trauma scoring
TRANSCRIPT
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
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
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
classified [email protected]
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
Trauma Scoring
Anatomical indices
AIS
ISS
NISS
Physiological scale
Trauma score
Revised Trauma Score
CRAMS scale
predict outcome from trauma
know the prognosis
Abbreviated Injury Scale
Anatomical-based coding system to
classify and describe the severity of
injury
The score describe; type, location, and
severity
AIS: Body region
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
AIS: Anatomic structure
AIS Code Region
1 Whole area
2 Vessels
3 Nerve
4 Organs + muscle / ligaments
5 Skeletal + joints
6 Los s of conscious (head only)
AIS: whole area
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
AIS: whole area
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
Injury Severity Score
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
6 IIS Body region
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
Injury Severity Score (ISS)
ISS = sum of 3 highest2AIS
= a2 + b2 + c2
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
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
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
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
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%
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
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
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
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
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.
CRAMS scale
Major trauma ≤ score 8
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
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
Early Severity Scales
Burden of injury: live or dead
Live: bleeding or not bleeding
Injured: treated or not treated
Treated: ER, released, or admitted
Pre-hospital triage score
Variables Points
GCS 3-15
Blunt trauma 4
SBP 120 mmHg = 5, 60-120 mmHg = 3
Age > 60 years = 5
Risk Point Mortality
low 23-29 2.8%
intermediate 18-22 15%
high <18 48%
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
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
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
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
EARLY WARNING
SCORE
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
MODIFIED
EARLY WARNING
SCORE
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
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
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
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
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).
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
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).
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
Scoring system
Patient safety
Preventing harm
Reduce in-hospital cardiac arrest
• Early recognition
• Rx of deteriorating patient.