Assessment of the severity of injury

Scale of injury assessment

Trauma Score (Champion NA, et al., 1981)

The trauma evaluation scale assesses the key physiological parameters, a change in which, after trauma, allows patients at risk to be identified. The scale includes five main vital indicators: respiration rate, respiration pattern, systolic blood pressure, capillary filling time, Glasgow coma scale (GCS).

Options	Characteristics	Points
Capillary filling time	Naughty	2
	Delay	1
	Absent	0
Scale Coma Glasgow	14-15	5
	11-13	4
	8-10	3
	5-7	2
	3-4	1
Breathing rate	> 36 per minute	2
	25-35 per minute	3
	10-24 per minute	4
	0-9 per minute	1
	Absent	0
The nature of breathing	Normal	1
	Superficial	0
	Intermittent	0
Systolic blood pressure, mm Hg. Art.	> 90 mm Hg. Art.	4
	70-89 mm Hg. Art.	3
	50-69 mm Hg. Art.	2
	0-49 mm Hg. Art.	1
	Lack of pulse	0

Score on the injury scale is made by summing the results according to the five characteristics presented above. The maximum score is 16 points, and the minimum score is 1 point.

The impact of the evaluation on the injury scale (PI) on the probability of survival (BB) is presented below.

PC	16	15	14	13	12	Eleven	10	9	8	7th	6th	4	3	2	1
BB	99	98	95	91	83	71	55	37	22	12	07	04	02	01	0

Modified scale of injury assessment

Revised Trauma Score (RTS) (Champion HR et al., 1986)

A modified scale for assessing trauma is often used in case of emergency with a large number of victims right at the scene.

Options	Characteristics	Points
Breathing rate	10-29 per minute	4
	> 29 per minute	3
	6-9 per minute	2
	1-5 per minute	1
	0	0
Systolic blood pressure	> 89 mm Hg. Art.	4
	76-89 mm Hg. Art.	3
	50-75 mm Hg. Art.	2
	1-49 mm Hg. Art.	1
	0	0
Scale Coma Glasgow	13-15	4
	9-12	3
	6-8	2
	4-5	1
	3	0

An evaluation of the modified injury scale is carried out by summing up the results for each individual trait.

The maximum score (reflecting the degree of maximum damage) is 12 points, and the minimum (minimum damage) is 0.

When assessing <11 points, the trauma is potentially dangerous, and such patients must be hospitalized in specialized departments. 3.

Injury index

Trauma Index (Kirkpatric JR, Youmans RL, 1971)

Options	Characteristics	Points
	Head or neck	6th
Area of damage	Chest or stomach	4
	Back	3
	Skin or limbs	1
	Mixed trauma	6th
Type of damage	Blunt Trauma	4
	Knife wound	3
	Rupture or bruise	1
	Lack of pulse	6th
	Blood pressure <80 HR> 140	4
The cardiovascular system	Blood pressure <100 HR> 100	3
	External bleeding	1
	Norm	0
	Coma	6th
Central nervous system	Loss of sensitivity and movement	4
	Sopor	3
	Stunning	1
	Norm	0
	Lack of breathing and cyanosis	6th
	The presence of aspiration	4
Respiratory system	Violation of the rhythm of breathing and hemoptysis	3
	Chest pain	1
	Norm	0

The injury index can be used to quickly assess patients with traumatic injury.

Gradation of severity of damage:

Minimal damage is 1 point.

Damage of moderate severity - 3-4 points.

Severe damage - 6 points.

The score on the injury index is based on the summation of the results of the study of all signs of the scale. The minimum score is 2 points, and the maximum is 30. When assessing more than 7 points the patient must be hospitalized.

Nb !: The injury index is not intended to assess the severity of patients with burns.

Scale of severity assessment of injuries CRAMS

CRAMS Scale Score (ClemmerT, P. Et al., 1985)

The CRAMS scale (circulation, respiration, abdomen, motor, speech) is based on 5 parameters, the rapid assessment of which allows us to identify a group of patients in need of transportation to specialized departments. This approach allows us to sort patients who do not need treatment in specialized trauma units. The scale includes five main indicators:

1. Systolic BP or time of capillary filling.
2. Breath.
3. The nature of damage to the chest or abdomen.
4. Physical activity.
5. Speech reaction. 

