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Trauma scoring

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Score to detect injured patient

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Trauma scoring

  1. 1. Trauma Scoring ผศ.ดร.กรองได อุณหสูต RN, Ed.D krongdai@gmail.com
  2. 2. การบาดเจ็บ The disease entity resulting from physical injury ICD International Statistical Classification of Disease and Related Health Problem ICD-10 บัญชีจาแนกโรคระหว่างประเทศ ฉบับปรับปรุงแก้ไขครั้งที่ 10 S00–T88 Injury, poisoning and certain other consequences of external causes V00-Y99 External causes of morbidity krongdai@gmail.com
  3. 3. ICD-10-CM Diagnosis Codes S00-S09 Injuries to the head S10-S19 Injuries to the neck S20-S29 Injuries to the thorax S30-S39 Injuries to the abdomen, lower back, lumbar spine and pelvis S40-S49 Injuries to the shoulder and upper arm S50-S59 Injuries to the elbow and forearm S60-S69 Injuries to the wrist, hand and fingers S70-S79 Injuries to the hip and thigh S80-S89 Injuries to the knee and lower leg S90-S99 Injuries to the ankle and foot T07-T07 Injuries involving multiple body regions T14-T14 Injuries to unspecified body region T15-T19 Effects of foreign body entering through natural orifice krongdai@gmail.com
  4. 4. ICD-10-CM Diagnosis Codes T20-T32 Burns and corrosions T20-T25 Burns and corrosions of external body surface, specific site T26-T28 Burns and corrosions confined to eye and internal organs T30-T32 Burns and corrosions of multiple and unspecified body region T33-T34 Frostbite T36-T50 Poisoning by, adverse effect of and underdosing of drugs, medicament, and biologic substances T51-T65 Toxic effects of substance chiefly nonmedicinal as to source T66-T78 Other and unspecified effects of external causes T79-T79 Certain early complications of trauma T80-T88 Complications of surgical and medical care, not elsewhere classified krongdai@gmail.com
  5. 5. ICD-10-CM Diagnosis Codes V00-V09 Pedestrian injured in transport accident V10-V19 Pedal cycle rider injured in transport accident V20-V29 Motorcycle rider injured in transport accident V30-V39 Occupant of 3-wheeled motor vehicle injured in transport accident V40-V49 Car occupant injured injured in transport accident V50-V59 Occupant of pick-up truck or van injured in transport accident V60-V69 Occupant of heavy transport vehicle injured in transport accident V70-V79 Bus occupant injured in transport accident V80-V89 Other land transport accident V90-V94 Water transport accident V95-V97 Air and space transport accident V98-V99 Other and unspecified transport accidents krongdai@gmail.com
  6. 6. ICD-10 (Injury Diagnosis Codes) S40-S49 Injuries to the shoulder and upper arm krongdai@gmail.com
  7. 7. Trauma Scoring Anatomical indices AIS ISS NISS Physiological scale Trauma score Revised Trauma Score CRAMS scale krongdai@gmail.com  predict outcome from trauma  know the prognosis
  8. 8. Abbreviated Injury Scale krongdai@gmail.com  Anatomical-based coding system to classify and describe the severity of injury  The score describe; type, location, and severity
  9. 9. AIS: Body region krongdai@gmail.com AIS Code Region 1 Head 2 Face 3 Neck 4 Thorax 5 Abdomen 6 Spine 7 Upper extremity 8 Lower extremity 9 Unspecified AIS Code Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Unsurvivable / Maximum
  10. 10. AIS: Anatomic structure krongdai@gmail.com AIS Code Region 1 Whole area 2 Vessels 3 Nerve 4 Organs + muscle / ligaments 5 Skeletal + joints 6 Los s of conscious (head only)
  11. 11. AIS: whole area krongdai@gmail.com AIS Code Region 02 Skin abrasion 04 Contusion 06 Laceration 08 Avulsion 10 Amputation 20 Burn 30 Crush 40 Degloving 50 Injury - NFS 60 Penetrating
