TRAUMA SCORING SYSTEM.pptx

An academic presentation at the National Orthopaedic hospital dala, kano

1. TRAUMA SCORING SYSTEM By Muhyideen shehu 18/06/21

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 S everity of the anatomic trauma T he level of the physiologic response The inherent patient reserves in terms of comorbidities The age, Immunologic parameters G enetic predisposition parameters.

7. INTRODUCTION Applications P redict outcome ( for patient and family counseling) Field trauma scoring Trauma care research Quality assurance

8. CLASSIFICATION Anatomic scores Abbreviated injury scale (AIS) Injury severity score (ISS) New injury severity score (NISS) Anatomic profile (AP) Organ injury scale (OIS)

9. CLASSIFICATION CONT. Physiologic scores Glasgow coma score (GCS) Trauma score (TS) Revised trauma score (RTS) Acute physiology and chronic health evaluation (APACHE) Combine scores trauma and injury severity score (TRISS) A severity characterization of trauma (ASCOT)

10. ANATOMIC SCORES

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. T he OIS template can be found on the AAST web site.

21. PHYSIOLOGIC SCORES

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 process es 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. 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

28. APACHE II cont.

29. 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

30. COMBINED SCORES

31. 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 .

32. 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.

33. 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

34. 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.

35. THANK YOU

36. REFERENCES Rockwood and green et al. Fractures in adult: trauma scoring. (vol1, 8ed.) :316 - 319 Bouillon B, Lefering R, Vorweg M, et al. Trauma score systems: Cologne Validation Study . J Trauma. 1997;42(4): 652–658 Boyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. J Trauma. 1987;27(4):370–378 . Bouillon B, Neugebauer E. Outcome after polytrauma . Langenbecks Arch Surg. 1998; 383(3–4):228–234.