Options	Characteristics	Points
Systolic blood pressure or capillary filling time	AD> 100 mm. Gt; Art. Or normal capillary filling time	2
	85	1
	Blood pressure <85 mm. Gt; Art. Or lack of capillary filling	0
Breath	Normal	2
	Abnormal (difficult, weak, frequent)> 35 per minute	1
	Absent	0
The nature of damage to the chest or abdomen	Abdominal or thoracic walls painless	2
	Abdominal or thoracic walls painless	1
	The abdominal wall is strained, the chest wall flotates or deep penetrating wounds of both cavities	0
The motor reaction	Normal	2
	Only in pain	1
	Absent	0
Speech Reaction	Correct	2
	Some indistinct words	1
	Speech is absent	0

Dependence of mortality on the severity of injury on the CRAMS scale

Severity of injury according to the CRAMS scale	0	1	2	3	4	5	6th	7th	8	9	10
Mortality,%	100	80	83	86	80	32	15	3.3	0.5	0	0

CRAMS score = Results of systolic blood pressure or time of capillary filling + Results of breath study + Damage assessment + Motor reaction evaluation + Evaluation of speech production.

The maximum score (indicating the smallest defeat) is 10, and the minimum score (indicating the largest defeat) is 0 points.

A score of <8 points indicates severe trauma (patients need urgent surgical intervention), and in assessing 5-9 points, only minimal damage occurs.

The abbreviated scale of damage

Abbreviated Injury Scale (AIS) (Copes WS, Sacco WJ, Champion HR, Bain LW, 1969)

The abbreviated (short) AIS damage scale is an injury assessment system that allows you to accurately determine the severity of the damage. It was first proposed in 1969, but at present it has undergone significant changes. The latest changes were made to the scale in 1990.

Damages are ranked on a scale from 1 to 6 points, where 1 is the minimum damage, 5 - heavy and 6 - disparate with life.

AIS scores	Damage
1	Lung
2	Medium
3	Heavy
4	Very heavy
5	Extremely heavy
6th	Terminal

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Injury Severity Score (ISS) (Baker SP et al., 1974) 

The ISS severity rating is an anatomical system for assessing the severity of injury, which was suggested for use in patients with multiple wounds. The ISS score is based on gradations of severity of damage that are used in the AIS scale and are ranked from 1 to 5 points:

1. score - trauma of mild severity;
2. score - a trauma of an average degree of gravity;
3. score - not a life-threatening injury of moderate severity;
4. score - a life-threatening injury with a high probability of survival of the patient;
5. points - a trauma incompatible with life.

At the same time, it should be noted that, unlike the AIS scale, all lesions are distributed over the anatomical areas (head and neck, chest, abdomen, limbs and pelvis, external injuries), which makes it possible to identify areas with the most severe injuries.

When analyzing the severity of damage, only the maximum damage assessment of each area of the body is used. For the total assessment on the ISS scale, the three most affected areas of the body are taken, after which the most severe lesions in these areas are allocated and their estimates are squared. The overall score on the ISS scale is equal to the sum of the squares of the estimates of the three most severe lesions. An example of the ISS scale calculation is presented below.

Anatomical Region	Description of damage	Evaluation	Evaluation
Head and neck	Cerebral Contusion	3	9
Face	No Injury	0
Chest	Flail Chest	4	16
Stomach	Minor Contusion of Liver	2
	Complex Rupture Spleen	5	25
Limbs and pelvis	Fractured femur	3
Leather, soft fabrics	No Injury	0
Overall score on the ISS scale			50

The maximum score on the ISS scale is 75 points, and the minimum score is zero. In the event that at least one damage has an estimate of five, the total score on the ISS scale is immediately estimated at 75 points.

The ISS scale is in fact the only anatomical assessment system and closely correlates with mortality, morbidity, hospital stay and other severity criteria.

Mortality correlation with the ISS score

Evaluation	Mortality,% <49	Mortality,% 50-69	Mortality,%> 70
5	0	3	13
10	2	4	15
15	3	5	16
20	6th	16	31
25	9	26th	44
Thirty	21	42	65
35	31	56	82
40	47	62	92
45	61	67	100
50	75	83	100
55	89	100	100

At the same time, despite the numerous advantages of the ISS scale, it should be noted that a mistake in assessing the degree of severity on the AIS scale can lead to errors in the overall assessment of ISS. It should also be noted that various injuries can get the same score on the ISS scale, while the effect of the damage area on the final score on the scale is not yet determined.

In addition, the ISS scale can not be used to sort victims, as in most cases the final diagnosis can not always be established without detailed patient examination or surgical intervention.

Scale for assessing the severity of injury and injury

Trauma and Injury Severity Score (TRISS) (Boyd CR, Toison MA, Copes WS, 1987)

The scale for assessing the severity of injuries and injuries was developed to determine the amount of necessary trauma care in patients with severe injuries by predicting survival.

It is designed for use in small hospitals to assess the quality of care or compare outcomes in different health facilities.

