Trauma Scoring - Surgical Foundations Residency Program

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Trauma Scoring
BC Trauma Registry
October 24, 2011
Nasira Lakha
Dori Williams
We’ll talk about…
 Abbreviated
Injury
Scale (AIS)
 Injury Severity
Score (ISS)
 Revised Trauma
Score (RTS)
 TRISS




What do they mean?
Why are they important?
How does my
documentation make an
impact?
What is it all used for?
Trauma Scoring
 “Several
trauma severity scales are used
to quantify injury severity and describe
patient severity casemix. Once injury is
thus characterized, the results can be
applied to triage, resourcing, research and
quality of care assessment.”

1. Champion, HR: Trauma Scoring. Scandinavian Journal of Surgery 91: 2002.
 Different
scoring systems exist to predict
survival probability.
 Although each scale can be used on its
own as a predictive model, injury
characterization involves complex
descriptors which are both anatomical
and physiological.
 Therefore, there is a need for more than
one single descriptor for injury
characterization.
Abbreviated Injury Scale
 The Abbreviated
Injury Scale (AIS) is an
anatomical global scoring system first
introduced in 1971 by an Injury Scaling
Committee of the Association for the
Advancement of Automotive Medicine.
 The AIS provides a standardized
numerical method for ranking and
describing the severity of injuries
throughout the body.
history…







In mid-1960s, there was a need for a standardized system for
categorizing injury type and severity at the same time as the first
generation of multi-disciplinary motor vehicle crash investigation
teams came to be.
Teams comprised of specialists in engineering, medicine,
anatomy/physiology and crash investigation were responsible for
collecting data for evaluation of vehicle design in relation to injury
incidence and mechanism.
The goal was to obtain standardized data on frequency and severity of
motor vehicle related injuries.
Under the sponsorship of the AAAM, American Medical Association
and the Society of Automotive Engineers and about 35 other
consultants, the first AIS was published.
The Injury Severity Score was then developed.
AIS was expanded to include injuries other than those that occur with
vehicular trauma.
Several revisions followed – AIS 85, AIS 90, AIS 95, AIS 2005
AIS
9 Chapters
Head
Face
Neck
Thorax
Abdomen & Pelvic Contents
Spine
Upper Extremities
Lower Extremities
External, Burns & Other Trauma
AIS
Severity Code
AIS Code
Injury Description
1
Minor
2
Moderate
3
Serious
4
Severe
5
Critical
6
Maximal
(currently untreatable)
Structure of Numerical Identifier:
E.g. Tibial shaft fracture, open = 853422.3
8 = Body Region: Lower Extremity
5 = Type of Anatomic Structure: Skeletal
34 = Specific Anatomic Structure: Tibia
22 = Level of Injury: Shaft
.3 = Severity Code: Serious
AIS injuries are categorized as
follows within each chapter:
Whole Area
Vessels
Nerves
Internal Organs
Skeletal
Some chapters have more detail:
Head– has two additional categories:
 Length of Unconsciousness
 Level of Unconsciousness
Spine– is divided into 3 sections: Cervical, Thoracic
and Lumbar and has a unique structure:
 Cord Injury
 Disc Injury
 Ligament Injury
 Nerve Root Injury
 Whole Area
Cervical Spine also contains: Brachial Plexus injury
Lumbar Spine also contains: Cauda Equina injury
And…
Abdomen & Pelvic Contents - does not contain
skeletal injuries
Upper & Lower Extremities - includes 2 additional
categories:
 muscles, tendons, ligaments
 joints
External, Burns, Other Trauma has a unique structure:
 Skin and Subcutaneous Tissue
 Burns
 Other Trauma
Injury descriptors affect the severity
score of AIS:
Loss of nerve function (total or partial)
Basal skull fracture (CSF leak or not)
Closed head injury/Blunt abdominal injury (leads to a non-specific
code)
Blood loss (pre-hospital and hospital)
Vessel laceration (complete vs. incomplete transection)
Pneumothorax (delayed appearance – complication?)
Spinal cord injury (contusion vs. laceration and incomplete vs.
complete)
Skin injuries (length of laceration, size of avulsion or depth of
penetrating injury)
Pelvic Fracture (major vessel injury involvement?)
Abdominal organ injuries (Organ Injury Scaling)
Primary Injury Types
Blunt





