Collective Reviews
Trauma scoring systems: a review12

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Glasgow Coma Scale

Developed in 1974 by Teasdale and Jennett7 from the University of Glasgow, Scotland, the Glasgow Coma Scale (GCS) was the first attempt to quantify severity of head injury. The scale included assessment of three variables (Table 1). The authors chose best motor response to reflect level of CNS function, best verbal response to reflect CNS integrative ability, and eye opening to reflect brainstem function. The admission GCS is predictive of severity of injury.8 It is used as an initial

Trauma Score and revised Trauma Score

In 1981, Champion and associates11 published the Trauma Score (TS) as a system for field triage. At the outset, the authors hypothesized that most early trauma deaths were secondary to injury to one or more of three systems: CNS, cardiovascular system, and respiratory system. They next analyzed a large number of variables representing the functional status of these three systems against a cohort of 1,084 patients to select the most independent predictors of outcomes. The resulting TS included

Injury Severity Scale

The first significant scoring system to be based primarily on anatomic criteria was developed in 1974 by Baker and colleagues15 from Johns Hopkins University. The Injury Severity Scale (ISS) was created to define injury severity for comparative purposes. It is not a field triage system. The best application of ISS comes in providing researchers a control of the variability of trauma severity for evaluating outcomes. Before this system was developed, it was exceedingly difficult for surgeons to

Pediatric Trauma Score

The number one cause of death in the American pediatric population is trauma.25 Most of the field triage tools are not applicable for pediatric trauma victims. For example, normal respiratory rate, heart rate, and systolic blood pressure vary considerably with infancy and childhood. Additionally, the verbal response as used in GCS is obviously inaccurate for young children. For these reasons, Tepas and colleagues26 created the Pediatric Trauma Score (PTS). In their scale, six variables are

Other scoring systems

A number of other scoring systems deserve mention both for completion and because, although not universally adopted, each has contributed to the overall understanding of trauma triage and injury severity. The Triage Index32 and the Illness-Injury Severity Index33 were both excellent early attempts to combine physiologic and anatomic indices for quantifying injury severity that unfortunately never caught on. The CRAMS (circulation, respiration, abdomen, motor, speech)34 and Trauma Triage Rule 35

TRISS

By combining the anatomic criteria of the ISS with the physiologic criteria of the RTS, the “TRISS method” for analyzing trauma data was elucidated.38 Using logistic regression analysis, the TRISS method correlates RTS with ISS to create an S50 isobar on which a 50% survival is predicted. Patient probability of survival is then plotted on the RTS versus ISS graph (Fig. 1). With the isobar in place, survivors who fall above the isobar (unexpected survivors) and those deaths below the isobar

ASCOT

In an attempt to further improve TRISS, Champion and associates43 in 1990, created ASCOT (A Severity Characteristic of Trauma) using the Anatomic Profile.44 Like ISS, the Anatomic Profile is based on AIS scores with some important differences. The Anatomic Profile created four components: component A included head, brain, and spinal cord injuries; component B included thoracic and anterior neck injuries; component C included all other major injuries; and component D included all minor injuries.

Additional statistical terms for understanding TRISS and ASCOT

In addition to grasping the complexities of the logistic regression analysis formulas previously shown, one must also understand a few more terms:

ICD-9 and ICISS systems

The latest injury severity scoring systems to arrive are the ICD-9–based models. The idea to use ICD-9 coded data to create an injury severity scoring system was a response to the amount of resources needed to implement ISS-based systems. To classify patients by AIS, a dedicated trauma registry and staff to encode, enter, and police the data is required. The AIS90 scoring is complicated and requires significant knowledge and training. Many major urban trauma centers have dedicated staff who

Overtriage and undertriage

All scoring and triage systems are susceptible to the problem of overtriage and undertriage. Overtriage is defined as the number of patients with minor injuries who are transported to a specialized trauma center. Undertriage is defined as the number of patients with severe injuries who were inappropriately triaged to nontrauma centers. There is general agreement that efforts to minimize undertriage to less than 5% to 10% at the expense of increased overtriage is desirable.57, 58 The American

Population data sets

Predictions of injury severity are only as good as the data entered and are not necessarily always representative of the patient. It is paramount to understand that prediction of outcomes cannot apply to clinical decision-making for an individual patient. These survival probabilities and triage criteria are based on the evaluation of large data sets. It is inappropriate to predict outcomes of the individual patient or to initiate treatment based on predicted outcomes. A clinician must

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    1

    No competing interests declared.

    2

    Some introductory material in this article appears in Shatz D, Kirton OC, McKenney MG, Civetta JM. Manual of Trauma and Emergency Surgery, Philadelphia: WB Saunders (October).

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