Evaluation and Management of Pediatric Patients With Penetrating Trauma to the Torso

The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems, The Pediatric Trauma Score (PTS) stratifies the severity of injury and mortality risk in pediatric trauma patients, and The Glasgow Coma Scale (GCS) assesses impairment in a patient's level of consciousness using eye, verbal, and motor criteria.

1. Injury Severity Score (ISS)
2. Pediatric Trauma Score (PTS)
3. Glasgow Coma Scale

Injury Severity Score (ISS)

• Introduction
• Points & Pearls
• Why and When to Use and Next Steps
• Calculator Review Author
• Instructions
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

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Points & Pearls

• The Injury Severity Score (ISS) was initially derived in patients with blunt traumatic injury from motor vehicle accidents.
• The ISS is not intended to be used for bedside decision-making for a single patient in the emergency department setting, but rather as a tool to standardize the study of trauma patients.
• Due to the nature of the score, multiple combinations of Abbreviated Injury Scale (AIS) scores may result in the same ISS, each of which may indicate a different mortality rate. For example, an ISS of 17 can be calculated from patients with a combination of points based on the 3 most se-vere injuries, such as (4, 1, 0) or (3, 2, 2). The ISS assigns equal value to each body region.

Why and When to Use and Next Steps

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Max Berger, MD

Alexandra Ortego, MD

Instructions

First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no injury) to 6 (unsurvivable injury). Next, those scores are used to determine the 3 most injured body systems. Finally, the ISS is calculated by squaring the AIS score for each of the 3 most injured body systems, then adding up the 3 squared numbers (A2 + B2 + C2 = ISS, where A, B, and C are the AIS scores of the most severe injury in each of the 3 most severely injured body systems). Patients with an AIS of 6 in any body system are automatically assigned an ISS of 75, the maximum possible score.

The ISS is used primarily in research settings, so calculation of the score should not delay initial management of patients with traumatic injuries.

Critical Actions

• In all trauma patients, the initial treatment strategy should focus on the primary and secondary survey, and assessing and stabilizing the patient.
• Although the ISS score is intended primarily for research purposes, it may have broader clinical use in the intensive care unit for prognostication following the initial stabilization of traumatic injuries.

Evidence Appraisal

The ISS was derived by Baker et al (1974) by taking the previously used AIS (American Medical Association Committee on Medical Aspects of Automotive Safety 1971) and adding the squared value of each of the 3 most severely injured body systems, in an effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were used to calculate the final score because it had been shown that injuries that would not necessarily be life-threatening in isolation could have a significant effect on mortality when they occurred in combination with other severe injuries. The derivation study included only injuries sustained from motor vehicle collisions, including the occupants of the vehicles and any pedestrians involved.

Further studies have validated the ISS to include other mechanisms of injury. A study by Beverland et al (1983) of 875 patients with gunshot wounds showed that an increasing ISS was associated with increasing mortality (chi-squared = 83.31, P < .001). A study by Bull (1978) confirmed the correlation between increasing ISS and increasing mortality in road traffic accidents, and showed correlation between increasing ISS and increasing mean hospital length of stay.

In a study of 8852 trauma patients from the Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had similar findings to Baker et al regarding the relationship between ISS and mortality. They also found that the ISS correlated with hospital length of stay.

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Susan P. Baker, MPH

References

Original/Primary Reference

• Baker SP, O'Neill B, Haddon W, et al. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-196.

Validation References

• Beverland DE, Rutherford WH. An assessment of the validity of the injury severity score when applied to gunshot wounds. Injury. 1983;15(1):19-22. 
• Committee on Medical Aspects of Automotive Safety. Rating the severity of tissue damage: I. The abbreviated scale. JAMA. 1971;215(2):277-280.
• Semmlow JL, Cone R. Utility of the injury severity score: a confirmation. Health Serv Res. 1976;11(1):45-52.
• Bull JP. Measures of severity of injury. Injury. 1978;9(3):184-187.
• Copes WS, Champion HR, Sacco WJ, et al. The Injury Severity Score revisited. J Trauma. 1988;28(1):69-77.

Pediatric Trauma Score (PTS)

• Introduction
• Points & Pearls
• Why and When to Use and Next Steps
• Calculator Review Author
• Advice
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

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Points & Pearls

• The Pediatric Trauma Score (PTS) is best used as a general predictor for stratifying traumatic injury severity.
• The PTS is poorly validated in blunt abdominal trauma and has not been shown to reliably predict isolated injuries to the liver or spleen (Saladino 1991).

Why and When to Use and Next Steps

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Matthew Lecuyer, MD

Advice

A low PTS correlates with high mortality risk, so a patient with a low score should be triaged for immediate medical attention at a pediatric trauma center (if nearby) or for stabilization at the nearest medical facility, at the discretion of the first responder.

Patients who have higher scores are less likely to have significant morbidity and mortality, but require reassessment as symptoms evolve. These patients should still be evaluated by a clinician, and a complete history and physical examination should be performed.

Critical Actions

Reassessment is an essential component of patient care in all trauma cases. Patients who have a low initial PTS, which indicates high risk for morbidity and mortality, may have changes in their clinical status, so recalculation may be necessary. Patients who have a high PTS should not be advised against further medical attention, as evaluation by a clinician is still recommended.

