Presented at First Pediatric Anesthesia Conference, Cairo, Egypt, www.egyptpac.org

1. SCORING SYSTEMS
in
TRAUMATIZED CHILDREN
Prof. Mohamed Ezzat Moemen
Founder of
anaesthesia & intensive care,
faculty of medicine,
Zagazig university

2. Scoring systems aim to reduce
large amounts of data
to
simple grades or numbers
Aim

3. Do we need scoring systems ?

4. Trauma deaths
- Immediate
- Second peak
- Late

5. Patient triage
- Priorities
- Labels
- Repetition

6. Glasgow Coma Scale (adults)
PointsResponseBehavior
4
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

7. 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

8. Pediatric Trauma Score
Tubelirer 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

9. Age-Specific Pediatric Trauma Score
(Potoka et al 2001)
Coded
Score
RRPulseSBPGCS
3NormalNormalNormal14-15
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

10. ScoreVariableScoreVariable
Capillary RefillRespiratory Rate
2
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 Effort
1
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)

11. 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

12. 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)

13. 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)

14. 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.

15. TRISS Method
Chart
TS x coefficient ISS x coefficient Age x coefficient

16. 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 index
Kirkpatrick and Yeoman’s, (1971)

17. 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).

18. 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

19. APS in
APACHE II

20. (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 :

21. 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

22. ‫صفحه‬32
APACHE III Score

23. ( 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 :

24. 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

25. Determination of outcome :
Outcome
Age
Diagnosis
Illness severity
Treatment
Chronic illness
Biological reserve

26. Key points
• Trauma scoring systems in children can
play a complementary role in deciding
patient outcome.
• Some trauma scoring systems are useful for
triaging of traumatized children and also
for testing quality assurance of trauma
centers or comparing their performance.