Assessing the severity of the injury

Trauma Rating Scale

Trauma Score (Champion N. A. et al., 1981)

The Trauma Assessment Scale evaluates key physiological parameters, changes in which after trauma allow us to identify patients at risk. The scale includes five main vital signs: respiratory rate, breathing pattern, systolic blood pressure, capillary refill time, and the Glasgow Coma Scale (GCS).

Parameters	Characteristics	Points
Capillary refill time	Nomal	2
	Delay	1
	Absent	0
Glasgow Coma Scale	14-15	5
	11-13	4
	8-10	3
	5-7	2
	3-4	1
Respiratory rate	>36 per minute	2
	25-35 per minute	3
	10-24 per minute	4
	0-9 per minute	1
	Absent	0
Breathing pattern	Normal	1
	Superficial	0
	Intermittent	0
Systolic blood pressure, mmHg	>90 mmHg	4
	70-89 mm Hg	3
	50-69 mm Hg	2
	0-49 mmHg	1
	No pulse	0

The trauma scale is scored by summing up the results for the five features presented above. The maximum score is 16 points, and the minimum is 1 point.

The impact of the trauma scale (TS) score on the probability of survival (PP) is presented below.

Pcs	16	15	14	13	12	11	10	9	8	7	6	4	3	2	1
BB	99	98	95	91	83	71	55	37	22	12	07	04	02	01	0

Modified Trauma Rating Scale

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

The Modified Trauma Assessment Scale is often used in emergency situations involving large numbers of casualties at the scene of an incident.

Parameters	Characteristics	Points
Respiratory 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 mmHg	4
	76-89 mm Hg	3
	50-75 mm Hg	2
	1-49 mmHg	1
	0	0
Glasgow Coma Scale	13-15	4
	9-12	3
	6-8	2
	4-5	1
	3	0

The modified trauma scale is scored by summing the results for each individual feature.

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

If the score is < 11 points, the injury is potentially dangerous and such patients should be hospitalized in specialized departments. 3.

Trauma Index

Trauma Index (Kirkpatric JR, Youmans RL, 1971)

Parameters	Characteristics	Points
	Head or neck	6
Damage area	Chest or belly	4
	Back	3
	Skin or limbs	1
	Mixed trauma	6
Damage type	Blunt trauma	4
	Stab wound	3
	Rupture or bruise	1
	No pulse	6
	BP <80 HR > 140	4
Cardiovascular system	BP < 100 HR > 100	3
	External bleeding	1
	Norm	0
	Coma	6
Central nervous system	Loss of sensation and movement	4
	Sopor	3
	Stun	1
	Norm	0
	Absence of breath and cyanosis	6
	Presence of aspiration	4
Respiratory system	Respiratory rhythm disturbances and hemoptysis	3
	Chest pain	1
	Norm	0

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

Grading of damage severity:

Minimum damage - 1 point.

Moderate injury - 3-4 points.

Severe injury - 6 points.

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

Nb!: The Trauma Index is not intended to assess the severity of burn injuries in patients.

CRAMS Injury Severity Rating Scale

CRAMS Scale Score (Clemmer T. P. et al., 1985)

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

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

Parameters	Characteristics	Points
Systolic BP or capillary filling time	BP > 100 mmHg or normal capillary refill time	2
	85 < BP < 100 mmHg, or delayed capillary refill time	1
	BP <85 mmHg or no capillary refill	0
Breath	Normal	2
	Abnormal (labored, weak, frequent) > 35 per minute	1
	Absent	0
The nature of the injury to the chest or abdomen	The abdominal or chest walls are painless	2
	The abdominal or chest walls are painless	1
	The abdominal wall is tense, the chest wall is floating or deep penetrating wounds of both cavities	0
Motor reaction	Normal	2
	Only for pain	1
	Absent	0
Speech response	Correct	2
	Some unintelligible words	1
	Speech is absent	0

Mortality dependence on injury severity according to the CRAMS scale

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

CRAMS score = Systolic BP or capillary refill time results + Respiratory test results + Damage assessment + Motor response assessment + Speech production assessment.

The maximum score (indicating the least damage) is 10, and the minimum score (indicating the greatest damage) is 0 points.

A score of < 8 points indicates severe injury (patients require emergency surgery), while a score of 5–9 points indicates only minimal injury.

Abbreviated Damage Scale

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

The AIS Abbreviated Injury Scale is a trauma assessment system that allows for a fairly accurate assessment of the severity of injuries. It was first proposed in 1969, but has since undergone significant changes. The most recent changes were made to the scale in 1990.

Damage is graded on a scale of 1 to 6, where 1 is minimal damage, 5 is severe, and 6 is damage beyond the limits of life.

AIS Points	Damage
1	Lung
2	Medium degree
3	Heavy
4	Very heavy
5	Extremely difficult
6	Terminal

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

The Injury Severity Scale (ISS) is an anatomical injury severity rating system that has been proposed for use in patients with multiple wounds. The ISS score is based on the injury severity gradations used in the AIS and ranges from 1 to 5:

1. point - mild injury;
2. points - moderate injury;
3. points - non-life-threatening injury of moderate severity;
4. points - life-threatening injury with a high probability of patient survival;
5. points - injury incompatible with life.

