Trauma scoring 23 พค.2558
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Traumatic scoring and Monitoring ผศ.ดร.กรองได อุณหสูต คณะพยาบาลศาสตร์ มหาวิทยาลัยมหิดล
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Transcript of Trauma scoring 23 พค.2558
Traumatic scoring and Monitoring
ผศ.ดร.กรองได อณหสต คณะพยาบาลศาสตร มหาวทยาลยมหดล
Trauma Scoring
Anatomical indices
AIS
ISS
NSS
Physiological scale
Trauma score
Revised Trauma Score
CRAMS scale
The Injury Severity Score (ISS)
summarize the severity of the condition of multiply injured patients.
The ISS is the sum of squares of the highest AIS grades in each of the 3 most severely injured body regions.
ISS = sum of 3 highest2AIS = a2 + b2 + c2
ISS calculation Region Injury
Description AIS Square
Top Three
Head & Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion of Liver Complex Rupture Spleen
2 5
25
Extremity Fractured femur 3
External No Injury 0
ISS = (The 3 most AIS score )2 and added together 50
www.trauma.org/archive/scores/iss
AIS: detail Score Injury Severity
1 Minor บาดแผลฉกขาดเลกนอย แผลซาหรอถลอก กระดกนวมอนวเทาหก แตกไมเคลอน
2 Moderate บาดแผลฉกขาดทมความยาว > 2 นว ตามบรเวณลาตว และยาวไมเกน 1 นว บรเวณใบหนา มการกระทบกระเทอนไมรนแรง กระดกแขนราว
3 Serious การบาดเจบรนแรงแตไมทาใหเสยชวต บาดแผลฉกขาดรนแรงมความยาวต งแต 4 นวขนไป บรเวณใบหนาหรอบาดแผลทลกเขไป ในเนอเยอหรอกลามเนอ มกระดกหกหรอเคลอนของแขนขา
4 Severe การบาดเจบทอยในภาวะฉกเฉนหรอวกฤต (critical)
5 Critical มความรนแรง เปนตายเทากน
6 Survivable บาดเจบรนแรงมากจนไมสามารถรกษาใหรอดชวตได มเลอดใน สมองอยางมาก มการฉดขาดของเสนเลอดใหญทออกจากหวใจ
Injury Severity Score; ISS Region Injury Description AIS Square Top Three
Head & Neck Cerebral Contusion 3 9
Face No Injury 0
Chest Flail Chest 4 16
Abdomen Minor Contusion of Liver Complex Rupture Spleen
2 5
25
Extremity Fractured femur 3
External No Injury 0
Injury Severity Score: 50
AIS Score Injury
1 Minor
2 Moderate
3 Serious
4 Severe
5 Critical
6 Survivable
ISS 1-8 Minor 9-15 Moderate 16-24 Serious 25-49 Severe 50-74 Critical 75 Maximum
TRISS; Trauma Score-Injury Severity Score
TRISS determines the probability of survival (Ps) of trauma patient from the RTS and ISS using the following formulae:
Ps = 1 (1+e-b)
b = b0+b1(RTS)+b2(ISS)+b3(ageIndex)
AgeIndex = 0 if the patient is below 54 years = 1 if 55 years and over If the patient is less than 15, the blunt coefficients
are used regardless of mechanism.
