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Trauma Scoring Systems

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Limitations of Revised Trauma Score Not practical in field Underestimate the severity of head injury Problems: Intubated patients Influence of alcohol Drugs The ... – PowerPoint PPT presentation

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Title: Trauma Scoring Systems


1
Trauma Scoring Systems
2
  • To understand the basic principles of injury
    scoring systems.
  • To review the principal of anatomical and
    physiological injury scoring systems.

3
  • Why should severity be assessed in trauma
    patients
  • How can severity be assessed in trauma patients
  • Where pre-hospital or hospital
  • What is advantages and dis-advantages

4
INTRODUCTION
5
Trauma has been termed the neglected disease of
modern society, is among the leading causes of
death in all age groups. Each year it is
estimated that around 5.8 million people
worldwide die as a result of trauma, with 90 of
these deaths occurring in middle- and low-income
countries.
6
  • Trauma is the third cause of death after cancer
    and cardiovascular diseases in the overall
    population.
  • Hemorrhagic shock and traumatic brain injury
    (TBI) remain the leading causes of death
    accounting respectively for 30 and 50 in trauma
    patients arriving alive at the hospital
    (Harroisetal 2013)

7
Severity assessment in trauma patients is
mandatory. when? It started during initial phone
call that alerts emergency services when a trauma
occurred. On-call physician assesses severity
based on witness provided information, to adapt
emergency response.
8
Whenever information comes, it helps providing
adequate therapeutics and orientating the patient
to the appropriate hospital. Severity assessment
is based upon pre-trauma medical conditions,
mechanism of injury, anatomical lesions and their
consequences on physiology.
9
Assessment of injury severity is important
clinically to
10
How can severity be assessed in trauma patients
11
  • Three main groups of trauma scores
  • Anatomical ( measure static component of injury).
  • Physiological (measure acute dynamic component).
  • Combined

12
  • Traumatic patients may have normal physiology but
    may have anatomical lesions that require high
    level of care
  • Injury Severity Score (ISS)
  • Abbreviated Injury Scale (AIS)
  • New Injury Severity Score (NISS)
  • Anatomic Profile (AP)

13
  • (help determining prognosis)
  • Revised Trauma Score (RTS).
  • Glasgow Coma Score (GCS).

14
  • Trauma related Injury Severity Score - (TRISS).
  • International Classification of Diseases
    Diseases-based ISS - (ICISS).

15
  • Was developed to rate and compare blunt injuries
    from road vehicle accidents.
  • It has undergone several modifications since its
    introduction in 1971. currently updating AIS
    -2000.
  • The AIS scores individual injuries and classifies
    them into one of six categories, each with an
    associated severity score ranges from1 (minor) to
    6 (lethal).
  • The severity scores were subjectively assigned by
    experts.

16
  • Abbreviated Injury Scale - (AIS)
  • Injury - AIS score
  • Minor
  • Moderate
  • Serious
  • Severe
  • Critical
  • Un-survivable (fatal).

17
  • AIS Limitations
  • No comprehensive measure of severity
  • Subjective
  • Not predicting patient outcomes or mortality

18
  • Hospital score
  • The first significant scoring system to be based
    primarily on anatomic criteria was developed in
    1974.
  • Was created to define injury severity for
    comparative purposes.
  • The strength of this system lies in its
    incorporation of anatomic indices and severity
    indices.

19
  • Injury Severity Score
  • Six body regions
  • Head.
  • Face.
  • Chest.
  • Abdomen (including Pelvis).
  • Extremities.
  • External.

20
Example Injury Severity Score
Square top 3 AIS injury descripition Region
9 0 16 25 50 3 0 4 5 3 0 Cerebral contusion No injury Flail chest Liver contusion, spleen Fracture femur No injury ------------------------------- Headneck Face Chest Abdomen Extremity External ISS
21
  • Injury Severity Score
  • 3 most severely injured body regions score
    squared and added
  • ISS a2b2c2
  • Values ( 0 75 )
  • Patient with an ISS above 15 is considered as
    severe trauma patient.
  • Any lesion with an AIS of 6 will automatically
    lead to increase ISS severity score.

22
  • Limitations of Injury Severity Score
  • Error in AIS scoring increases ISS error
  • Limits total number of injuries to 3 regions
  • Description of patient injuries unknown
  • Not a triage tool
  • Does not take into account age or co-morbidities
  • Not accurate for grading penetrating trauma

23
  • New Injury Severity Score - NISS
  • Modified in 1997 from ISS
  • It equals The sum of the squares of the AIS of
    each of the three most severe AIS injuries,
    regardless of the body region in which they occur.

24
  • New Injury Severity Score
  • Predicts survival
  • Easier to calculate than ISS
  • Limitations of New Injury Severity Score
  • No account for physiological variables

25
  • Anatomic Profile - (AP)
  • Because of ISS limitations,a multidimensional
    characterization was sought that considers the
    number, location and severity of anatomic
    injuries and their influence on outcome.
    Includes all the serious and non-serious a
    injuries.