  12. 12. AIS: whole area krongdai@gmail.com AIS Code Region Example Prob. of death 1 Minor Superficial laceration 0% 2 Moderate Fracture sternum 1-2% 3 Serious Open fracture humerus 8-10% 4 Severe Perforated trachea 50-50% 5 Critical Ruptured liver 50-50% 6 Maximum Severance of aorta 100% 9 No further specified https://en.wikipedia.org/wiki/Abbreviated_Injury_Scale
  13. 13. Injury Severity Score krongdai@gmail.com  Medical score to assess trauma severity  Correlates with mortality, morbidity and hospitalization after trauma  ISS score range from 1-75  ISS score > 15 = major trauma /polytrauma
  14. 14. 6 IIS Body region krongdai@gmail.com Region Head or neck + cervical spine Face + facial skeleton, nose, mouth, eyes and ears Chest + thoracic spine, diaphragm Abdomen + abdominal organs, lumbar spine Extremities + pelvic skeleton External
  15. 15. Injury Severity Score (ISS) ISS = sum of 3 highest2AIS = a2 + b2 + c2 krongdai@gmail.com Region Injury Description AIS score Square Top Three Head & Neck Lacerate wound 2 4 Face No Injury 0 0 Chest Flail Chest 4 16 Abdomen No injury 0 0 Extremity Fractured femur 3 9 External Contusion 1 1 Injury Severity Score: 29
  16. 16. Injury Severity Score; ISS Region Injury Description AIS Square Top Three Head & Neck No injury 0 0 Face No Injury 0 0 Chest Flail Chest 4 16 Abdomen No injury 0 0 Extremity Fractured femur 3 9 External Contusion 1 1 Injury Severity Score: 26 AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Survivable ISS 1-8 Minor 9-15 Moderate 16-24 Serious 25-49 Severe 50-74 Critical 75 Maximum krongdai@gmail.com
  17. 17. NISS  New ISS  The sum of the square of the AIS of each of the patient’s 3 most severe AIS injuries ISS The sum of squares of the highest AIS grades in each of the 3 most severely injured body regions krongdai@gmail.com
  18. 18. Trauma Score Capillary refill time SBP RR Respiratory expansion GCS Coded value 14-15 5 >90 10-24 11-13 4 70-89 25-35 8-10 3 Normal 60-69 > 36 5-7 2 Delayed 0-49 1-9 Normal 3-4 1 None no pulse None Shallow / Retract 0 krongdai@gmail.com
  19. 19. Trauma Score Prob. of Survival 16 99% 15 96% 14 95% 13 91% 12 83% 11 71% 10 55% 9 37% 8 22 7 12% 6 7% 5 4% 4 2% 3 1% 2 0% 1 0% krongdai@gmail.com
  20. 20. Revise Trauma Score GCS SBP RR Coded 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 RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR krongdai@gmail.com
  21. 21. FOUR ScoreGCS krongdai@gmail.com GCS FOUR score  8 0-7 9-12 8-14 13-15 15-16
  22. 22. Eye response 4 = Eyelids open or opened, tracking or blinking to command 3 = Eyelids open but not to tracking 2 = Eyelids closed but opens to loud voice 1 = Eyelids closed but opens to pain 0 = Eyelids remain closed with pain stimuli krongdai@gmail.com
  23. 23. Motor response 4 = Thumbs up, fist, or peace sign 3 = Localizing to pain 2 = Flexion response to pain 1 = Extension response 0 = No response to pain or generalized Myoclonus status krongdai@gmail.com
  24. 24. Brainstem reflexes 4 = Pupil and corneal reflexes present 3 = One pupil wide and fixed 2 = Pupil or corneal reflexes absent 1 = Pupil and corneal reflexes absent 0 = Absent pupil, corneal, or cough reflex krongdai@gmail.com
  25. 25. Respiration 4 = Regular breathing pattern 3 = Cheyne-Stokes breathing pattern 2 = Irregular breathing 1 = Triggers ventilator or breathes above ventilator rate 0 = Apnea or breathes at ventilator rate. krongdai@gmail.com
  26. 26. CRAMS scale Major trauma ≤ score 8 krongdai@gmail.com Assess 2 1 0 C : circulation Normal capillary refill and SBP ≥ 100 Delay capillary refill or SBP ≥ 85 < 100 No capillary refill or SBP < 85 R : respirations Normal Labored or shallow Absent A : abdomen Abdomen and thorax no tender Abdomen and thorax tender Abdomen & rigid or flail chest M : motor Normal Response only pain No response S : speech normal confused No intelligible words
  27. 27. Major Trauma / Polytrauma ISS score > 15 Serious krongdai@gmail.com CRAMS scores  8 Major trauma