Blunt Penetrating b0 -0.4499 -2.5355 b1 0.8085 0.9934 b2 -0.0835 -0.0651 b3 -1.7430 -1.1360
Region Injury Description AIS Square Top Three Head & Neck Cerebral Contusion 3 9 Face No Injury 0 Chest Flail Chest 4 16 Abdomen Minor Contusion of Liver
Complex Rupture Spleen 2 5
25
Extremity Fractured femur 3 External No Injury 0
Injury Severity Score: 50
AIS Score Injury 1 Minor 2 Moderate 3 Serious 4 Severe 5 Critical 6 Survivable
REVISED TRAUMA SCORE RTS = 0.9368 GCS + 0.7326 SBP + 0.2908 RR GCS SBP RR Coded Value
13-15 >89 10-29 4
9-12 76-89 >29 3
6-8 50-75 6-9 2
4-5 1-49 1-5 1
3 0 0 0
Major trauma CRAMS scale ≤ score 8
2 1 0 C : circulation Normal capillary
refill & SBP ≥ 100
Delay capillary refill or SBP ≥ 85 < 100
No capillary refill or SBP < 85
R : respirations Normal Labored or shallow
Absent
A : abdomen Abdomen & thorax no tender
Abdomen & thorax tender
Abdomen & rigid or flail chest
M : motor Normal Response only pain
No response
S : speech normal confused No intelligible words
Injury prevention
Pre-hospital care
In-house and
resuscitation
Rehabili-tation
SALT Mass Casualty Triage Algorithm (Sort, Assess, Lifesaving Interventions, Treatment/Transport)
Triage
Emergent
Definite care
Urgent
Admit Observe
Non urgent
Discharge
AHS The American hospital association
Triage
Resuscitation
Immediately
Emergent
15 minute
Urgent
30 minute
Less urgent
60 minute
Non urgent
120 minute
CTAS Canadian Triage and Acuity Scale
Japan
Triage
Category I
life threatening conditions
Category II
urgently require
treatment
Category III
minor injuries, do not require
ambulance transport
Category 0
who are dead, or injuries
make survival
Hillerød Adaptive Process Triage categories (HAPT)
Triage
red
resuscitation
0 min
orange
emergent
re-evaluation every 10
min
yellow
urgent
re-evaluation every 60
min
green
Non urgent
re-evaluation every 180
min
blue
minor injuries
re-evaluation every 240
min
การจาแนกประเภทผประสบภย ตามหลก MCS
Triage
วกฤต (critical)
ผประสบภยทม ภาวะคกคามชวต
รนแรง (severe)
ผประสบภยทไดรบการทาหตถการ
ปานกลาง (moderate)
ผประสบภยทรอรบการทาหตถการได
Eye response 4 = Eyelids open or opened, tracking or blinking to command 3 = Eyelids open but not to tracking 2 = Eyelids closed but opens to loud voice 1 = Eyelids closed but opens to pain 0 = Eyelids remain closed with pain stimuli
4 = Thumbs up, fist, or peace sign 3 = Localizing to pain 2 = Flexion response to pain 1 = Extension response 0 = No response to pain or generalized Myoclonus status
Motor response
4 = Pupil and corneal reflexes present 3 = One pupil wide and fixed 2 = Pupil or corneal reflexes absent 1 = Pupil and corneal reflexes absent 0 = Absent pupil, corneal, or cough reflex
Brainstem reflexes
4 = Regular breathing pattern 3 = Cheyne-Stokes breathing pattern 2 = Irregular breathing 1 = Triggers ventilator or breathes above ventilator rate 0 = Apnea or breathes at ventilator rate.
Respiration
The early warning score Norfolk & Norwich University
3 2 1 0 1 2 3
HR <40 41-50 51-100 101-110
111-130
>130
SBP <70 71-80 81-100 101-199 >200
RR <8 9-14 15-20 21-29 >30
Temp <35.0 35.1-36.5
36.6-37.4
37.5
LOC A V P U
Score Activity
≥3 Repeat scoring within 15 min
Adult EWS Call 3 2 1 0 1 2 3 Call
RR <5 5-8 9-20 21-30 31-35 >35
SBP <70 70-79 80-89 90-99
100-180
>180
HR <40 40-49 50-100
101-110
111-130
131-140
>140
4 Hr Urine Output
<80 80-120
>120
LOC U P Confuse V A
Score Activity
≥8 Stay with patient
6-7 Record q 20 min
4-5 Record q 1 h
1-3 Manage & observe
MEWS 3 2 1 0 1 2 3
RR <8 9-14 15-20 21-29 >30
HR <40 40-50 51-100 101-110
111-129
>129
SBP <70 71-80 81-100 101-199 >200
LOC U P V A Confuse
Temp (°C) <35.0 35.1-36
36.1-38 38.1-38.5
>38.6
Hourly Urine for 2 hours
