trauma scoring
TRANSCRIPT
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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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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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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]
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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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Trauma Scoring
Anatomical indices
AIS
ISS
NISS
Physiological scale
Trauma score
Revised Trauma Score
CRAMS scale
predict outcome from trauma
know the prognosis
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Abbreviated Injury Scale
Anatomical-based coding system to
classify and describe the severity of
injury
The score describe; type, location, and
severity
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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
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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)
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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
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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
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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
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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
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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
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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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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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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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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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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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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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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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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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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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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
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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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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
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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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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%
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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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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
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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
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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
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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
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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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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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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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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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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).
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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
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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).
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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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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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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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Scoring system
Patient safety
Preventing harm
Reduce in-hospital cardiac arrest
• Early recognition
• Rx of deteriorating patient.