Trauma scoring 23 พค.2558

Traumatic scoring
and Monitoring
ผศ.ดร.กรองได อุณหสูต
คณะพยาบาลศาสตร์ มหาวิทยาลัยมหิดล

Trauma Scoring
Anatomical indices
AIS
ISS
NSS
Physiological scale
Trauma score
Revised Trauma Score
CRAMS scale
Krongdai.unh@mahidol.ac.th

The Injury Severity Score (ISS)
 summarize the severity of the condition
of multiply injured patients.
 The ISS is the sum of squares of the highest
AIS grades in each of the 3 most severely
injured body regions.
ISS = sum of 3 highest2AIS
= a2 + b2 + c2

ISS calculation
Region Injury
Description
AIS Square
Top Three
Head & Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion of Liver
Complex Rupture Spleen
2
5 25
Extremity Fractured femur 3
External No Injury 0
ISS = (The 3 most AIS score )2 and added together 50
www.trauma.org/archive/scores/iss

AIS: detail
Score Injury Severity
1 Minor บาดแผลฉีกขาดเล็กน้อย แผลซ้ําหรือถลอก กระดูกนิ้วมือนิ้วเท้าหัก
แตกไม่เคลื่อน
2 Moderate บาดแผลฉีกขาดที่มีความยาว > 2 นิ้ว ตามบริเวณลําตัว และยาวไม่
เกิน 1 นิ้ว บริเวณใบหน้า มีการกระทบกระเทือนไม่รุนแรง กระดูก
แขนร้าว
3 Serious การบาดเจ็บรุนแรงแต่ไม่ทําให้เสียชีวิต บาดแผลฉีกขาดรุนแรงมี
ความยาวตั้งแต่ 4 นิ้วขึ้นไป บริเวณใบหน้าหรือบาดแผลที่ลึกเข้ไป
ในเนื้อเยื่อหรือกล้ามเนื้อ มีกระดูกหักหรือเคลื่อนของแขนขา
4 Severe การบาดเจ็บที่อยู่ในภาวะฉุกเฉินหรือวิกฤต (critical)
5 Critical มีความรุนแรง เป็ นตายเท่ากัน
6 Survivable บาดเจ็บรุนแรงมากจนไม่สามารถรักษาให้รอดชีวิตได้ มีเลือดใน
สมองอย่างมาก มีการฉีดขาดของเส้นเลือดใหญ่ที่ออกจากหัวใจ

Injury Severity Score; ISS
Region Injury Description AIS Square Top Three
Face No Injury 0
2
5 25
Injury Severity Score: 50
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

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)

b = b0+b1(RTS)+b2(ISS)+b3(ageIndex)
AgeIndex = 0 if the patient is below 54 years
= 1 if 55 years and over
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

Region Injury Description AIS Square Top Three
Face No Injury 0
2
5 25
Injury Severity Score: 50
AIS Score Injury
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Survivable

REVISED TRAUMA SCORE
RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR
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

Major trauma
CRAMS scale ≤ score 8
2 1 0
C : circulation Normal capillary
refill & 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 &
thorax no tender
Abdomen & thorax
tender
Abdomen & rigid
or flail chest
M : motor Normal Response only
pain
No response
S : speech normal confused No intelligible
words

Injury
prevention
Pre-hospital
care
In-house
and
resuscitation
Rehabili-
tation

START (Simple triage and rapid treatment)

SALT Mass Casualty Triage Algorithm
(Sort, Assess, Lifesaving Interventions, Treatment/Transport)

Triage
Emergent
Definite
care
Urgent
Admit Observe
Non
urgent
Discharge
AHS
The American hospital association

Triage
Resuscitation
Immediately
Emergent
15 minute
Urgent
30 minute
Less
urgent
60 minute
Non urgent
120 minute
CTAS
Canadian Triage and Acuity Scale

Japan
Triage
Category I
life
threatening
conditions
Category II
urgently
require
treatment
Category III
minor injuries,
do not require
ambulance
transport
Category 0
who are dead,
or injuries
make survival

Hillerød Adaptive Process
Triage categories (HAPT)
Triage
red
resuscitation
0 min
orange
emergent
re-
evaluation
every 10
min
yellow
urgent
re-
evaluation
every 60
min
green
Non
urgent
re-
evaluation
every 180
min
blue
minor
injuries
re-
evaluation
every 240
min

การจําแนกประเภทผู้ประสบภัย
ตามหลัก MCS
Triage
วิกฤติ
(critical)
ผู้ประสบภัยที่มี
ภาวะคุกคามชีวิต
รุนแรง
(severe)
ผู้ประสบภัยที่ได้รับ
การทําหัตถการ
ปานกลาง
(moderate)
ผู้ประสบภัยที่รอรับ
การทําหัตถการได้

FOUR ScoreGCS

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

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
Motor response

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
Brainstem reflexes

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.
Respiration

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

Adult EWS
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

MEWS
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

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

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

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

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

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

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

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

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

Scoring system
Patient safety
 Preventing harm
 Reduce in-hospital cardiac arrest
• Early recognition
• Rx of deteriorating patient.

Trauma scoring 23 พค.2558

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