>10 cc/hr
>30 cc/hr
>45 cc/hr
Score Activity
1-2 Observe q 2 hr
3 Observe q 1 hr
>4 Observe q 30 mins
DENVER POST-INJURY MULTIPLE ORGAN FAILURE SCORE
(MOORE) ISS >15, survived longer 48 hr, ≥ 16 years of age
Dysfunction 0 1 2 3 Pulmonary PaO2/FiO2 >208 208-165 165-83 <83
Renal Creatinine (umol/l)
>159 160-210 211-420 >420
Hepatic Total Birilubin (umol/l)
<34 34-68 69-137 >137
Cardiac Inotropes
No inotropes Only one inotrope at a small dose
Any inotrope at moderate dose or >1 agent, all at small dose
Any inotrope at large dose or >2 agents, at moderate dose
Multiple Organ Dysfunction Score Marshall,J.C.(2003)
Organ indicator none minimal mild moderate severe
Respiratory PaO2/FiO2 ratio
> 300 226-300 151-225 76-150 ≤ 75
Renal Serum creatinine (umol/L)
≤ 100 101-200 201-350 351-500 > 500
Hepatic Serum birirubin (umol/L)
≤ 20 21-60 61-120 121-240 > 240
Cardiovascular CVP/MAP < 10.0 10.1-15.0 15.1-20.0 20.1-30.0 > 30.0
Hematologic Platelet count (mm3)
> 120,000 81,000-120,000
51,000-80,000
21,000-50,000
≤ 20,000
Neurologic GCS 15 13-14 10-12 7-9 ≤ 6
SOFA score 0 1 2 3 4
Respiration PaO2FiO2 or SaO2/FiO2 mmHg
>400 <400 221-301
<300 142-220
<200 67-141
<100 <67
Coagulation >150 <150 <100 <50 <20
Liver Birilubin(mg/dl)
<1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0
Cardiovascular Hypotension
No hypotension
MAP <70 Dopamine ≤5 or any
Dopamine >5 or
notepinephrine ≤0.1
Dopamine >15 or
norepinephrine >0.1
CNS (GCS) 15 13-14 10-12 6-9 <6
Renal Creatinine (mg/dl) or urine output (ml/d)
<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00
>5.0 or <200
SOFA Score The European Society of Intensive Care Medicine
SOFA score 0 1 2 3 4
Respiration PaO2FiO2 or SaO2/FiO2 mmHg
>400 <400 221-301
<300 142-220
<200 67-141
<100 <67
Coagulation >150 <150 <100 <50 <20
Liver Birilubin(mg/dl)
<1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0
Cardiovascular Hypotension
No hypotension
MAP <70 Dopamine ≤5 or any
Dopamine >5 or
notepinephrine ≤0.1
Dopamine >15 or
norepinephrine >0.1
CNS (GCS) 15 13-14 10-12 6-9 <6
Renal Creatinine (mg/dl) or urine output (ml/d)
<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00
>5.0 or <200
SOFA Score The European Society of Intensive Care Medicine
Mortality SOFA score
<10% 0-6
15-20% 7-9
40-50% 10-12
50-60% 13-14
>80% 15
>90% 15-24
Mortality Score trend (First 48 hrs)
>50% Increasing
27-35% Unchanged
<27% Decreasing
SAP II
Age (year)
HR (bpm)
SBP (mmHg)
Temp (C/F)
GCS
MV/CPAP (Yes/No)
PaO2 (mmHg) FiO2 (%)
Urine output (cc/hr)
BUN (mg/dl)
Na (mEq/L)
K (mEq/L)
HCO3 (mEq/L)
Bilirubin (mg/dl)
WBC (x109/L)
Chronic disease (Ca, Hematologic, AIDS)
Type of admission (scheduled surg, Med, Unscheduled surg)
Mortality SAP II score
10% 29 25% 40 50% 52 75% 64 90% 77
Death rate Score 4% 0-4 8% 5-9
15% 10-14 25% 15-19 40% 20-24 55% 25-29 75% 30-34 85% >34
SIRS At least 2 of the following criteria: fever >38.0°C or hypothermia <36.0°C tachycardia >90 beats/minute tachypnea >20 breaths/minute leucocytosis >12*109/l
or leucopoenia <4*109/l
Stage of Sepsis SIRS
• pyrexia or hypothermia
• tachycardia in the absence of b-blocker • tachypnea or requirement for
mechanical ventilation) • WBC > 12 or < 4 x 10
Severe SIRS • SIRS with altered organ perfusion
or dysfunction not due to infection
Sepsis • SIRS with a documented source
of infection
Severe sepsis • sepsis associated with
organ dysfunction, hypoperfusion, or hypotension
Septic shock • sepsis with hypotension
despite adequate fluid resuscitation with the presence of perfusion abnormalities
Scoring system
Patient safety Preventing harm Reduce in-hospital cardiac arrest
• Early recognition • Rx of deteriorating patient.
