scoring systems in traumatized children
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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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