Trauma ScoringTrauma ScoringBC Trauma RegistryBC Trauma Registry

October 24, 2011October 24, 2011

Nasira LakhaNasira LakhaDori WilliamsDori Williams

We’ll talk about…We’ll talk about…

Abbreviated Injury Abbreviated Injury Scale (AIS)Scale (AIS)

Injury Severity Injury Severity Score (ISS)Score (ISS)

Revised Trauma Revised Trauma Score (RTS)Score (RTS)

TRISS TRISS

What do they mean?What do they mean? Why are they important?Why are they important? How does my How does my

documentation make an documentation make an impact?impact?

What is it all used for?What is it all used for?

Trauma ScoringTrauma Scoring

““Several trauma severity scales are used Several trauma severity scales are used to quantify injury severity and describe to quantify injury severity and describe patient severity casemix. Once injury is patient severity casemix. Once injury is thus characterized, the results can be thus characterized, the results can be applied to triage, resourcing, research and applied to triage, resourcing, research and quality of care assessment.”quality of care assessment.”

1. Champion, HR: Trauma Scoring. Scandinavian Journal of Surgery 91: 2002.1. Champion, HR: Trauma Scoring. Scandinavian Journal of Surgery 91: 2002.

Different scoring systems exist to predict Different scoring systems exist to predict survival probability.survival probability.

Although each scale can be used on its Although each scale can be used on its own as a predictive model, injury own as a predictive model, injury characterization involves complex characterization involves complex descriptors which are both descriptors which are both anatomicalanatomical and and physiologicalphysiological..

Therefore, there is a need for more than Therefore, there is a need for more than one single descriptor for injury one single descriptor for injury characterization.characterization.

Abbreviated Injury ScaleAbbreviated Injury Scale

The Abbreviated Injury Scale (AIS) is an The Abbreviated Injury Scale (AIS) is an anatomical global scoring system first anatomical global scoring system first introduced in 1971 by an Injury Scaling introduced in 1971 by an Injury Scaling Committee of the Association for the Committee of the Association for the Advancement of Automotive Medicine.Advancement of Automotive Medicine.

The AIS provides a standardized The AIS provides a standardized numerical method for ranking and numerical method for ranking and describing the severity of injuries describing the severity of injuries throughout the body. throughout the body.

history…history… In mid-1960s, there was a need for a standardized system for In mid-1960s, there was a need for a standardized system for

categorizing injury type and severity at the same time as the first categorizing injury type and severity at the same time as the first generation of multi-disciplinary motor vehicle crash investigation generation of multi-disciplinary motor vehicle crash investigation teams came to be.teams came to be.

Teams comprised of specialists in engineering, medicine, Teams comprised of specialists in engineering, medicine, anatomy/physiology and crash investigation were responsible for anatomy/physiology and crash investigation were responsible for collecting data for evaluation of vehicle design in relation to injury collecting data for evaluation of vehicle design in relation to injury incidence and mechanism.incidence and mechanism.

The goal was to obtain standardized data on frequency and severity of The goal was to obtain standardized data on frequency and severity of motor vehicle related injuries.motor vehicle related injuries.

Under the sponsorship of the AAAM, American Medical Association Under the sponsorship of the AAAM, American Medical Association and the Society of Automotive Engineers and about 35 other and the Society of Automotive Engineers and about 35 other consultants, the first AIS was published.consultants, the first AIS was published.

The Injury Severity Score was then developed.The Injury Severity Score was then developed. AIS was expanded to include injuries other than those that occur with AIS was expanded to include injuries other than those that occur with

vehicular trauma.vehicular trauma. Several revisions followed – AIS 85, AIS 90, AIS 95, AIS 2005Several revisions followed – AIS 85, AIS 90, AIS 95, AIS 2005

AIS AIS 9 Chapters9 Chapters

HeadHead

FaceFace

NeckNeck

ThoraxThorax

Abdomen & Pelvic ContentsAbdomen & Pelvic Contents

SpineSpine

Upper ExtremitiesUpper Extremities

Lower ExtremitiesLower Extremities

External, Burns & Other TraumaExternal, Burns & Other Trauma

AIS AIS Severity CodeSeverity Code

AIS CodeAIS Code InjuryInjury DescriptionDescription

1 1 Minor Minor

2 2 Moderate Moderate

3 3 Serious Serious

4 4 Severe Severe

5 5 Critical Critical

6 6 Maximal Maximal (currently untreatable)(currently untreatable)

Structure of Numerical Identifier:Structure of Numerical Identifier:

E.g. Tibial shaft fracture, open = 853422.3E.g. Tibial shaft fracture, open = 853422.3