The scale is represented by three subscales (modified RTS injury scale, ISS scale, patient age rating scale) and coefficients for blunt and penetrating wound.

Evaluation of the modified scale of injury RTS is carried out at the time of admission to hospital, and on the scale of ISS - after the diagnosis of damage.

Components of the modified injury scale (RTS)

Options	Characteristics	Points
The Glasgow Coma Scale	13-15	4
	9-12	3
	6-8	2
	4-5	1
	3	0
Systolic blood pressure	> 89	4
	76-89	3
	50 75	2
	1-49	1
	0	0
Breathing rate	10-29	4
	> 29	3
	6-9	2
	1-5	1
	0	0

The overall score for the modified injury scale is RTS = (0.9368 x Score for the Glasgow score) + (0.7326 x Systolic BP score) + (0.2908 x BT score).

General assessment of the severity of damage on the ISS scale = First maximum score on the IIS2 scale + Second maximum score on the IIS2 scale + Third maximum score on the ISS2 scale.

The maximum score for ISS is 75 points.

Estimating patient's age

Age, years	Points
<54	0
> 55	1

Coefficients for calculating the TRISS equation

Research	Type of injury	Coefficient	Value
The coefficients obtained in the study MT08 *	Dumb	IN	-1.2470
		IN 1	0.9544
		AT 2	-0.0768
		VZ	-1.9.052
	Penetrating	IN	-0.6029
		IN 1	1.1430
		AT 2	-0.1516
		VZ	-2.6676
Coefficients obtained in the Satrip study, 1990	Dumb	IN	-1.3054
		IN 1	0.9756
		AT 2	-0.0807
		VZ	-1.9829
	Penetrating	IN	-1.8973
		IN 1	1.0069
		AT 2	-0.0885
		VZ	-1.1422

* - MTOS - Major Trauma Outcome Study (study on the evaluation of outcomes of severe trauma). The data obtained before 1986 were used.

Equation TRISS (probability of survival):

B = BO + (BI x RTS) + (B2 x ISS) + (W3 x (Points for age)). Probability of survival = 1 / (1 + Exp ((-1) x B)). Limitations: a number of researchers believe that the reliability of the results obtained by TRISS is not always high. It is suggested that additional studies may be needed to obtain more accurate coefficients for different patient groups.

Scales for assessing the severity of injury in children

Pediatric injury scale

Pediatric Trauma Score (PTS) (Tepas J. J. Et al., 1985)

Characteristic	+2	+ 1	-1
Weight, kg	> 20	10-20	<10
Respiratory tract	Norm	Partially passable	Inaccessible, additional measures are required
HELL	> 90 mm. Gt; The heart rate is determined by a. Radialis	50-90 mm. Gt; Art., palpable carotid pulse	<50 mm. Gt; Art., pulse is not palpable
Level of consciousness	In the mind	Disrupted	Coma
Open wounds	None	Small	Large or penetrating
Damage to the skeleton	None	The minimum	Open or multiple

The total score on the scale:

9 - 12 points light trauma;

6-8 points - a potential threat to life; 0-5 points - a life-threatening condition; Less than 0 points is a fatal situation.

Score by PTS	Exodus
8	Probability of death <1%
<8	It is necessary to be hospitalized in a specialized department
4	Probability of death is 50%
<1	Probability of death> 98%

Children's scale of severity of trauma (Rogsy E., 1994)

Clinical category	Score
	+2	+1	-1
Body mass	> 20 kg	10-20 kg	<10 kg
Respiratory tract	Normal	Passable	Impenetrable
Systolic blood pressure	> 90 mm Hg. Art.	50-90 mm Hg. Art.	<90 mm Hg. Art.
Central nervous system	Consciousness is clear	Confusion / loss of consciousness	Coma / Decerebriation
Open wound	No	Minor	Extensive / penetrating
Bone system	No	Closed fracture	Open / multiple fractures

If there is no cuff for determining blood pressure, use the following scores: + 2-pulse at the wrist is palpated; +1 - the pulse in the groin is not palpable; -1 - the pulse is not palpable.

If the overall score on a scale of <8 points, immediately begin to provide care and hospitalize the child in the hospital. 7.3.

Modified scale of severity of injury

Modified assessment of injury, scores	Scale Coma Glasgow	Systolic blood pressure, mm Hg. Art.	Respiratory rate, min
4	13-15	> 89	10-20
3	9-12	76-89	> 29
2	6-8	50-75	6-9
1	4-5	1-49	1-5
0	3	0	0

Each indicator has an estimate from 0 to 4 points, then all points are added (the amount is from 1 to 12). A score of <11 points indicates a serious injury.

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