26
  • Anatomic Profile
  • To describe apatients injuries
  • It uses Four categories (variables)

A - Head and spinal cord B - Thorax and anterior
neck C - All remaining serious injuries D - All
non serious injuries.
  • Serious ? (AIS 3)

27
  • Anatomic Profile
  • The scores are combined using an Euclidean
    Distance Model viz. the square root of the sum of
    the squares of the AIS scores of all serious
    injuries in each region.
  • No injury Zero
  • allowing for decreasing influence of injuries as
    the number of injuries increases.
  • Limitations
  • Mathematical complexity

28
Physiological Scores
29
  • Trauma Score 1980 (TS)
  • The widely used pre-hospital field triage tool
    ,it has stood the test of time.
  • a useful predictor of outcome for patients with
    blunt or penetrating injuries.
  • Components
  • Glasgow Coma Scale (GCS)
  • Systolic Blood Pressure (SBP)
  • Respiratory Rate (RR )
  • Respiratory expansion
  • Capillary refill

30
  • Triage-Revised Trauma Score 1989 (RTS)
  • Components
  • Glasgow Coma Scale (GCS)
  • Systolic Blood Pressure (SBP)
  • Respiratory Rate (RR)

31
  • Two types of RTS
  • The coded form of the RTS is more frequently used
    for quality assurance and outcome prediction. The
    coded RTS is calculated as follows RTSc 0.7326
    SBPc 0.2908 RRc 0 .9368 GCSc
  • Triage RTS Determined by adding each of the
    coded values together.

32
TheTriage- Revised Trauma Score
33
  • Triage-Revised Trauma Score
  • Ranges 012
  • Score lt 11 - transfer to trauma center
    (specificity 82, sensitivity59)
  • Predicting mortality with RTS

RTS Mortality()
12 lt1 10 12 6 37 2 70 0 gt99
Champion HR, Sacco WJ, Copes WS, et al. A
revision of the trauma score. J Trauma
198929625, with permission
34
  • Limitations of Revised Trauma Score
  • Not practical in field
  • Underestimate the severity of head injury
  • Problems
  • Intubated patients
  • Influence of alcohol
  • Drugs

35
The Glasgow Coma Scale - (GCS)
  1. No eye opening.
  2. Eye opening to pain.
  3. Eye opening to verbal command.
  4. Eyes open spontaneously.
  1. No motor response.
  2. Extension to pain.
  3. Flexion to pain.
  4. Withdrawal from pain.
  5. Localising pain.
  6. Obeys Commands.
  1. No verbal response
  2. Incomprehensible sounds.
  3. Inappropriate words.
  4. Confused
  5. Orientated

36
Combination Indices/Models
37
  • Combination scoring system
  • Probability of trauma survival using anatomical
    and physiological scores.
  • A logarithmic regression equation is used
  • Ps 1/ (1e(-b)) , The bs are regression
    coefficients.
  • where b bo b1(RTS) b2(ISS) b3(AgeScore).
  • RTS (0.9368 x GCS) (0.7326 x BPsys) (0.2908
    x RR)
  • ISS calculated as above
  • AgeScore 0 if lt55y or 1 if gt55y.
  • Coefficients (b0 b3) depend on type of trauma

38
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39
  • TRISS Limitations
  • Only moderately accurate for predicting survival
  • Problems already noted with the ISS
  • Similar to RTS, it cant include tubed patients
    as RR verbal responses not obtainable
  • Multiple injuries to same body region cannot
    measure

40
TRISS has been the pre-eminent trauma outcome
prediction model for the past 20 years. It is
used to compare patient outcomes. Its greatest
frailty is related to the Injury Severity Score
(ISS). For that reason, ISS was replaced in the
TRISS formulation by AP to create ASCOT.
41
When comparing ASCOT and TRISS, the ASCOT
performs much better on outcome prediction than
TRISS. However its complexity has deterred many
from implementing it and TRISS still remains the
mainstay of comparative analysis of trauma
patients. A study reporting the replacement of
ISS with NISS in TRISS would be a worthwhile
contribution.
42
In an attempt to create a score that assesses
severity in patients with medical prehospital
care, Sartorius et al. identified four items that
should be pooled
43
NEW GAP
44
Risk categories in new GAP(Rebecca etal 2010)
MGAP (Total points) GAP (Total points)
23 29 18 22 3 17 19 24 11 18 3 10 lt5 550 gt50 Low Medium High
45
  • Kondo et al. Critical Care 2011,
  • They studied 35,732 trauma patients in the Japan
    Trauma Data Bank from 2004 to 2009 in
    multicenters, as a prospective, observational
    study to assess whether the new Glasgow Coma
    Scale, Age, and Systolic Blood Pressure (GAP)
    scoring system, better predicts in-hospital
    mortality and can be applied more easily than
    previous trauma scores among trauma patients in
    the emergency department (ED). they concluded
    that The GAP scoring system can predict
    in-hospital mortality more accurately than the
    previously developed trauma scoring systems.

46
  • All the above-mentioned scores have been
    developed to predict mortality.
  • Severity assessment of trauma patient helps
    guiding therapeutic, as well as orientating the
    patient in an adequate hospital.
  • the GCS , RTS and GAP recommend these as the most
    reliable prehospital triage instruments.
  • Instruments include ISS,NISS, TRISS and ASCOT
    systems for assessing outcomes and mortality.

47
  • Why should severity be assessed in trauma
    patients?
  • How can severity be assessed in trauma patients?
  • Where pre-hospital or hospital?
  • What is advantages and dis-advantages?

48
  • http.//www.ATLS.org
  • http.//www.ITLS.org
  • http//www.jhsph.edu/Research/Centers/CIRP/ The
    Johns
  • Hopkins Center for Injury Research Policy
  • http//www.trauma.org/A British web web-based
    trauma resource center
  • http//www.trauma.org/scores/rtscalc.html/Revised

49
THANK YOU
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