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

In injury severity analysis, only the maximum damage score for each body region is used. For the total ISS score, the three most severely damaged body regions are taken, the most severe damage in these regions is identified, and their scores are squared. The total ISS score is the sum of the squares of the three most severe damage scores. An example of an ISS calculation is shown below.

Anatomical region	Description of damage	Grade	Grade
Head and neck	Cerebral Contusion	3	9
Face	No Injury	0
Breast	Flail Chest	4	16
Stomach	Minor Contusion of Liver	2
	Complex Rupture Spleen	5	25
Limbs and pelvis	Fractured femur	3
Leather, soft tissues	No Injury	0
Overall ISS score			50

The maximum score on the ISS scale is 75 points, and the minimum is zero. If at least one damage has a score of five, the total score on the ISS scale is immediately estimated at 75 points.

The ISS scale is virtually the only anatomical scoring system and closely correlates with mortality, morbidity, hospital stay, and other measures of disease severity.

Correlation of mortality with ISS score

Grade	Mortality, % <49	Mortality, % 50-69	Mortality, % >70
5	0	3	13
10	2	4	15
15	3	5	16
20	6	16	31
25	9	26	44
30	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 an error in assessing the severity of the AIS scale can lead to errors in the overall ISS assessment. It should also be noted that different injuries can receive the same assessment on the ISS scale, while the influence of the area of injury on the final assessment on the scale has not yet been determined.

In addition, the ISS scale cannot be used for triage of victims, since in most cases a definitive diagnosis cannot always be established without a detailed examination of the patient or surgical intervention.

Injury and Damage Severity Rating Scale

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

The Trauma Severity Assessment Scale was developed to determine the amount of trauma care needed in severely injured patients by predicting survival.

It is intended for use in small hospitals to assess the quality of care provided or to compare outcomes across different health care settings.

The scale consists of three subscales (modified RTS trauma scale, ISS scale, patient age assessment scale) and coefficients for blunt and penetrating wounds.

The assessment according to the modified RTS trauma scale is carried out at the time of the patient's admission to the hospital, and according to the ISS scale - after the diagnosis of injuries.

Components of the modified trauma scale (RTS)

Parameters	Characteristics	Points
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
Respiratory rate	10-29	4
	>29	3
	6-9	2
	1-5	1
	0	0

Total modified RTS trauma scale score = (0.9368 x Glasgow trauma scale score) + (0.7326 x Systolic blood pressure score) + (0.2908 x Respiratory rate score).

Total ISS injury severity score = First maximum IIS2 score + Second maximum IIS2 score + Third maximum ISS2 score.

The maximum ISS score is 75 points.

Patient age assessment

Age, years	Points
<54	0
>55	1

Coefficients for calculating the TRISS equation

Research	Type of injury	Coefficient	Meaning
Coefficients obtained in the MT08 study*	Dumb	IN	-1.2470
		B1	0.9544
		B2	-0.0768
		VZ	-1.9.052
	Penetrating	IN	-0.6029
		B1	1.1430
		B2	-0.1516
		VZ	-2.6676
Coefficients obtained in the study by Satrip, 1990	Dumb	IN	-1.3054
		B1	0.9756
		B2	-0.0807
		VZ	-1.9829
	Penetrating	IN	-1.8973
		B1	1.0069
		B2	-0.0885
		VZ	-1.1422

*- MTOS - Major Trauma Outcome Study. Data obtained before 1986 were used.

TRISS (probability of survival) equation:

B = BO + (BI x RTS) + (B2 x ISS) + (B3 x (Age Score)). Probability of survival = 1/(1 + Exp ((-1) x B)). Limitations: Some 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 groups of patients.

Scales for assessing the severity of trauma in children

Pediatric Trauma Scale

Pediatric Trauma Score (PTS) (Tepas J. etal., 1985)

Characteristic	+2	+ 1	-1
Weight, kg	>20	10-20	<10
Respiratory tract	Norm	Partially passable	Impassable, additional measures required
HELL	>90 mm Hg, pulse is determined on a. radialis	50-90 mm Hg, carotid pulse is palpable	<50 mmHg, pulse not palpable
Level of consciousness	In consciousness	Violated	Coma
Open wounds	None	Small	Large or penetrating
Skeletal injuries	None	Minimum	Open or multiple

Total score on the scale:

9-12 points minor injury;

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

PTS Rating	Exodus
8	Chance of death < 1%
<8	Hospitalization in a specialized department is required.
4	Chance of death 50%
<1	Probability of death > 98%

Children's Injury Severity Scale (Rogsi E. V., 1994)

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

If there is no cuff to determine blood pressure, use the following points: +2 - pulse at the wrist is palpable; +1 - pulse in the groin is not palpable; -1 - pulse is not palpable.

If the overall score on the scale is < 8 points, immediate assistance should be provided and the child should be hospitalized. 7.3.

Modified Injury Severity Scale

Modified Trauma Score, points	Glasgow Coma Scale	Systolic blood pressure, mmHg	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 a score from 0 to 4 points, then all the points are added together (the sum ranges from 1 to 12). A score of <11 points on the scale indicates the presence of a serious injury.

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