This document provides guidance on completing various diagnosis fields in the Alaska Trauma Registry. It discusses entering trauma diagnoses, important injuries like burns and smoke inhalation that require special attention, and non-trauma diagnoses. Comorbidities that were present before the injury are also to be included. Specific ICD-10 codes, injury descriptions, severity indicators, and other details are to be carefully documented to ensure accurate calculation of scores like ISS and TRISS. Special considerations for injuries related to burns, hypothermia, and COVID-19 during the pandemic are also outlined.

1. Alaska Trauma
Registry Training
TRAUMA PROGRAM
RURAL AND COMMUNITY HEALTH SYSTEMS
STATE OF ALASKA, DIVISION OF PUBLIC HEALTH

2. Diagnosis

3. Four tabs under
Diagnosis:
Trauma Diagnosis
Non Trauma Diagnosis
Comorbidities
Notes

4. Let’s look at the registry

5. Diagnosis: Trauma Diagnosis
• Injury Diagnosis
• S00-S99 A,B,C; T07, T14, T15-T19 T20-T28*, T30-T32, T33-T34*,T68, T71, T73-
T76*, T79*
• Enter all letters in caps
• Enter injury narrative as described by physicians, radiologist, consults and
nurses
• Enter one diagnosis per line
• Leave blank if only Non-Trauma Diagnosis
• Do not enter NA or unknown

6. Diagnosis: Trauma Diagnosis
• Select “Tri-Code” button
• Auto-generate the diagnosis in Trauma Diagnosis Grid
• ICD 10 code, PreDot, Severity and ISS Body Region
• Invalid ICD10 Code description “@ <Non-trauma code>”
• Check code (typo or not all caps)
• Non-trauma diagnosis
• ISS and TRISS calculated

7. Diagnosis: Trauma Diagnosis

8. Diagnosis: Trauma Diagnosis
• Injuries Needing Special Attention
• Burns
• Smoke Inhalation
• Hypothermia
• COVID (2020)

9. Diagnosis: Trauma Diagnosis
• Burns
• Tricoder does not automatically calculate the % TBSA burn List each body part
burned by degree
• Or calculates % TBSA inaccurately
• Add statement for TBSA % for each degree
• 2% TBSA 1st degree burns
• 5% TBSA 2nd degree burns
• 10% TBSA 3rd degree burns
• Tri-code
• Look for T31.0 diagnosis in Trauma Diagnoses Grid
• Matches actual TBSA burned

10. Diagnosis: Trauma Diagnosis - Burns

11. Diagnosis: Trauma Diagnosis - Burns

12. Diagnosis: Trauma Diagnosis - Burns

13. Diagnosis: Trauma Diagnosis
• Smoke Inhalation
• Inhalation lung injuries with descriptions
• Read all physician/nurses notes
• Findings upon visualization (e.g. intubation, bronchoscopy)
• Erythema
• Carbonaceous deposits
• Edema
• Bronchorrhea
• Obstruction
• With out findings Tricode gives NFS code without severity
• Severe injury requiring appropriate severity code for ISS

14. Diagnosis: Smoke Inhalation AAAM Guidelines
• Smoke Inhalation

15. Diagnosis: Trauma Diagnosis
• Hypothermia
• Enter lowest temperature patient experienced (or documented) to get
accurate PreDot and ISS
• Prehospital, document in provider notes
• Can either be in C or F

16. Diagnosis: Trauma Diagnosis - Hypothermia

17. Diagnosis: Trauma Diagnosis - Hypothermia

18. Diagnosis: Trauma Diagnosis - Hypothermia

19. Diagnosis: Trauma Diagnosis
• COVID19
• ACS (American College of Surgeon) Request due to COVID19 Pandemic
• Enter diagnosis on Trauma Diagnosis Screen
• ACS:
• CONFIRMED = U07.1
• SUSPECTED, POSSIBLE, PROBABLE = Z20.828
• ACS is expecting this information on all trauma patients as of April 1, 2020 but
will accept back to Jan 1, 2020

20. Diagnosis: Trauma Diagnosis – COVID19

21. Diagnosis: Trauma Diagnosis
• ISS
• Reflect the level of severity of the patient’s injuries
• Auto-calculated from Trauma Grid
• TRISS
• Survival probability (Ps) for a patient
• Injury Type (blunt/penetrating)
• RTS
• Systolic BP, Respiratory Rate, GCS
• ISS
• Injury Diagnosis

22. Diagnosis: Trauma Diagnosis
• % TBSA 2nd & 3rd Degree Burn
• Total percentage of body surface area of 2nd and 3rd degree burns
• Rule of Nine
• Enter NOT APPLICABLE – when not a burn or fire victim.
• Smoke inhalation victims without burns, enter 0%

23. Four tabs under
Diagnosis:
Trauma Diagnosis
Non Trauma Diagnosis
Comorbidities
Notes

24. Diagnosis: Non Trauma Diagnosis
• Non Trauma Diagnosis – Reason for Admission
• Poisonings (Codes T36-T60, T65-T66)
• Injury Diagnosis not accepted on the Trauma Diagnosis screen
• T15-T19 (foreign bodies)
• T73-T74 (abuse, confirmed) [not diagnosis code, is mechanism code]
• T76 (abuse, suspected) ) [not diagnosis code, is mechanism code]
• T79.1-T79.7 (sequalae to trauma)
• Air embolism, fat embolism, secondary or recurrent hemorrhage, shock,
anuria, muscle ischemia, subq emphysema)
• Compartment syndrome entered on Trauma Diagnosis screen
• No non-trauma diagnosis leave screen blank

25. Diagnosis: Non Trauma Diagnosis
• Check
• There must be at least one trauma or non-trauma diagnosis

26. Four tabs under
Diagnosis:
Trauma Diagnosis
Non Trauma Diagnosis
Comorbidities
Notes

27. Diagnosis: Comorbidities
• Comorbidities
• Pre-existing co-morbid factors
• Present before patient arrival at the ED/hospital (injury)
• Enter up to 20
• Valid Co-Morbid Condition has a diagnosis in medical record
• Definition listed in Alaska Data Dictionary
• Other comorbidities
• Select other
• Free-text in “if other” box

29. Thank you