  28. 28. TRISS; Trauma Score-Injury Severity Score  TRISS determines the probability of survival (Ps) of trauma patient from the RTS and ISS using the following formulae: Ps = 1 (1+e-b) krongdai@gmail.com
  29. 29. b = b0+b1(RTS)+b2(ISS)+b3(ageIndex) AgeIndex = 0 if the patient is below 54 years = 1 if 55 years and over krongdai@gmail.com If the patient is less than 15 the blunt coefficients are used regardless of mechanism Blunt Penetrating b0 -0.4499 -2.5355 b1 0.8085 0.9934 b2 -0.0835 -0.0651 b3 -1.7430 -1.1360
  30. 30. Important data ISS krongdai@gmail.com Age Mechanism of injury RTS
  31. 31. Early Severity Scales Burden of injury: live or dead Live: bleeding or not bleeding Injured: treated or not treated Treated: ER, released, or admitted krongdai@gmail.com
  32. 32. Pre-hospital triage score Variables Points GCS 3-15 Blunt trauma 4 SBP 120 mmHg = 5, 60-120 mmHg = 3 Age > 60 years = 5 krongdai@gmail.com Risk Point Mortality low 23-29 2.8% intermediate 18-22 15% high <18 48%
  33. 33. Emergency Trauma Score 0 1 2 3 Age <40 years 40-60 years 61-75 years > 75 years GCS 13-15 10-12 6-9 3-5 Base excess > -1 -5 through -1 -10 through - 5.1 ≤ 10 Prothombin time < 80% 80-50 % 49-20% >20% 30 minutes, accurately predicts mortality krongdai@gmail.com
  34. 34. Mangled Extremity Severity Score (MESS) Tissue Injury Characteristics Details Points 1 Low energy Stab wound, simple closed #, small-caliber 1 2 Medium energy Opened #, dislocate, moderate crush 2 3 High energy Short gun, high velocity 3 4 Massive crush Logging, rail road 4 Shock 1 Normotension BP stable 0 2 Hypotensive transient BP unstable, SBP  90 mmHg 1 3 Hypotension In OR 2 Ischemia 1 None No signs of ischemia 0 2 Mild Diminish pulse 1 3 Moderate Paresthesia, diminish motor activity 2 4 Advanced Pulseless 3 Age 1  30 y 0 2 30 – 50 y 1 3  50 y 2 Score  6: salvageable limb, Score 7: highly predictive of amputation
  35. 35. The early warning score Norfolk & Norwich University 3 2 1 0 1 2 3 HR <40 41-50 51-100 101- 110 111- 130 >130 SBP <70 71-80 81-100 101-199 >200 RR <8 9-14 15-20 21-29 >30 Temp <35.0 35.1- 36.5 36.6- 37.4 37.5 LOC A V P U Score Activity 3 Repeat scoring within 15 min
  36. 36. Call 3 2 1 0 1 2 3 Call RR <5 5-8 9-20 21-30 31-35 >35 SBP <70 70-79 80-89 90- 99 100- 180 >180 HR <40 40-49 50- 100 101- 110 111- 130 131- 140 >140 4 Hr Urine Output <80 80- 120 >120 LOC U P Confuse V A Score Activity 8 Stay with patient 6-7 Record q 20 min 4-5 Record q 1 h 1-3 Manage & observe krongdai@gmail.com EARLY WARNING SCORE
  37. 37. 3 2 1 0 1 2 3 RR <8 9-14 15-20 21-29 >30 HR <40 40-50 51-100 101- 110 111- 129 >129 SBP <70 71-80 81-100 101-199 >200 LOC U P V A Confuse Temp (C) <35.0 35.1- 36 36.1-38 38.1- 38.5 >38.6 Hourly Urine for 2 hours >10 cc/hr >30 cc/hr >45 cc/hr Score Activity 1-2 Observe q 2 hr 3 Observe q 1 hr >4 Observe q 30 mins krongdai@gmail.com MODIFIED EARLY WARNING SCORE
  38. 38. Multiple Organ Dysfunction Score Marshall,J.C.(2003) Organ indicator none minimal mild moderate severe Respiratory PaO2/FiO2 ratio > 300 226-300 151-225 76-150 ≤ 75 Renal Serum creatinine (umol/L) ≤ 100 101-200 201-350 351-500 > 500 Hepatic Serum birirubin (umol/L) ≤ 20 21-60 61-120 121-240 > 240 Cardiovascular CVP/MAP < 10.0 10.1-15.0 15.1-20.0 20.1-30.0 > 30.0 Hematologic Platelet count (mm3) > 120,000 81,000- 120,000 51,000- 80,000 21,000- 50,000 ≤ 20,000 Neurologic GCS 15 13-14 10-12 7-9 ≤ 6 krongdai@gmail.com
  39. 39. DENVER POST-INJURY MULTIPLE ORGAN FAILURE SCORE (MOORE) ISS >15, survived longer 48 hr,  16 years of age Dysfunction 0 1 2 3 Pulmonary PaO2/FiO2 >208 208-165 165-83 <83 Renal Creatinine (umol/l) >159 160-210 211-420 >420 Hepatic Total Birilubin (umol/l) <34 34-68 69-137 >137 Cardiac Inotropes No inotropes Only one inotrope at a small dose Any inotrope at moderate dose or >1 agent, all at small dose Any inotrope at large dose or >2 agents, at moderate dose krongdai@gmail.com