8 = Body Region: Lower Extremity8 = Body Region: Lower Extremity

5 = Type of Anatomic Structure: Skeletal5 = Type of Anatomic Structure: Skeletal

34 = Specific Anatomic Structure: Tibia34 = Specific Anatomic Structure: Tibia

22 = Level of Injury: Shaft22 = Level of Injury: Shaft

.3 = Severity Code: Serious.3 = Severity Code: Serious

AIS injuries are categorized as AIS injuries are categorized as follows within each chapter:follows within each chapter:

Whole AreaWhole Area

VesselsVessels

NervesNerves

Internal OrgansInternal Organs

SkeletalSkeletal

Some chapters have more detail:Some chapters have more detail:

HeadHead– has two additional categories:– has two additional categories: Length of UnconsciousnessLength of Unconsciousness Level of UnconsciousnessLevel of UnconsciousnessSpineSpine– is divided into 3 sections: Cervical, Thoracic – is divided into 3 sections: Cervical, Thoracic

and Lumbar and has a unique structure: and Lumbar and has a unique structure: Cord InjuryCord Injury Disc InjuryDisc Injury Ligament InjuryLigament Injury Nerve Root InjuryNerve Root Injury Whole Area Whole Area Cervical Spine also contains: Brachial Plexus injuryCervical Spine also contains: Brachial Plexus injury Lumbar Spine also contains: Cauda Equina injuryLumbar Spine also contains: Cauda Equina injury

And…And…

Abdomen & Pelvic Contents -Abdomen & Pelvic Contents - does not contain skeletal does not contain skeletal injuriesinjuries

Upper & Lower Extremities - Upper & Lower Extremities - includes 2 additional includes 2 additional categories: categories:

muscles, tendons, ligaments muscles, tendons, ligaments jointsjoints

External, Burns, Other TraumaExternal, Burns, Other Trauma - -

has a unique structure:has a unique structure: Skin and Subcutaneous TissueSkin and Subcutaneous Tissue BurnsBurns Other TraumaOther Trauma

Injury descriptors affect the severity Injury descriptors affect the severity score of AIS:score of AIS:

Loss of nerve function (total or partial)Loss of nerve function (total or partial)Basal skull fracture (CSF leak or not)Basal skull fracture (CSF leak or not)Closed head injury/Blunt abdominal injury (leads to a non-specific Closed head injury/Blunt abdominal injury (leads to a non-specific

code)code)Blood loss (pre-hospital and hospital)Blood loss (pre-hospital and hospital)Vessel laceration (complete vs. incomplete transection)Vessel laceration (complete vs. incomplete transection)Pneumothorax (delayed appearance – complication?)Pneumothorax (delayed appearance – complication?)Spinal cord injury (contusion vs. laceration and incomplete vs. Spinal cord injury (contusion vs. laceration and incomplete vs.

complete)complete)Skin injuries (length of laceration, size of avulsion or depth of Skin injuries (length of laceration, size of avulsion or depth of

penetrating injury)penetrating injury)Pelvic Fracture (major vessel injury involvement?)Pelvic Fracture (major vessel injury involvement?)Abdominal organ injuries (Organ Injury Scaling)Abdominal organ injuries (Organ Injury Scaling)

Primary Injury TypesPrimary Injury Types

BluntBlunt AssaultAssault Crush Crush Falls (3 categories)Falls (3 categories) Other BluntOther Blunt Vehicular CrashVehicular Crash

PenetratingPenetrating CutCut FirearmFirearm StabStab

ThermalThermal BurnBurn Cold ExposureCold Exposure ElectricalElectrical

AsphyxiaAsphyxia DrowningDrowning SuffocationSuffocation StrangulationStrangulation

ScenarioScenario

The patient was involved in a multi-vehicle The patient was involved in a multi-vehicle car crash. Chest CT indicated multiple car crash. Chest CT indicated multiple displaced and comminuted rib fractures displaced and comminuted rib fractures bilaterally, a (L) pulmonary contusion, bilaterally, a (L) pulmonary contusion, hemomediastinum, a fractured sternum hemomediastinum, a fractured sternum and a (L) lung laceration. The patient was and a (L) lung laceration. The patient was admitted to ICU for ventilatory support. admitted to ICU for ventilatory support. There were also contusions to the arms, There were also contusions to the arms, legs, chest and forehead.legs, chest and forehead.

abstract worksheet 04.01.08 – Copyright BC Trauma Registry

B.C. TRAUMA REGISTRY A.I.S. WORKSHEET

ABBREVIATED INJURY SCALE (A.I.S.)

BODY REGION

INJURY DESCRIPTION

A.I.S. . . .

. . . .

HEAD

OR

NECK

.

(contusion – forehead 210402 . 1 . . .

FACE

.

