2. OUTLINE
• Introduction
– Definition
– Historical perspective
• Characteristics of an ideal trauma scoring system
• Applications of trauma scoring system
• Classification
– Anatomic scores
– Physiologic scores
– Combine scores
• Conclusion
• References
3. INTRODUCTION
• TRAUMA – the exchange of energy between the human body
and it’s environment to an that exceeding it’s resilience and
leading to injury.
• Trauma patients are a very heterogeneous population.
• The need for comparative analysis of the injury-, management-
, and outcome, among the different patient groups, hospitals,
trauma management strategies, and health systems
• This stimulated the development of many trauma scoring
systems
4. • These scoring systems represent not only a means of
quantifying injuries, but also serve as a common language
between clinicians and researchers.
• Initially, they were designed for the purpose of field triage but
have evolved to a more complex and research-focused
systems.
5. INTRODUCTION-
historical perspective
• The concept of trauma scoring system is relatively new. It began about
50years ago.
• In 1971, a group of researchers known as association for the advancement
of automotive medicine (AAAM) developed the abbreviated injury scale
(AIS), which was modified in 2005 by the international scaling committee
(IISC) to grade the severity of individual injuries.
• In 1974, Baker et al introduced the injury severity score using the AIS as a
bases
• Since then multiple scoring systems have been proposed each with its own
problems and limitations
6. INTRODUCTION
• An ideal trauma scoring system should reflect
– Severity of the anatomic trauma
– The level of the physiologic response
– The inherent patient reserves in terms of comorbidities
– The age,
– Immunologic parameters
– Genetic predisposition parameters.
11. ABBREVIATED INJURY SCALE (AIS)
• this an anatomically based consensus-derived global severity
scoring system that classifies each body injury in every body
region according to its relative severity on a six-point ordinal
scale.
Score Description
1 Minor injury
2 Moderate injury
3 Serious injury
4 Severe injury
5 Critical injury
6 Virtually unsurvivable injury
12. AIS CONT.
• The nine AIS body regions
Numerical descriptor AIS section descriptor Body region included
1 Head Cranium, brain
2 Face Eye, ear, lips
3 Neck Neck, throat
4 Thorax Thoracic content including
ribs-cage
5 Abdomen/pelvic content Abdominal /pelvic organs
6 Spine Spinal column/cord
7 Upper extremities Upper limbs including
shoulder
8 Lower extremities Lower limbs including
pelvis
9 External Integumentary system,
including burns
13. INJURY SEVERITY SCORE (ISS)
• It is an established medical score to assess trauma severity
• It has a linear correlation with mortality, morbidity, hospital
stay, and other measures of injury severity.
• It is the most widely used and is the gold standard anatomic
trauma scoring systems
• It is used to defined major trauma (ISS > 15)
• It is based upon the abbreviated injury scale
14. ISS CONT.
• ISS is defined as the sum of squares of the highest AIS grade
in the 3 most severely injured body region.
• The six body regions are
– Head and neck- including the cervical spine
– Face – including facial skeleton, nose, mouth, eyes and ears
– Chest – thoracic spine and diaphragm
– Abdomen / pelvic contents – abdominal organs and lumbar spine
– Extremities or pelvic girdle – pelvic skeleton
– External
15. ISS cont.
ISS = A² + B² + C²
Were A,B,C are AIS score of the 3 most injured ISS body region
• ISS ranges from 3 to 75, since a score of 6 is unsurvivable
• Minor < 9, moderate 9 – 16, serious 16 – 25, severe injury >25
16. ISS cont.
• Limitations of ISS
– It does not account for multiple injuries to the same body region
– It limit the number of contributing injuries to only 3
– It weights injuries to each body region equally, disregarding the
importance of head injuries in mortality
17. NEW INJURY SEVERITY SCORE (NISS)
• In 1997 Osler et al described the new ISS (NISS) in order to
address some of the disadvantages of the ISS
• This is calculated as the sum of the squares of the highest three
AIS severity scores regardless of the ISS-body regions.
•
• It has been found to be better than the ISS especially for
orthopedic trauma and penetrating injuries.
• However, it is still have not been extensively evaluated and
has the disadvantage of requiring an accurate injury diagnosis
before a precise calculation can be made
18. ANATOMIC PROFILE (AP)
• AP was also introduced to address some of the weaknesses of the
ISS.
• It includes all the serious injuries (AIS severity ≥3) of all the body
regions.
• It is also weighted more toward the head and the torso.
• All serious injuries are grouped into four categories:
– A = head and spine,
– B = thorax and anterior neck,
– C = all remaining serious injuries,
– D = all nonserious injuries
19. AP cont.
• The square root of the sum of squares of the AIS-scores of all
the injuries in each of the four categories is computed and by
logistic regression analysis a probability of survival is
calculated.
• The AP has been proven to be superior to the ISS in
discriminating survivors from nonsurvivors. However, its
complex computational model has restricted its applications
and limited its use.
