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Paediatric Injury Scoring and Trauma Registry 167
Table 26.6: Trauma Score The Triage-RTS (T-RTS), which is designed for prehospital use,
1
represents the sum of the values of the GCS, SBP, and RR, with the
Clinical parameter Parameter category Coded value
scores ranging from 0 to 12. A score of 0 represents the worst prognosis,
Respiratory Rate (cycle/min) 10–24 4 with P(s) equalling 0. A score of 12 represents the best prognosis, with
P(s) equalling 0.99. It is recommended that injured patients with a
1,2
25–35 3 T-RTS value ≤11 be admitted to a trauma centre for care. 1,17 .
>35 2 Circulation, Respiration, Abdomen, Motor, and Speech Scale
Another physiologic trauma scoring system is the CRAMS scale. It
<10 1 was developed in 1982 as a prehospital score to assist in trauma triage,
4
distinguishing those with major trauma from those with minor injuries.
0 0
CRAMS scores five physiologic parameters and physical examination
Respiratory expansion/effort Normal 1 findings, including circulation, respiration, trauma to the abdomen and
thorax, motor function, and speech on a scale ranging from 0 to 2 (Table
Abnormal 0 26.8). A score of 0 indicates severe injury or absence of the parameter,
2
Systolic blood pressure (mm Hg) >90 4 and a score of 2 signifies no deficit. A value of 0 on the CRAMS scale
indicates the worst prognosis or death, and a value of 10 indicates the
1
70–90 3 best prognosis or lack of injury. A CRAMS score ≤8 indicates a major
2
1
trauma, and a score ≥9 signifies a minor trauma. CRAMS is cumber-
50–69 2 some for field use and is limited by its reliance on subjective prehospi-
tal clinical components, such as capillary refill and respiratory effort. It
<50 1
is also often difficult to examine patients with thoracic and abdominal
1
0 0 trauma in the field.
The Apache Scale
Capillary refill Normal 2
The Acute Physiology and Chronic Health Evaluation scale is a more
Delayed 1 complex physiologic scoring system used predominantly later in the
course of care to predict morbidity and mortality. The APACHE I was
Absent 0 introduced in 1981 and had 34 physiological elements. This was revised
in 1985, resulting in the APACHE II, which retained only 12 of the 34
Glasgow Coma Scale 14–15 5
physiological elements. The APACHE scale will not be discussed here.
11–13 4 Readers interested in this scoring system should refer to the appropri-
ate literature.
8–10 3 Combined Anatomic and Physiologic Injury
5–7 2 Scoring Systems
Combined systems use anatomic and physiologic scoring to estimate
3–4 1 morbidity and mortality risk for an individual patient as well as for
trauma populations. These systems have an improved accuracy of both
anatomic injuries caused by trauma and physiologic derangements
Table 26.7: Revised Trauma Score.
caused by the patient’s underlying chronic health state. As such, they
Glasgow Coma Systolic blood Respiratory rate Coded value are better predictors of survival than those systems based on anatomic
Scale (GCS) pressure (SBP) (RR) (RTS) 2
or physiologic criteria alone. However, they can be cumbersome.
13–15 >89 10–29 4 They are most often used in inpatient settings after the patient has
been initially stabilised. Examples of this model are the Paediatric
9–12 76–89 >29 3
Trauma Score (PTS), Trauma and Injury Severity Score (TRISS), and A
2
6–8 50–75 6–9 2 Severity Characterisation Of Trauma (ASCOT). These are also known
as outcome analysis systems.
1
4–5 1–49 1–5 1 Paediatric Trauma Score
3 0 0 0 The PTS was devised specifically for the triage of paediatric trauma
patients. The PTS is calculated as the sum of individual scores from
3
six clinical variables (Table 26.9). The variables include weight, airway,
SBP, and RR (Table 26.7). 16,17 These three elements of the RTS are SBP, central nervous system (CNS) status (level of consciousness),
1,3
considered reliable and were selected due to their statistical associa- presence of an open wound, and skeletal injuries. Two of the clinical
tion with trauma mortality. Thus, the RTS is easier to use than the TS parameters, airway and CNS status, are somewhat subjective measures.
2,3
and is a highly sensitive and strong predictor of survival. The RTS is Each of the six clinical parameters is assigned a score ranging from no
3
calculated by multiplying each component score by a weighting factor injury to a major or life-threatening injury. The PTS is calculated as
and then summing the weighted scores by using the following formula: the sum of individual scores, and its total values range from –6 to +12.
A PTS ≤ 8 is recommended as an indication for prehospital triage of a
RTS = (0.9368 × GCS value) + (0.7326 × SBP value) + (0.2908 × RR value). patient to a trauma centre. There are conflicting reports on the effec-
2
RTS values range from 0.0 to 7.8408. The RTS correlates well tiveness of the PTS as a tool for assessing prognosis and in identifying
1
with survival, with higher values being more predictive of survival. those who will need a transfer to a paediatric trauma centre. 1,3,5,15,16
However, the use of the RTS as the sole predictor of mortality in Further refinements of the PTS include the Age-Specific PTS and
paediatric cases is not recommended. It is, however, the most widely the triage Age-Specific PTS. These scoring systems, however, have not
1
used triage scoring system in the world trauma literature. yet been validated and are rarely used.