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Injury Severity Score (ISS) the Injury Severity Score (ISS) Standardizes the Severity of Traumatic Injury Based on the 3 Worst Injuries from 6 Body Systems

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Injury Severity Score (ISS) the Injury Severity Score (ISS) Standardizes the Severity of Traumatic Injury Based on the 3 Worst Injuries from 6 Body Systems CalculatedPOWERED BY Decisions Clinical Decision Support for Pediatric Emergency Medicine Practice Subscribers Injury Severity Score (ISS) The Injury Severity Score (ISS) standardizes the severity of traumatic injury based on the 3 worst injuries from 6 body systems. Click the thumbnail above to access the calculator. Points & Pearls Why to Use • The Injury Severity Score (ISS) was initially de- Due to the heterogeneous nature of trauma rived in patients with blunt traumatic injury from patients, standardizing the severity of traumatic motor vehicle accidents. injuries allows for comparison of much larger • The ISS is not intended to be used for bedside sample populations in trauma research studies. decision-making for a single patient in the emer- gency department setting, but rather as a tool When to Use to standardize the study of trauma patients. The ISS attempts to standardize the severity • Due to the nature of the score, multiple combi- of injuries sustained during trauma. This nations of Abbreviated Injury Scale (AIS) scores standardization allows for more accurate study may result in the same ISS, each of which may and prediction of morbidity and mortality indicate a different mortality rate. For example, outcomes after traumatic injuries. an ISS of 17 can be calculated from patients with a combination of points based on the 3 most se- Next Steps vere injuries, such as (4, 1, 0) or (3, 2, 2). The ISS As the ISS is intended primarily as a research assigns equal value to each body region. tool, the score should not affect the initial management of a patient with traumatic injuries. Instructions First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no scores of the most severe injury in each of the 3 injury) to 6 (unsurvivable injury). Next, those scores most severely injured body systems). Patients with are used to determine the 3 most injured body an AIS of 6 in any body system are automatically as- systems. Finally, the ISS is calculated by squaring signed an ISS of 75, the maximum possible score. the AIS score for each of the 3 most injured body The ISS is used primarily in research settings, systems, then adding up the 3 squared numbers so calculation of the score should not delay initial (A2 + B2 + C2 = ISS, where A, B, and C are the AIS management of patients with traumatic injuries. Critical Actions CALCULATOR REVIEW AUTHORS • In all trauma patients, the initial treatment strat- Max Berger, MD egy should focus on the primary and secondary Ronald O. Perelman Department of Emergency survey, and assessing and stabilizing the patient. Medicine, NYU Langone Health, New York, NY • Although the ISS score is intended primarily for research purposes, it may have broader clinical Alexandra Ortego, MD use in the intensive care unit for prognostica- Ronald O. Perelman Department of Emergency tion following the initial stabilization of traumatic Medicine, NYU Langone Health, New York, NY injuries. CD1 www.ebmedicine.net Evidence Appraisal Use the Calculator Now The ISS was derived by Baker et al (1974) by taking Click here to access the ISS on MDCalc. the previously used AIS (American Medical Associa- tion Committee on Medical Aspects of Automotive Calculator Creator Safety 1971) and adding the squared value of each Susan P. Baker, MPH of the 3 most severely injured body systems, in an Click here to read more about Professor Baker. effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were References used to calculate the final score because it had been Original/Primary Reference shown that injuries that would not necessarily be • Baker SP, O'Neill B, Haddon W, et al. The injury severity score: life-threatening in isolation could have a significant a method for describing patients with multiple injuries and evaluating emergency care. J Trauma. 1974;14(3):187-196. effect on mortality when they occurred in combina- https://www.ncbi.nlm.nih.gov/pubmed/4814394 tion with other severe injuries. The derivation study Validation References included only injuries sustained from motor vehicle • Beverland DE, Rutherford WH. An assessment of the valid- collisions, including the occupants of the vehicles ity of the injury severity score when applied to gunshot and any pedestrians involved. wounds. Injury. 