JOURNAL OF INTERNATIONAL SCIENTIFIC RESEARCH
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Online ISSN: 3030-3508
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TRAUMA SCORING SYSTEMS
Mukhamadiyev S
.
U
., Eminov R.I.
Department of Traumatology and Orthopedics of Fergana
Public Health Medical Institute
ARTICLE INFO
ABSTRACT:
ARTICLE HISTORY:
Worldwide, traumas represent an actual theme of
discussion. The recognition and interpretation of
severe traumas are essential for choosing the right
treatment strategy. There are two approaches to
mark the patients with a high risk of unfavorable
evolution and death. First, to use the terms as
“major
trauma”,
“severe
trauma”
and
“polytrauma”, without ability to stratify the patients
according the severity of lesions inside categories
mentioned above. Second, to implement the trauma
scoring systems (anatomical, physiological or
mixed), when a doctor uses a mathematical
algorithm/model to calculate the risks for each
trauma patient. At the same time, according to the
articles found on PubMed/Medline, Web of Science,
and EBSCO databases, there is no international
consensus concerning the most accurate traumatic
score. This article’s goal was to revise the existing
trauma scoring systems to highlight the potential
scoring systems that in perspective can be validated
in the Moldovan medical system.
Received:10.12.2024
Revised: 11.12.2024
Accepted:12.12.2024
KEYWORDS:
Trauma assessment
systems, injury
evaluation, triage
protocols, trauma
scoring, emergency
response, critical care,
diagnostic tools, trauma
registry, patient
monitoring, severity
index.
INTRODUCTION.
Actually, traumas represent an actual subject at international scale, being the main cause
of death in the world for the patients in the age category of 1-40 years [1, 2]. In the Republic
of Moldova, according to the National Center for Management of the National Agency of
Public Health, in the period of 2008-2017, traumas are on the 4th place in the list of causes
of lethal outcome, constituting 8.1% (36889 cases) of all registered cases, being placed after
the cardiovascular diseases (61%, 226195 cases), tumors (15.8%, 58518 cases) and
digestive system diseases (10%, 36889 cases). The analysis of lethality structures according
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to the age showed that in the first year of life, traumas are placed on the 2nd place (30.3%)
after the respiratory system diseases (57.9%).
The lethality rate related to traumas is progressing along with the age and has its
maximum incidence at the age of 18 years (81.3%), after that, it is decreasing, the lethality
rate of traumas being 24.1%, and loses it predominance in the age category of 44 years and
further, when the cardiovascular diseases are dominant (26.3%), being in decrease until 0%
at the senile age category [3]. The recognition and interpretation of severe traumas is
essential for choosing the right treatment strategy.
Trauma is your div's response to a horrific, shocking, or dangerous event. Examples of
traumatic events may include experiencing or witnessing an accident, crime, natural
disaster, abuse, neglect, violence, or war.
It's completely normal to feel fear and sadness after a traumatic event. How everyone
experiences a scary or dangerous event differs—some don't experience any symptoms,
while others develop post-traumatic stress disorder .
Trauma may occur after you witness or experience a stressful or dangerous event.3 It is
estimated that up to 60-75% of people in North America will experience a traumatic event
at some point in their lives.2
There are several types of trauma. If you experience a traumatic event, you may develop
one of the following.
Acute trauma: Results from a single stressful or dangerous event
Chronic trauma: Repeated or prolonged exposure to a stressful event
Complex trauma: Exposure to multiple traumatic events
Post-traumatic stress disorder (PTSD): Trauma that lasts longer than one month
Symptoms of Trauma. Trauma symptoms can be serious enough to interfere with your
daily life. Everyone's experience with trauma can vary—some experience symptoms for a
handful of days, while others have symptoms severe enough to develop PTSD. If you've just
encountered or lived through a traumatic event, it's possible to develop the following
symptoms:2
Excessive worry or anxiety
Being easily startled
Sadness and frequent episodes of crying
Having flashbacks
Trouble sleeping
Difficulty concentrating
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Withdrawing from social activities
Avoiding places that remind you of the traumatic event
Feeling angry or fearful
To describe the patients with a high risk of unfavorable evolution and also of death, there
exists a series of terms like ―severe trauma‖, ―major trauma‖ and ―polytrauma‖. The
analysis of entries/documents in Web of Science database shows 24441, 19471 and 2813
entries for these notions, respectively. The terms ―severe trauma‖ and ―major trauma‖ are
very similar, synonymic, but the criteria are not precise and fixed, the critical value of ISS
(Injury Severity Score) or NISS (New Injury Severity Score) varies in different studies at
the threshold of 16-17 points [4, 5 ,6]. The polytraumas represent the most unexplored and
unresearched part of traumas, being a narrow notion compared to severe trauma and major
trauma. There are a lot of definitions for polytrauma. In most of the sources, the criteria for
polytrauma represents the anatomical scale ISS, the value of more than 15 being the
threshold. At the same time, according to other authors, this value varies from 15 up to 26
and more. In a study made in 1996, it was proven that the medical personnel’s
incompetence represents one of the causes of the errors in the usage of ISS for polytrauma
diagnosis. Another criteria used for polytrauma definition are at least two lesions in any
topographical region and at least one of them is a threat for the patient’s life [9]. According
to the New Berlin Definition, proposed and validated in studies with high evidence, the
polytrauma is defined as severe lesions for at least 2 div regions, appreciated by AIS
(Abbreviated Injury Scale) with a score of ≥ 3 being present at least one of the 5
physiological parameters (systolic blood pressure ≤ 90 mmHg, GCS ≤ 8, acidosis,
coagulopathy and age ≥ 70 years) [11]. At the same time a series of scores and algorithms
are created to assess the severity of traumas, but at the moment, as a study has shown, there
is no international consensus in the articles found on PubMed/Medline, Web of Science, and
EBSCO databases according the most efficient scale, many of them claiming different
things, this situation being related to geographical factors and differences in the medical
systems, particularities of demographic structure On the other hand, the Moldovan medical
system doesn’t use any trauma scoring system that was validated in order to evaluate the
patient’s risk of death and complications in case of trauma. Because of that, at the patient’s
evaluation there are disagreements on the prognostic, different scores often estimating the
outcomes completely different. The solution for this problem includes a few stages as
follows. First of all, we need to revise the existing trauma scoring systems that can be used
in the Moldovan medical system. Secondly, to validate these scores for the Moldovan
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medical system and to elaborate the new trauma scoring systems. Lastly, the comparative
evaluation of the trauma scoring systems is necessary in order to identify the ones that have
the optimal ability (determination, calibration and discrimination) to predict the outcomes
for the medical system of Moldova. This article’s goal is to accomplish the first task listed
above, especially to revise the existing trauma scoring systems to highlight the potential
scoring systems that in perspective can be validated in the Moldovan medical system.