Assault
Crush
Falls (3 categories)
Other Blunt
Vehicular Crash
Thermal



Burn
Cold Exposure
Electrical
Penetrating



Cut
Firearm
Stab
Asphyxia



Drowning
Suffocation
Strangulation
Scenario
 The
patient was involved in a multi-vehicle
car crash. Chest CT indicated multiple
displaced and comminuted rib fractures
bilaterally, a (L) pulmonary contusion,
hemomediastinum, a fractured sternum
and a (L) lung laceration. The patient was
admitted to ICU for ventilatory support.
There were also contusions to the arms,
legs, chest and forehead.
B.C. TRAUMA REGISTRY A.I.S. WORKSHEET
ABBREVIATED INJURY SCALE (A.I.S.)
BODY REGION
INJURY DESCRIPTION
.
.
.
.
.
.
.
.
HEAD
OR
NECK
(contusion – forehead
210402 . 1
.
.
.
.
FACE
CHEST
A.I.S.
# ribs: (L) and (R) – displaced / comminuted
(L) pulmonary contusion
# sternum
(L) lung laceration with hemomediastinum
450250 . 3
441406 . 3
450804 . 2
441434 . 4
4
.
contusion – chest
410402 . 1
.
.
.
.
.
.
.
.
.
.
.
.
ABDOMINAL
OR
PELVIC
CONTENTS
EXTREMITIES
OR
PELVIC
GIRDLE
(contusion - arms
(contusion - legs
710402 . 1
810402 . 1
.
.
.
.
EXTERNAL
INJURY SEVERITY SCORE (I.S.S.)
HIGHEST A.I.S. FOR THE 3 MOST SEVERELY INJURED
BODY REGIONS
2
2
2
_____4 ___+ ___1 ___ + _________
abstract worksheet 04.01.08 – Copyright BC Trauma Registry
=____17___
1
INJURY SEVERITY SCORE

The Injury Severity Score was derived to
summarize the severity of the condition of
multiply injured patients.
 Each injury is assigned an AIS score, allocated
to one of six ISS body regions (Head or Neck,
Face, Chest, Abdominal or Pelvic Contents,
Extremities or Pelvic Girdle, External).
 Only the highest AIS score in each ISS body
region is used. The ISS is calculated as the:
Sum of the squares of the highest AIS
code in each of the three most severely
injured ISS body regions
Example
ISS Body
Region
Injury Description
Head & Neck
Cerebral Contusion
3
Face
No Injury
-
Chest
Flail Chest
4
16
Abdomen
Minor Contusion of Liver
Complex Rupture Spleen
2
5
25
Extremity
Fracture femur
3
External
No Injury
-
Injury Severity Score:
AIS
Square Top Three
9
50
ISS ranges from 1 – 75
 A score
of 75 results in one of two ways,
either with three AIS 5 injuries, or with at
least one AIS 6 injury.
 Any injury coded as AIS 6 is automatically
assigned an ISS of 75.
 It is not possible to calculate an ISS on a
patient who has AIS 9 injury (the AIS code
is unknown); hence, the need for detailed
injury information.
Revised Trauma Score
The Revised Trauma Score is a physiological
scoring system. It is scored from the initial data
obtained on the patient.
The RTS correlates with the probability of survival.
Components:
 Glasgow Coma Score
 Systolic Blood Pressure
 Respiratory Rate
TRISS Methodology
Trauma and Injury Severity Score (TRISS) was
designed to calculate individual patient survival
probabilities and to identify major trauma patients
with unexpected outcomes.
Risk adjusted mortality is calculated using TRISS
methodology as a benchmarking tool to define
performance against an historical international
benchmark, the Major Trauma Outcome Study
(MTOS).
Components:
 Revised Trauma Score (RTS)
 Injury Severity Score (ISS)
 Patient age
 Mechanism of injury
This comprehensive dataset on
the most severely injured
patients in BC is utilized for:
 Research
activities
 Injury prevention
 Program reports
 System planning
 Performance improvement
 Resource utilization
 Patient care
QUESTIONS?
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