SCORING SYSTEMS

in

TRAUMATIZED CHILDREN

Prof. Mohamed Ezzat Moemen

Founder of

anaesthesia & intensive care,

faculty of medicine,

Zagazig university

Scoring systems aim to reduce

large amounts of data

to

simple grades or numbers

Aim

Do we need scoring systems ?

Trauma deaths

- Immediate

- Second peak

- Late

Patient triage

- Priorities

- Labels

- Repetition

Glasgow Coma Scale (adults)

PointsResponseBehavior4

3

2

1

Spontaneous

To speech

To pain

Nil

Eye opening

5

4

3

2

1

Oriented

Confused conversation

Inappropriate words

Incomprehensive sounds

Nil

Verbal response

6

5

4

3

2

1

Obeys

Localizes

Withdraws

Abnormal flexion

Extends

Nil

Motor response

Modification of Glasgow Coma Scale For Children

Score

5

4

3

2

1

Best Verbal Response :-Appropriate words or social smiles,

fixes on and follows objects

-Cries but consolable

-Persistantly irritable

-Restless, agitated

-Silent

Eye and Motor Responses:Scored as in the scale for adults

Pediatric Trauma ScoreTubelirer et al (1990)

-1+1+2Component

<1010 - 20> 20Size (kg)

< 5050 - 90> 90SBP (mmHg)

Difficult to maintainCan be

maintained

NormalAirway

Coma or decerebrateObtundedAwakeCNS

Open or multiple

fractures

Closed fractureNoneSkeletal

Major or penetratingMinorNoneCutaneous

Age-Specific Pediatric Trauma Score(Potoka et al 2001)

Coded

Score

RRPulseSBPGCS

3Normal Normal Normal 14-15

2Tachypnea

(RR>mean+SD)

Tachycardia

(Pulse>mean+SD)

Mild to moderate

hypotension

(SBP<mean-2SD)

10-13

1Hypoventilation

(RR<mean-SD)

Bradycardia

(Pulse<mean-SD)

Severe

hypotension

(SBP<mean-3SD)

4-9

00 or intubated003

ScoreVariableScoreVariable

Capillary RefillRespiratory Rate2

1

0

Normal

Delayed (>2 s)

Non

5

4

3

2

1

10 – 24 / min

25 – 35 / min

>35 / min

>10 / min

0 / min

Glasgow Coma Scale

5

4

3

2

1

14 – 15

11 – 13

8 – 10

5 – 7

3 – 4

Respiratory Effort1

0

Normal

Shallow or retractive

Systolic Blood Pressure

Total Score

4

3

2

1

0

> 90 mmHg

70 – 90 mmHg

50 – 69 mmHg

< 50 mmHg

0 mmHg

Trauma Score (adults)

Revised

Trauma Score

(RTSc)

ScoreX Weighting

value

Coded

Factor

0.2908

4

3

2

1

0

Respiratory rate (b/min):

10 – 29

>29

6 – 9

0 – 5

0

0.7326

4

3

2

1

0

Systolic B P (mmHg):

>89

76 – 89

50 – 75

1 – 49

0

0.9368

4

3

2

1

0

Glasgow coma scale :

13 – 15

9 – 12

6 – 8

4 – 5

3

The Abbreviated Injury Score (AIS)

Division of the body into six regions:

1- Thorax 2- Abdomen and viscera

3- Head and Neck 4- Face

5- Bony pelvis and extremities

6- External structures

Scoring for each region injury as:

No injury (0), minor (1), moderate (2), serious (3), severe (4),

critical (5), incompatible with life (6)

The sum of squares from the highest AIS

grades in each of the three most severely

injured areas.

•75 points = worst outcome

•AIS of any region : 6 points = worst outcome

•30-40 points = 50% survival

Injury Severity Score (ISS)(Baker et al 1974)

New Injury Severity Score (NISS)(Osler et al 1997)

• The AIS is the frame.

• Based on the three most severe

injuries regardless the body regions.

• Useful for penetrating injuries.

TRISS Method

Chart

TS x coefficient ISS x coefficient Age x coefficient

Score 1 2 3 4 Region affected

Skin / extremity

Back Chest / abdomen

Head / neck

Type of injury

Laceration / contusion

Stab Blunt Missile

Cardiac vascular

Hemorrhage present

BP<100 HR>100

BP<80 HR>140

Pulse less

CNS Drowsy Chest pain

Stupor Focal exam

Coma

Respiratory Dyspnea / hemoptysis

Aspiration Apena/ cyanosis

Trauma indexKirkpatrick and Yeoman’s, (1971)

Variable Score Circulation

Capillary refill normal BP>100 mmHg Delayed capillary refill or BP 85 – 100 mmHg No capillary refill or BP<85 mmHg

2

1

0

Respiratory Normal Labored or Shallow Absent

2 1 0

Abdomen / Thorax Abdomen & thorax non-tender Abdomen or thorax tender Abdomen rigid, flail chest, or Penetrating injury

2 1 0

Motor Normal Responds only to pain Decerebrate or no response

2 1 0

Speech Normal Confused No intelligible words

2 1 0

CRAMS Scale Gormican, (1982).

APACHE II

• A) 12 physiological variables: 60 points

• B) Age:

• 44 yrs = 0 points

• >75 yrs = 6 points

• C) Chronic Health points :

• -Non-oper or emerg. Postop. ….. 5 points

• -Elective postop. ….. 2 points

APS in

APACHE II

(R / 1-R) = -3.517 + (APACHE II x 0.146 + S + D)

R = Risk of hospital death

S = Risk of emergency surgery

D = Risk of specific disease

APACHE II equation :

APACHE III Score

- Variables & weights :

Added weights to APS, Age, and CHE

Refined Glasgow Coma Scale

- Interactions

PH , PaCO2 Creatinine , U.O.

R.R , Ventilator

- 5 new variables :

BUN U.O

Albumin Bilirubin

Glucose

32صفحه

APACHE III Score

( R / 1-R ) =( APACHE III x 0.053 )+ S+D+L

R = Risk of hospital death

S = Risk of emergency surgery

D = Risk of specific disease

L = Risk of patient location

APACHE III equation :

Pediatric Trauma BIG Score

Borgman MA et al .Pediatrics 2011 ;127 : 892 -7

BIG Score = (BD) + (2.5xINR) + (15 - GCS)

10+(2.5x3.5)+6=26= Predicted mortality : 50%

IRAQ & AFGANESTAN Military study

Penetrating & blunt injuries

BIG Score needs laboratory

BIG Score is suitable for research

Determination of outcome :

Outcome

Age

Diagnosis

Illness severity

Treatment

Chronic illness

Biological reserve

Key points

• Trauma scoring systems in children canplay a complementary role in decidingpatient outcome.

• Some trauma scoring systems are useful fortriaging of traumatized children and alsofor testing quality assurance of traumacenters or comparing their performance.

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