CHAPTER 26 Paediatric Injury Scoring and Trauma Registry Francis A. Abantanga Erin A. Teeple Benedict C. Nwomeh Introduction Table 26.1: The Abbreviated Injury Scale. Injury scoring systems are designed to accurately assess injury severity, Type of injury AIS score appropriately triage the injured, and develop and refine trauma patient care.1 Trauma scores quantify the severity and extent of injury, aid with Minor 1 the prediction of survival and subsequent morbidity,2 and allow health Moderate 2 Severe, but not life-threatening 3 care providers to communicate in common terms. One disadvantage of Severe, life-threatening, survival probable 4 injury scoring systems is that patient information is reduced to a simple Critical, survival uncertain 5 score, and important details may be lost. To accurately estimate patient Not survivable/virtually unsurvivable 6 outcome, it is necessary to precisely assess the patient’s anatomic and physiologic injury, as well as any preexisting medical conditions that can impair the patient’s ability to respond to the stress of the injuries sustained. Injury Severity Score Understanding and appropriate use of trauma scoring systems, along The ISS, like the AIS, is an anatomic scoring system that provides an with the use of specific treatment guidelines, can significantly contribute overall score for patients with multiple injuries.8 Each injury must be to improvement in the prognosis of injured children. The majority of the assigned an AIS score, allocated to one of six body regions: head and injury scoring systems used in children today are extrapolations of the neck, face, thorax, abdomen and visceral pelvis, extremities and bony same systems used in adults but with some modifications.3 pelvis, and external structures.6 Injuries in each region are given an AIS Injury scoring systems are divided into anatomic, physiologic, and score, and the highest AIS score in each body region is used. To generate combined categories.2,3 Some of the scoring systems are discussed in the ISS, square the AIS score of each of the three most severely injured further detail within the following sections, with demonstrations of their body regions (those with the highest AIS scores, including only one from use where possible. each body region) and add the squares together.6,8 The ISS has a good predictive power and correlates well with mortality, morbidity, length of Anatomic Injury Scoring Systems hospital stay, and other measures of severity. The minimum score is 1 Anatomic injury scoring systems clearly characterise the degree of anatom- 2 and the maximum possible score is 75, with higher scores reflecting an ic disruption but fail to delineate organ system derangements. Examples increased injury severity and mortality.9 The ISS is not calculated when of injury methods that evaluate anatomic status include the Abbreviated any single body region has an AIS value of 6; in such cases, an ISS value Injury Scale (AIS), Injury Severity Score (ISS), and Anatomical Profile 6 2 of 75 is automatically assigned. Injury Severity Scores higher than 15 (AP). These injury scoring systems are based upon anatomic descriptions have been used as a proxy for injuries of sufficient magnitude to require of identified injuries and are retrospectively used to analyse trauma popu- 4 1 hospital or trauma centre care. However, it is inappropriate to use this as lations. In these systems, the site of the injury is important. the sole criterion for triaging because it does not also measure alterations Abbreviated Injury Scale in the physiology of the trauma patient. The AIS was first introduced in 1969 as an anatomic scoring system to There are several disadvantages to using the ISS.2 For example, the categorise automobile victims for epidemiological purposes.5 It under- ISS cannot be used as an initial triage tool because detailed assessment, went revision in 1990, and body regions for the AIS were identified as fol- and in some cases surgical exploration, must be performed before a full lows: head, face, neck, thorax, abdomen and pelvic content, spine, upper description of the injuries can be obtained. Also, the patient’s age and extremities, lower extremities, and unspecified. In this revised version, comorbidities are not taken into account. Furthermore, multiple injuries external injuries are dispersed across body regions, and the AIS provides a to the same body area are not weighted higher than a single injury to that reasonably accurate way of ranking the severity of injury by body regions. area. Lastly, the ISS uses only three regions, so that injuries from the With the AIS, injuries are ranked on an ordinal scale ranging from 1 to three remaining regions are not taken into account. 