20. ORGAN INJURY SCALE (OIS)
• The organ injury scaling committee of the American Association for
the Surgery of Trauma (AAST) developed this scoring system in
1987
• The OIS is a scale of anatomic injury within an organ system or
body structure.
• OIS offers a common language between trauma surgeons, but it is
not designed to correlate with patient outcomes.
• The severity of each organ injury may be graded from 1 to 6 using
the AIS.
• The OIS template can be found on the AAST web site.
22. GLASGOW COMA SCALE (GCS)
• GCS is the standard measure used to quantify level of
consciousness in head injured patients.
• It composed of 3 parameters
– Best eye opening (4)
– Best verbal response (5)
– Best motor response (6)
• A GCS of
– 13 to 15 correspond to mild head injury
– 9 to 12 correspond to moderate head injury
– 8 or less correspond to severe head injury
23. Cons of GCS
It does not take into
account
• Focal or lateralizing sign
• Diffuse metabolic
processes
• intoxication
24. TRAUMA SCORE (TS)
• Champion et al. hypothesized that early trauma deaths are
associated with one of the three basic systems: the central
nervous, cardiovascular, and respiratory systems.
• trauma score (TS), based on five parameters:
– The Glasgow coma scale (GCS)
– The unassisted RR
– Respiratory expansion
– Systolic blood pressure (SBP)
– Capillary refill.
25. TS cont.
• It was useful in predicting survival outcomes, with good inter-
rater reliability.
• However, it incorporated parameters, such as respiratory
expansion and capillary refill, which were difficult to assess in
the field
26. REVICED TRAUMA SCORE (RTS)
• This includes three variables (GCS, RR, SBP), and a coded
value from 0 to 4 can be assigned to each based on there
severity.
• It range from 0 to 12 with lower scores representing a more
critical status.
• The threshold of 11 is used as a decision-making tool for
transferring an injured patient to a dedicated trauma center.
• This was internationally adopted and is still in clinical use as
both a field triage and a clinical research tool.
27.
28. ACUTE PHYSIOLOGY AND CHRONIC HEALTH
EVALUATION II (APACHE II)
• It is a severity–of–disease classification system.
• One of several ICU scoring system and it is applied within
24hour of ICU admission.
• It is from 0 to 71 based on several measurement. High scores
correspond to more severe diseases and a higher risk of death.
Score of 25 = predicted mortality of 50%, > 35 = predicted
mortality of 80%
• APACHE II = acute physiology score + age points + chronic
health points
30. APACHE II cont.
• Chronic health points
– Severe organ insufficiency (liver dx, HF, resp dx, dialysis dependent)
– Immunocompromised ( chemo, radiation, steroid, leukemia)
– For nonoperative or emergency post op = score 5 points
– For elective post op = score 2 points
32. TRAUMA AND INJURY SEVERITY SCORE (TRISS)
• The TRISS uses both the ISS and the RTS as well as the
patient’s age to predict survival.
• The probability for survival (Ps) is expressed using the
formula
Ps = 1/(1 + e−ᵇ),
where e = constant (approximately 2.718282) and
b = b0 + b1(RTS) + b2(ISS) + b3(age factor).
• The b coefficients are derived by regression analysis from the
MTOS database.
• The probability of survival according to this model ranges
from 0 to 1.000 for a patient with a 100% expectation of
survival.
33. A SEVERITY CHARACTERIZATION OF TRAUMA
(ASCOT)
• ASCOT incorporate anatomic (AP) and physiology (RTS)
parameters and patient’s age in a more efficient way than TRISS.
• The ASCOT score is also derived from the same formula
Ps = 1/(1 + e−ᵇ) as the TRISS
• The advantage of ASCOT was the use of the AP instead of the ISS,
which better reflected the cumulative anatomic injury load of the
patient.
• However, while the predictive performance of the ASCOT was
marginally better than that of the TRISS it is more complex.
34. MANGLED EXTRIMITY SEVRITY SCORE
• Describe by Johansen et al in 1990
• Used to predict necessity of amputation after lower extremity trauma
• Component
– Skeletal / soft tissue injury (1 – 4)
– Limb ischemia (1 – 3)
– Shock (0 – 2)
– Age (0 – 2)
• MSS score is determine by adding scores of components in the 4 categories
• MESS score of ≥ 7 have 100% positive predictive value for amputation.
• It is highly predictive but low sensitivity for amputation
35.
36. CONCLUSION
• Despite the considerable effort that has gone into designing these different
assessment methodologies and mathematical models, it is very difficult to
translate the multifactorial problems inherent in an injured patient into a
single number or score and all scoring systems will have advantages and
disadvantages.
• There is still a need to evaluate and incorporate additional factors such as
immunologic responses and possibly genetic predisposition to trauma
scoring system.
• Until the development of an “ideal” scoring model, we should be cautious
in our conclusions regarding the existing systems and the prediction of
outcome of the injured patient.