Injury Severity Score (ISS) and New Injury Severity Score (NISS):
In the past decades, ISS and NISS were used widely for the evaluation of the
severity of trauma. To estimate ISS, we have to use the following formula: ISS = A²
+ B² + C², where A, B, C are the highest AIS values present in each topographic
region. It can vary from 0 up to 75. In condition if there is a topographical region
with AIS = 6, ISS is automatically equal to 75 [15]. NISS in comparison with ISS,
estimates trauma severity taking into account three maximal values of AIS,
indifferent of the lesions localization [14]. For example, in case of trauma in 4
topographical regions AISabdomen = 2, AIShead and neck= 3, AIShead and neck = 3
and AISThorax = 5, the NISS value will be higher (NISS=5² + 3² + 3² = 43) versus
ISS (ISS=5² + 3² + 2² = 38). At the same time, according to the results obtained by
clinicians from China, NISS is similar to ISS in predicting the outcome of the
traumatic patients [2]. We suppose that such result can be explained by insufficient
determination coefficient (40%-60%) in equations that use NISS or ISS [16, 17].
Logarithm Injury Severity Score (LISS) and Exponential Injury Severity
Score (EISS):
LISS uses the natural logarithm of AIS as follows: LISS =
ln(A₁)5.53× 1.7987 + ln(A2 )5.53 × 1.7987 + ln(A3 )5.53× 1.7987, where A1 -A3 are
the AIS values for the three most severe traumas. For example, a patient with
AISabdomen = 3, AISthorax = 2, AIShead and neck = 4, AISlimbs = 5, will have
LISS = ln(3)5.53× 1.7987 + ln(4)5.53 × 1.7987 + ln(5)5.53× 1.7987 =
38.9716620395. According to the results obtained by certain researches it has
tendency to have better calibration and discrimination characteristics than NISS [18].
EISS is based as LISS on the most severe AIS scores that are used in the following
formula: EISS = 3A-2+3B-2 +3C-2, where A, B and C are the highest values of AIS
[19]. For example, a patient has AIShead and neck = 3, AISt horax = 4, AISabdomen
= 2 and AISlimbs = 5, in this case EISS = 35-2+34-2+33-2= 27+9+3=39.
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APC is a scale that was proposed by Copes et al. According to APC algorithm a
doctor has to take into consideration only the 3 most severe lesions according to AIS.
The AIS scores are grouped in relation to region – A (AIS = 3-5 head, neck, brain and
the spinal cord), B (AIS = 3-5 thorax), C ( the anterior region of the neck with AIS =
3-5, the abdomen and pelvis with AIS = 3-5, the spine with or without the spinal
column with AIS = 3, pelvic fractures with AIS = 4-5), D (the femoral artery with
AIS = 4-5, collapse above the knee with AIS = 4-5, amputation above the knee with
AIS = 4-5, the popliteal artery with AIS = 4, the face with AIS = 1-4, other traumas
with AIS = 1-2). All of the conditions described above being classified based on ICD-
9-CM, APC will be further on calculated using the following formula: APC = M0 +
M1 x A + M2 x B + M3 x B² + M4 x C², the used coefficients are: M0 = 4.0801; M1
= -0.4914; M2 = -0.2066; M3 = 0.0161; M4 = -0.0351. D was excluded because in
this case it wasn’t influencing the survival predictability, but in some geographical
regions it may be useful. The obtained value (APC) is considered in logistic
regression formula as b and P(survival) = eb /(1+eb ) [20]. For example, we have a
patient with AISabdomen = 2, AISHead and neck= 3, AISUpper limb = 4 and
AISThorax = 5, in this case APC = 4.0801 - 0.4914 x 3 – 0.2066 x 5 +0.0161 x 5² -
0.0351 x 0 = 1.9754, further on, P(survival) = e1.9754/(1+e1.9754)= 0.8781,
respectively, the chance for survival in this case is equal to approximately 87.81%.
Conclusion.
Trauma Assessment Systems are essential frameworks used in emergency
medicine to evaluate and manage patients suffering from traumatic injuries. These systems
aim to quickly determine the severity of injuries, prioritize treatment, and allocate resources
effectively. Key components include standardized protocols such as triage systems, trauma
scoring methods (e.g., Injury Severity Score and Glasgow Coma Scale), and diagnostic tools
like imaging technologies. By integrating data from patient monitoring, trauma registries,
and real-time assessments, these systems ensure timely interventions and improve patient
outcomes. Additionally, they support decision-making in pre-hospital and hospital settings,
helping to reduce mortality and morbidity rates. Advances in technology and data analytics
continue to enhance the efficiency and accuracy of trauma assessment systems, making
them vital for modern critical care and emergency response.
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