# ribs: (L) and (R) – displaced / comminuted 450250 . 3 (L) pulmonary contusion 441406 . 3 # sternum 450804 . 2 (L) lung laceration with hemomediastinum 441434 . 4 .

CHEST

contusion – chest 410402 . 1

4

. . . . . .

ABDOMINAL

OR

PELVIC

CONTENTS

.

. . . . . (contusion - arms 710402 . 1

EXTREMITIES

OR

PELVIC

GIRDLE

(contusion - legs 810402 . 1

. . .

EXTERNAL

.

1

INJURY SEVERITY SCORE (I.S.S.)

HIGHEST A.I.S. FOR THE 3 MOST SEVERELY INJURED

BODY REGIONS

_____42 ___+ ___12

___ + _________2 =____17___

INJURY SEVERITY SCOREINJURY SEVERITY SCORE

The Injury Severity Score was derived to The Injury Severity Score was derived to summarize the severity of the condition of summarize the severity of the condition of multiply injured patients. multiply injured patients.

Each injury is assigned an AIS score, allocated Each injury is assigned an AIS score, allocated to one of six ISS body regions (Head or Neck, to one of six ISS body regions (Head or Neck, Face, Chest, Abdominal or Pelvic Contents, Face, Chest, Abdominal or Pelvic Contents, Extremities or Pelvic Girdle, External). Extremities or Pelvic Girdle, External).

Only the highest AIS score in each ISS body Only the highest AIS score in each ISS body region is used. The ISS is calculated as the:region is used. The ISS is calculated as the:

Sum of the squares of the highest AIS Sum of the squares of the highest AIS code in each of the three most severely code in each of the three most severely

injured ISS body regionsinjured ISS body regions

ExampleExample

ISS Body ISS Body RegionRegion

Injury DescriptionInjury Description AISAIS Square Top ThreeSquare Top Three

Head & NeckHead & Neck Cerebral ContusionCerebral Contusion 33 99

FaceFace No InjuryNo Injury --

ChestChest Flail ChestFlail Chest 44 1616

AbdomenAbdomen Minor Contusion of LiverMinor Contusion of LiverComplex Rupture SpleenComplex Rupture Spleen

2255 2525

ExtremityExtremity Fracture femurFracture femur 33

ExternalExternal No InjuryNo Injury --

Injury Severity Score:Injury Severity Score: 5050

ISS ranges from 1 – 75ISS ranges from 1 – 75

A score of 75 results in one of two ways, A score of 75 results in one of two ways, either with three AIS 5 injuries, or with at either with three AIS 5 injuries, or with at least one AIS 6 injury. least one AIS 6 injury.

Any injury coded as AIS 6 is automatically Any injury coded as AIS 6 is automatically assigned an ISS of 75. assigned an ISS of 75.

It is not possible to calculate an ISS on a It is not possible to calculate an ISS on a patient who has AIS 9 injury (the AIS code patient who has AIS 9 injury (the AIS code is unknown); hence, the need for detailed is unknown); hence, the need for detailed injury information.injury information.

Revised Trauma ScoreRevised Trauma Score

The Revised Trauma Score is a physiological The Revised Trauma Score is a physiological scoring system. It is scored from the initial data scoring system. It is scored from the initial data obtained on the patient.obtained on the patient.

The RTS correlates with the probability of survival.The RTS correlates with the probability of survival.

ComponentsComponents:: Glasgow Coma ScoreGlasgow Coma Score Systolic Blood Pressure Systolic Blood Pressure Respiratory RateRespiratory Rate

TRISS MethodologyTRISS Methodology

Trauma and Injury Severity Score (TRISS) was designed Trauma and Injury Severity Score (TRISS) was designed to calculate individual patient survival probabilities to calculate individual patient survival probabilities and to identify major trauma patients with unexpected and to identify major trauma patients with unexpected outcomes. outcomes.

Risk adjusted mortality is calculated using TRISS Risk adjusted mortality is calculated using TRISS methodology as a benchmarking tool to define methodology as a benchmarking tool to define performance against an historical international performance against an historical international benchmark, the Major Trauma Outcome Study (MTOS). benchmark, the Major Trauma Outcome Study (MTOS).

ComponentsComponents:: Revised Trauma Score (RTS) Revised Trauma Score (RTS) Injury Severity Score (ISS) Injury Severity Score (ISS) Patient age Patient age Mechanism of injury Mechanism of injury

This comprehensive dataset on This comprehensive dataset on the most severely injured the most severely injured

patients in BC is utilized for:patients in BC is utilized for:

Research activitiesResearch activities Injury preventionInjury prevention Program reportsProgram reports System planningSystem planning Performance improvementPerformance improvement Resource utilizationResource utilization Patient carePatient care

QUESTIONS?QUESTIONS?