INJURY SEVERITY

SCORES
BY
DR. PRATHAP AVVARU
JR, DEPT OF SURGICAL DISCIPLINES

INTRODUCTION
INJURY CODING
INJURY SEVERITY SCORES
TYPES OF INJURY SEVERITY SCORES

INTRODUCTION

Trauma injury severity scoring quantifies the risk of an outcome

following trauma.
The primary outcome of interest is usually SURVIVAL

Clinically, these scores assist in

the pre-hospital triage of trauma patients

can help to more accurately predict patient outcomes to assist

with clinical decision making, especially at the end of life.

INJURY CODING
Accurate classification of a patients injuries,

also known as injury coding, is fundamental

to the validity and success of severity scoring
ISSs are uniformly based on two classification

schemes: the AIS and the ICD

AIS
ABBREVIATED INJURY SCORE
1971,2008
TRAUMA SPECIFIC
HAS TWO COMPONENTS
An injury descriptor (pre-dot) that is unique to
each injury
a severity score (post-dot) graded FROM 1 TO 6

AIS
The actual AIS code consists of two numerical components. The

first component is a six-digit injury descriptor code (pre-dot),

which is unique to each traumatic injury;
pre-dots classify the injury by region, type of anatomic

structure, specific structure, and level.

The second component is a severity score (post-dot), graded

from 1 (minor) to 5 (critical injury) AND all unsurvivable injuries

are scored 6

AIS
pre-dot codes include nine anatomic regions:

1, head;
2, face;
3, neck;
4, thorax;
5, abdomen and pelvic contents;
6, spine;
7, upper
extremity;
8, lower extremity;
9, unspecified

ICD
INTERNATIONAL STATISTICAL CLASSIFICATION

OF DISEASES
1983,2013
GENERAL, ALL PURPOSE DIAGNOSIS
CLASSIFICATION
CODES 800.0 TO 959.9 ARE TRAUMA SPECIFIC

INJURY SEVERITY SCORES

ISSs quantify the risk of an outcome after trauma, for

both clinical and research purposes.

majority of scores are based on either the traumaspecific AIS coding or the more general ICD-9
taxonomy.
still today there is no consensus on a best injury
scoring system

TYPES
four types of risk adjustments (equally

called scores) are calculated to account

for trauma
severity:
(1)

Anatomic Injury Scores;

(2)Physiological Derangement Scores;
(3) Comorbidity Scores; and
(4) A combination of the three.

ANATOMICAL SCORING
SYSTEMS
AIS(1971)
ISS(1974)
NISS(1997)
APS(1990)
ICDMAP-90(1990)
ICISS(1996)
TRAIS(2003)
OIS(1987)

AIS
PATIENT SURVIVAL
not only a method to classify injuries, also a validated

method to score injury severity.

Score ranges from 1 to 6
maximum AIS (maxAIS), which is the largest AIS
severity among all of a patients injuries, is highly
associated with mortality but ignores information
provided from other injuries.
Cannot predict functional impairment

AIS SCORING

ISS
Patient survival
ISS divides the body into six regions: head or neck,

face, abdominal, chest, extremities, and external.

Injuries in each region are given an AIS score and the
highest AIS scores in the 3 most severely injured
regions are squared and summed to form the ISS
Ranges from 1(least severe) to 75(unsurvivable)
.Any patient with an AIS severity of 6 is automatically
given an aggregate score of 75.

ISS
ISS is most widely used anatomical scoring

system
Correlates well with mortality
ISS only considers one injury in each of the
body regions and thus ignores important
injury information

NISS
Patient survival
address some of the ISS shortcomings, esp, its

omission of multiple occurrences of serious injuries

within the same body region
NISS is the sum of the squares of the three most
severe AIS severities, regardless of body region (and
keeps convention that an AIS of 6 automatically
results in a NISS of 75).

APS
Patient survival
Three modified components (head/brain

and spinal cord injury; thorax and neck injury;

all other serious injuries) are scored based on
AIS and weighted to form a single APS; only
serious injuries included
failed to supplant ISS

OIS

Not for patient outcomes

Anatomic injury within an organ system graded on an

ordinal scale, with Grade 1 being a minor injury and

Grade 5 being tissue-destructive and
likely fatal

Designed to standardize the descriptive language of

injury for 32 organ and body system regions.

No predictive abilities; Not widely adopted; not used

for risk adjustmen

PHYSIOLOGICAL SCORING SYS

TEMS
GCS(1976)
RTS(1989)
APACHE II(1985)
SAPS II
SOFA

GCS
PATIENT SURVIVAL AND BRAIN FUNCTION
Aggregate score of motor activity (scale of 1

6 points), verbal activity (15 points), and eyeopening (14 points)

RANGES FROM 3 TO 15
Simple to use, well validated,
Hard to measure all components in some
patients(sedated, intubated)

RTS
Patient survival
Two foms exist : TRIAGE RTS, other for

outcome evaluation and risk adjustment

Both are based on GCS, SBP, RR
TRIAGE RTS min score 0 and max score 12

OUTCOME RTS
Patient survival
RTS = 0.9368(GCS) +0.7326(SBP) +

0.2908(RR)
Ranges from 0 to 7.84
Lower scores more derangement
Contribution to TRISS model

APACHE-II
Patient survival and disease severity
Based on worst 12 physiological

measurements (HR, BP) in 1st 24 hrs of ICU

admission, as well as age and chronic health
conditions
Ranges from 0 to 71
Score >15 moderate to severe risk
ICU specific, superior to TRISS and ISS in
predicting mortality in TICU
Time consuming and complex to calculate

APACHE II
Age (0 to 6 pts ), past medical h/o (0 to 5),

Acute Physiological Score(0 to 60)

Temp, MAP, HR, RR, PaO2, Art PH, sr Na, sr
K ,Sr Cr, HCT, TLC, GCS

MORTALITY PREDICTION
BY APACHE-II
APACHE SCORE

Non op mortality

Post op mortality

0-4

5-9

10-14

15

15-19

24

12

20-24

40

30

25-29

55

35

30-34

73

73

>35

85

88

SAPS II
Simplified Acute Physiology Score
12 physiological variables and 3 disease

related variables
Ranges from 0 to 163
Greater scores high mortality

SAPS II PREDICTION
SAPS II SCORE

MORTALITY

29 pts

10%

40 pts

25%

52 pts

50%

64 pts

75%

>77 pts

90%

COMORBIDITY SCORING SYSTEMS

CHARLSON(1987)
TRISSCOM(2004)

TRISSCOM
Patient survival
Similar to TRISS with adjustments to age and

eight comorbidity variables(recorded as binary

variables y/n
Ranges from 0(un-survivable) to 1 (high likely
hood of survival)
Co morbidities not weighted based on
severity

COMBINED SCORING SYSTEMS

TRISS(1987)
ASCOT(1990)

TRISS
Patient survival
Trauma specific
Combines ISS, RTS and age
Regression coefficients from MTOS database
Different equations for penetrating and blunt

trauma
Ranges from 0(unsurvivable) to 1(high
survival)
Multiple variables, even if one is missing
TRISS cannot be calculated

THANK YOU