Evidence Appraisal

The PTS was first described by Tepas et al (1987) in a matched cohort study comparing 2 groups of 110 and 120 pediatric trauma patients, respectively. The study found a linear relationship between the PTS and the Injury Severity Score (ISS). The authors further validated their findings in a retrospective cohort study that included data for 615 children entered into the National Pediatric Trauma Registry between April and December 1985 (Tepas 1988). This study confirmed the correlation between increasing PTS and increasing ISS. Notably, the study authors did not correlate the findings with mechanism of injury. The study found that a PTS < 0 had a 100% mortality rate and a PTS > 8 was associated with no mortality; patients with a PTS of 0 to 8 had decreasing mortality rates as the PTS increased, showing an inverse linear correlation between increasing severity of injury and decreasing PTS.

Ramenofsky et al (1988) validated these findings in a cohort of 450 injured children who were evaluated by a paramedic in the field and a physician in the emergency department. The study confirmed an inverse linear correlation of PTS with injury severity and found a 93.6% correlation between the 2 clinicians (correlation coefficient = 0.991). A later study (Saladino 1991) found the PTS to be a poor predictor of isolated blunt abdominal injuries (eg, liver and spleen).

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Joseph J. Tepas, III, MD

References

Original/Primary Reference

• Tepas JJ, Mollitt DL, Talbert JL, et al. The pediatric trauma score as a predictor of injury severity in the injured child. J Pediatr Surg. 1987;22(1):14-18.

Validation References

• Tepas JJ, Ramenofsky ML, Mollitt DL, et al. The Pediatric Trauma Score as a predictor of injury severity: an objective assessment. J Trauma. 1988;28(4):425-429.
• Ramenofsky ML, Ramenofsky MB, Jurkovich GJ, et al. The predictive validity of the Pediatric Trauma Score. J Trauma. 1988;28(7):1038-1042.

Other Reference

• Saladino R, Lund D, Fleisher G. The spectrum of liver and spleen injuries in children: failure of the pediatric trauma score and clinical signs to predict isolated injuries. Ann Emerg Med. 1991;20(6):636-640.

Glasgow Coma Scale

• Introduction
• Points & Pearls
• Why and When to Use, Next Steps, and Advice
• Advice
• Calculator Review Author
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References
• Additional Reading

Introduction

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Points & Pearls

• The Glasgow Coma Scale (GCS) allows clinicians in multiple settings and with varying levels of training to communicate succinctly about a patient’s mental status.
• The GCS has been shown to have statistical correlation with a broad array of adverse neurologic outcomes, including brain injury, need for neurosurgery, and mortality.
• The GCS score has been incorporated into numerous guidelines and assessment scores.
• The correlation of the GCS score with outcome and severity is most accurate when applied to an individual patient over time; the trend in the patient's GCS score is important.
• A GCS score of 8 should not be the only factor used to determine whether or not to intubate a patient, but it does suggest a level of obtundation that should be evaluated carefully.
• The reproducibility of GCS scores can be low; the GCS creators provide training and education to help improve scoring agreement between providers at www.glasgowcomascale.org.
• There are simpler scores that have been shown to perform as well as the GCS in the prehospital and emergency department setting (for initial evaluation); these are often contracted versions of the GCS itself. For example, the Simplified Motor Score uses only the motor portion of the GCS. These contracted scores are less well-studied than the GCS for trending over time and for outcomes such as long-term mortality.

Why and When to Use, Next Steps, and Advice

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Daniel Runde, MD

Critical Actions

Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.

Evidence Appraisal

The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).

In the acute care setting, the GCS has been shown to have highly variable reproducibility and inter-rater reliability (eg, 56% among neurosurgeons in one study, 38% among emergency department physicians in another study). In its most common usage, the 3 sections of the GCS are often combined to provide a summary of severity. The authors themselves have explicitly objected to the GCS being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1E + 1V + 2M (for eye, verbal, and motor components, respectively), and a mortality rate of 27% if calculated 1E + 2V + 1M, but a mortality rate of only 19% if calculated 2E + 1V + 1M (Healey 2014).

In summary, the modified GCS provides an almost universally accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score results in information loss and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the GCS can perform as well as the GCS and is significantly less complicated. However, contracted scores may be less informative for patients with lesser injuries.

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Sir Graham Teasdale, MBBS, FRCP

References

Original/Primary Reference

• Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84.

Validation Reference

• Moore L, Lavoie A, Camden S, et al. Statistical validation of the Glasgow Coma Score. J Trauma. 2006;60(6):1238-1243; discussion 1243-1244.

Other References

• Teasdale G, Jennett B. Assessment of coma and severity of brain damage. Anesthesiology. 1978;49(3):225-226.
• Teasdale G, Jennett B, Murray L, et al. Glasgow coma scale: to sum or not to sum. Lancet. 1983;2(8351):678.
• Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671-678; discussion 678-680.
• Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale. Ann Emerg Med. 2011;58(5):427-430.
• Middleton PM. Practical use of the Glasgow Coma Scale; a comprehensive narrative review of GCS methodology. Australas Emerg Nurs J. 2012;15(3):170-183.
• Yeh DD. Glasgow Coma Scale 40 years later: in need of recalibration? JAMA Surg. 2014;149(7):734.
• Teasdale G. Forty years on: updating the Glasgow Coma Scale. Nurs Times. 2014;110(42):12-16.
• Gill M, Windemuth R, Steele R, et al. A comparison of the Glasgow Coma Scale score to simplified alternative scores for the prediction of traumatic brain injury outcomes. Ann Emerg Med. 2005;45(1):37-42.
• Haukoos JS, Gill MR, Rabon RE, et al. Validation of the Simplified Motor Score for the prediction of brain injury outcomes after trauma. Ann Emerg Med. 2007;50(1):18-24.
• Thompson DO, Hurtado TR, Liao MM, et al. Validation of the Simplified Motor Score in the out-of-hospital setting for the prediction of outcomes after traumatic brain injury. Ann Emerg Med. 2011;58(5):417-425.