6, with 1 being considered a minor injury or least severe, 5 being a severe In spite of these limitations, the ISS has been validated as a predictor of injury or survival uncertain, and 6 being an unsurvivable injury6 (Table trauma mortality, length of hospital stay, and length of intensive care unit 26.1). The AIS scores can be found in the AIS Dictionary Manual,7 a stay, and it may have usefulness in predicting morbidity. It is currently the compendium of more than 1200 injuries. An AIS score ≥3 is considered most widely used injury scoring system.1,9 Automated ISS calculators are serious. The AIS correlates well with the degree of injury but suffers as available to compute the value of the ISS once the AIS scores are entered. a prognostic tool because it does not take physiologic derangements or The ISS score can also be computed manually as follows: chronic health into account. It is not intended to reflect patient outcomes, ISS = ∑ [(AIS of most severe injury in ISS region)2 but only to score an individual injury. Its other limitation is that it does + (AIS score of next most severe injury in another not provide a comprehensive measure of severity of injury because it ISS region)2 focuses on singular but not combined injuries of the patient. + (AIS score of most severe injury in any remaining ISS region)2] Paediatric Injury Scoring and Trauma Registry 165 An illustration of how to calculate ISS is shown in Table 26.2. Table 26.2: Sample calculation of ISS. The ISS score for the example in Table 26.2 is 50, which is a very severe injury requiring the patient to be admitted to a hospital for Square of Body region Description of injury AIS score top three AIS trauma care. Patients with ISS scores ≥15 should be cared for in a scores hospital or trauma centre with adequate resources and experience in Head and neck Cerebral contusion 3 9 trauma care. The ISS calculations include spine injuries in the corresponding Face Minor injury 1 16 three ISS body regions: cervical in ISS head or neck, thoracic in ISS chest, and lumbar in ISS abdominal or pelvic contents. Chest Unilateral flail chest 4 25 New and Modified ISS Pneumothorax 3 In 1997, a simple modification of ISS was formulated and referred to Abdomen Minor contusion of bowel 2 as the New ISS (NISS).10 It is defined as the sum of the squares of the Completely shattered 5 AIS of each of the patient’s most severe AIS injuries irrespective of the spleen body region in which they occur.3,5,10 The NISS is reported to predict survival better3 than the ISS by better predicting mortality in the more Extremity Femoral shaft fracture 3 11 severely injured patients, and it is simpler to calculate. Skin Minor injury 1 There is also a Modified ISS (MISS), specifically intended for paediatric trauma cases. This modification was made to account for Injury Severity Score = 50 the predominance of head injuries in paediatric trauma patients.5 In the MISS, the number of body regions is reduced to four: face/neck, chest, abdomen/pelvic contents, and extremities/pelvis.5 The MISS uses the Table 26.3: The Modified Injury Severity Score (MISS). Glasgow Coma Scale (GCS; see next section) value categories (Table Glasgow Coma Scale Neurologic score 26.3) to determine the AIS head region scores and also assigns injuries of the skin/general category within any of the four body regions listed 15 1: Minor above. The MISS is calculated by summing the squared AIS values 13–14 2: Moderate for the three most severely injured body regions. Several studies have 9–12 3: Severe, not life-threatening validated the MISS in paediatric trauma and have shown it to accurately identify patients at high risk for mortality and long-term disability.12 In 5–8 4: Severe, survival probable spite of this, the MISS is not widely used because improvements have 3–4 5: Critical, survival uncertain been made in the more recent versions of the AIS and ISS. Anatomical Profile The AP addresses some of the shortcomings of the ISS. It uses the AIS descriptors of anatomic injury, but includes only four body regions: A = Table 26.4: Sample calculation of AP. head/brain and spinal cord; B = thorax/neck; C = all other serious inju- Component Injury AIS score ries other than in the areas of A and B; and D = all nonserious injuries.1,2 Injuries with an AIS value >2, which are defined as serious, are scored for 1. Head/brain 5 1 A the first three categories above. All minor injuries, defined as AIS scores 2. Spinal cord 3 2 of ≤2, are classified as nonserious, regardless of their anatomic location. 1. Thorax 4 The total AP score is the sum of the square roots of the sum of the squares B of the AIS for all individual injuries within a region1,2 (Table 26.4).