  40. 40. SIRS At least 2 of the following criteria:  fever >38.0°C or hypothermia <36.0°C  tachycardia >90 beats/minute  tachypnea >20 breaths/minute  leucocytosis >12*109/l or leucopoenia <4*109/l ≥ 2 criteria = SIRS 1 No SIRS 2 Mild SIRS 3 Moderate SIRS 4 Severe SIRS krongdai@gmail.com
  41. 41. Stage of Sepsis SIRS • pyrexia or hypothermia • tachycardia in the absence of b-blocker • tachypnea or requirement for mechanical ventilation) • WBC > 12 or < 4 x 10 Severe SIRS • SIRS with altered organ perfusion or dysfunction not due to infection Sepsis • SIRS with a documented source of infection Severe sepsis • sepsis associated with organ dysfunction, hypoperfusion, or hypotension Septic shock • sepsis with hypotension despite adequate fluid resuscitation with the presence of perfusion abnormalities krongdai@gmail.com
  42. 42. Acute Physiology and Chronic Health Evaluation  APACHE characterizes trauma patients inadequately  This system has 2 components, as follows: (1) the chronic health evaluation, which incorporates the influence of comorbid conditions (eg, diabetes mellitus, cirrhosis, chronic renal failure, heart disease malignancy), and (2) the Acute Physiology Score (APS).
  43. 43. Death rate Score 4% 0-4 8% 5-9 15% 10-14 25% 15-19 40% 20-24 55% 25-29 75% 30-34 85% >34
  44. 44. Sequential Organ Failure Assessment Score  SOFA score is a scoring system to determine the extent of a person's organ function or the rate of failure in critically ill patients.  The score is based on 6 different parameters, as follows:  respiratory system (PaO2/FiO2, mm Hg),  cardiovascular system (blood pressure/vasopressors),  hepatic system (bilirubin, mg/dL),  coagulation system (plateletsX103/mm3),  renal system (creatinine, mg/dL),  neurological system (Glasgow Coma Scale).
  45. 45. SOFA score 0 1 2 3 4 Respiration PaO2FiO2 or SaO2/FiO2 mmHg >400 <400 221-301 <300 142-220 <200 67-141 <100 <67 Coagulation >150 <150 <100 <50 <20 Liver Birilubin(mg/dl) <1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0 Cardiovascular Hypotension No hypotension MAP <70 Dopamine ≤5 or any Dopamine >5 or notepinephrine ≤0.1 Dopamine >15 or norepinephrine >0.1 CNS (GCS) 15 13-14 10-12 6-9 <6 Renal Creatinine (mg/dl) or urine output (ml/d) <1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00 >5.0 or <200 SOFA Score The European Society of Intensive Care Medicine Krongdaiu@nu.ac.th
  46. 46. SOFA score 0 1 2 3 4 Respiration PaO2FiO2 or SaO2/FiO2 mmHg >400 <400 221-301 <300 142-220 <200 67-141 <100 <67 Coagulation >150 <150 <100 <50 <20 Liver Birilubin(mg/dl) <1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0 Cardiovascular Hypotension No hypotension MAP <70 Dopamine ≤5 or any Dopamine >5 or notepinephrine ≤0.1 Dopamine >15 or norepinephrine >0.1 CNS (GCS) 15 13-14 10-12 6-9 <6 Renal Creatinine (mg/dl) or urine output (ml/d) <1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00 >5.0 or <200 SOFA Score The European Society of Intensive Care Medicine Mortality SOFA score <10% 0-6 15-20% 7-9 40-50% 10-12 50-60% 13-14 >80% 15 >90% 15-24 Mortality Score trend (First 48 hrs) >50% Increasing 27-35% Unchanged <27% Decreasing Krongdaiu@nu.ac.th
  47. 47. SAP II Age (year) HR (bpm) SBP (mmHg) Temp (C/F) GCS MV/CPAP (Yes/No) PaO2 (mmHg) FiO2 (%) Urine output (cc/hr) BUN (mg/dl) Na (mEq/L) K (mEq/L) HCO3 (mEq/L) Bilirubin (mg/dl) WBC (x109/L) Chronic disease (Ca, Hematologic, AIDS) Type of admission (scheduled surg, Med, Unscheduled surg) Mortality SAP II score 10% 29 25% 40 50% 52 75% 64 90% 77 Krongdaiu@nu.ac.th
  48. 48. Scoring system Patient safety  Preventing harm  Reduce in-hospital cardiac arrest • Early recognition • Rx of deteriorating patient. krongdai@gmail.com

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