trauma scoring

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Trauma Scoring ผศ.ดร.กรองได อุณหสูต RN, Ed.D [email protected]

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Page 1: Trauma scoring

Trauma Scoring

ผศ.ดร.กรองได อุณหสูต RN, Ed.D

[email protected]

Page 2: Trauma scoring

การบาดเจ็บ The disease entity resulting from physical injury

ICD International Statistical Classification of

Disease and Related Health Problem

ICD-10 บญัชีจ าแนกโรคระหวา่งประเทศ

ฉบบัปรบัปรุงแกไ้ขคร ัง้ที ่10

S00–T88 Injury, poisoning and certain other

consequences of external causes

V00-Y99 External causes of morbidity

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Page 3: Trauma scoring

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

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Page 4: Trauma scoring

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

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Page 5: Trauma scoring

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

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Page 6: Trauma scoring

ICD-10

(Injury Diagnosis Codes)

S40-S49 Injuries to the shoulder and upper arm

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Page 7: Trauma scoring

Trauma Scoring

Anatomical indices

AIS

ISS

NISS

Physiological scale

Trauma score

Revised Trauma Score

CRAMS scale

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predict outcome from trauma

know the prognosis

Page 8: Trauma scoring

Abbreviated Injury Scale

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Anatomical-based coding system to

classify and describe the severity of

injury

The score describe; type, location, and

severity

Page 9: Trauma scoring

AIS: Body region

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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

Page 10: Trauma scoring

AIS: Anatomic structure

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AIS Code Region

1 Whole area

2 Vessels

3 Nerve

4 Organs + muscle / ligaments

5 Skeletal + joints

6 Los s of conscious (head only)

Page 11: Trauma scoring

AIS: whole area

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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

Page 12: Trauma scoring

AIS: whole area

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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

Page 13: Trauma scoring

Injury Severity Score

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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

Page 14: Trauma scoring

6 IIS Body region

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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

Page 15: Trauma scoring

Injury Severity Score (ISS)

ISS = sum of 3 highest2AIS

= a2 + b2 + c2

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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

Page 16: Trauma scoring

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

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Page 17: Trauma scoring

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

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Page 18: Trauma scoring

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

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Page 19: Trauma scoring

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%

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Page 20: Trauma scoring

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

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Page 21: Trauma scoring

FOUR Score GCS

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GCS FOUR

score

8 0-7

9-12 8-14

13-15 15-16

Page 22: Trauma scoring

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

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Page 23: Trauma scoring

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

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Page 24: Trauma scoring

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

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Page 25: Trauma scoring

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.

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Page 26: Trauma scoring

CRAMS scale

Major trauma ≤ score 8

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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

Page 27: Trauma scoring

Major Trauma / Polytrauma

ISS score

> 15

Serious

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CRAMS scores

8

Major trauma

Page 28: Trauma scoring

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)

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Page 29: Trauma scoring

b = b0+b1(RTS)+b2(ISS)+b3(ageIndex)

AgeIndex = 0 if the patient is below 54 years

= 1 if 55 years and over

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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

Page 30: Trauma scoring

Important data

ISS

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Age

Mechanism

of injury

RTS

Page 31: Trauma scoring

Early Severity Scales

Burden of injury: live or dead

Live: bleeding or not bleeding

Injured: treated or not treated

Treated: ER, released, or admitted

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Page 32: Trauma scoring

Pre-hospital triage score

Variables Points

GCS 3-15

Blunt trauma 4

SBP 120 mmHg = 5, 60-120 mmHg = 3

Age > 60 years = 5

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Risk Point Mortality

low 23-29 2.8%

intermediate 18-22 15%

high <18 48%

Page 33: Trauma scoring

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

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Page 34: Trauma scoring

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

Page 35: Trauma scoring

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

Page 36: Trauma scoring

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

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EARLY WARNING

SCORE

Page 37: Trauma scoring

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

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MODIFIED

EARLY WARNING

SCORE

Page 38: Trauma scoring

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

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Page 39: Trauma scoring

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

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Page 40: Trauma scoring

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

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Page 41: Trauma scoring

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

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Page 42: Trauma scoring

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).

Page 43: Trauma scoring
Page 44: Trauma scoring

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

Page 45: Trauma scoring

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).

Page 46: Trauma scoring

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

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Page 47: Trauma scoring

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

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Page 48: Trauma scoring

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

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Page 49: Trauma scoring

Scoring system

Patient safety

Preventing harm

Reduce in-hospital cardiac arrest

• Early recognition

• Rx of deteriorating patient.

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