1983;15(1):19-22. DOI: https://doi.org/10.1016/0020-1383(83)90156-0 Further studies have validated the ISS to include • Committee on Medical Aspects of Automotive Safety. Rat- other mechanisms of injury. A study by Beverland ing the severity of tissue damage: I. The abbreviated scale. et al (1983) of 875 patients with gunshot wounds JAMA. 1971;215(2):277-280. showed that an increasing ISS was associated with DOI: https://doi.org/10.1001/jama.1971.03180150059012 increasing mortality (chi-squared = 83.31, P < .001). • Semmlow JL, Cone R. Utility of the injury severity score: a A study by Bull (1978) confirmed the correlation confirmation. Health Serv Res. 1976;11(1):45-52. https://www.ncbi.nlm.nih.gov/pubmed/965234 between increasing ISS and increasing mortality in • Bull JP. Measures of severity of injury. Injury. 1978;9(3):184-187. road traffic accidents, and showed correlation be- DOI: https://doi.org/10.1016/0020-1383(78)90004-9 tween increasing ISS and increasing mean hospital • Copes WS, Champion HR, Sacco WJ, et al. The Injury Sever- length of stay. ity Score revisited. J Trauma. 1988;28(1):69-77. In a study of 8852 trauma patients from the https://www.ncbi.nlm.nih.gov/pubmed/3123707 Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had Copyright © MDCalc • Reprinted with permission. similar findings to Baker et al regarding the relation- ship between ISS and mortality. They also found that the ISS correlated with hospital length of stay. Pediatric Emergency Medicine Practice • May 2019 CD2 Copyright © 2019 EB Medicine. All rights reserved. Pediatric Trauma Score (PTS) The Pediatric Trauma Score (PTS) stratifies the severity of injury and mortality risk in pediatric trauma patients. Click the thumbnail above to access the calculator. Points & Pearls Why to Use • The Pediatric Trauma Score (PTS) is best used The PTS helps clinicians stratify injury severity as a general predictor for stratifying traumatic and mortality risk in pediatric trauma patients. injury severity. It can also be used to triage patients in a • The PTS is poorly validated in blunt abdominal resource-limited environment, identifying the trauma and has not been shown to reliably patients who are at high mortality risk versus predict isolated injuries to the liver or spleen patients who may not be as critically ill and will (Saladino 1991). need fewer resources. Advice The PTS can be used for triage by first A low PTS correlates with high mortality risk, so responders on the scene to help determine a patient with a low score should be triaged for which patients require transfer to a pediatric immediate medical attention at a pediatric trauma trauma center. center (if nearby) or for stabilization at the near- est medical facility, at the discretion of the first When to Use responder. • The PTS should be used for pediatric Patients who have higher scores are less likely patients (aged < 18 years) who present to have significant morbidity and mortality, but with trauma. require reassessment as symptoms evolve. These • The score is poorly validated in patients patients should still be evaluated by a clinician, with blunt abdominal trauma, so it should and a complete history and physical examination be used with caution in this population. should be performed. • The PTS should not be used to predict the presence of isolated injuries. Critical Actions Reassessment is an essential component of patient Next Steps care in all trauma cases. Patients who have a low Patients should be monitored for any evolution initial PTS, which indicates high risk for morbidity of signs and symptoms, as conditions may and mortality, may have changes in their clinical change after the initial assessment and scoring status, so recalculation may be necessary. Patients who have a high PTS should not be advised against with the PTS. further medical attention, as evaluation by a clinician is still recommended. cohort study that included data for 615 children Evidence Appraisal entered into the National Pediatric Trauma Registry The PTS was first described by Tepas et al (1987) in between April and December 1985 (Tepas 1988). a matched cohort study comparing 2 groups of 110 This study confirmed the correlation between in- and 120 pediatric trauma patients, respectively. creasing PTS and increasing ISS. Notably, the study The study found a linear relationship between the authors did not correlate the findings with mecha- PTS and the Injury Severity Score (ISS). The authors nism of injury. The study found that a PTS < 0 had further validated their findings in a retrospective 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, CALCULATOR REVIEW AUTHOR showing an inverse linear correlation between in- creasing severity of injury and decreasing PTS. Matthew Lecuyer, MD Department of Emergency Medicine (Pediatrics), Warren Ramenofsky et al (1988) validated these find- Alpert Medical School of Brown University, Providence, RI ings in a cohort of 450 injured children who were evaluated by a paramedic in the field and a physi- CD3 www.ebmedicine.net cian in the emergency department. The study con- Validation References firmed an inverse linear correlation of PTS with injury • Tepas JJ, Ramenofsky ML, Mollitt DL, et al. The Pediatric severity and found a 93.6% correlation between the Trauma Score as a predictor of injury severity: an objective assessment.
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