no response 2 1 0 Speech Normal Confused No intelligible words 2 1 0 CRAMS Scale Gormican, (1982).
  18. 18. APACHE II • A) 12 physiological variables: 60 points • B) Age: • 44 yrs = 0 points • >75 yrs = 6 points • C) Chronic Health points : • -Non-oper or emerg. Postop. ….. 5 points • -Elective postop. ….. 2 points
  19. 19. APS in APACHE II
  20. 20. (R / 1-R) = -3.517 + (APACHE II x 0.146 + S + D) R = Risk of hospital death S = Risk of emergency surgery D = Risk of specific disease APACHE II equation :
  21. 21. APACHE III Score - Variables & weights: Added weights to APS, Age, and CHE Refined Glasgow Coma Scale -Interactions PH , PaCO2  Creatinine , U.O.  R.R , Ventilator - 5 new variables:  BUN  U.O  Albumin  Bilirubin  Glucose
  22. 22. ‫صفحه‬32 APACHE III Score
  23. 23. ( R / 1-R ) =( APACHE III x 0.053 )+ S+D+L R = Risk of hospital death S = Risk of emergency surgery D = Risk of specific disease L = Risk of patient location APACHE III equation :
  24. 24. Pediatric Trauma BIG Score Borgman MA et al .Pediatrics 2011 ;127 : 892 -7 BIG Score = (BD) + (2.5xINR) + (15 - GCS) 10+(2.5x3.5)+6=26= Predicted mortality : 50% IRAQ & AFGANESTAN Military study Penetrating & blunt injuries BIG Score needs laboratory BIG Score is suitable for research
  25. 25. Determination of outcome : Outcome Age Diagnosis Illness severity Treatment Chronic illness Biological reserve
  26. 26. Key points • Trauma scoring systems in children can play a complementary role in deciding patient outcome. • Some trauma scoring systems are useful for triaging of traumatized children and also for testing quality assurance of trauma centers or comparing their performance.

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