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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
1
care. Trauma scores quantify the severity and extent of injury, aid with Minor 1
2
the prediction of survival and subsequent morbidity, and allow health Moderate 2 3
Severe, but not life-threatening
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
.8
with the use of specific treatment guidelines, can significantly contribute overall score for patients with multiple injuries 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
6
same systems used in adults but with some modifications. 3 pelvis, and external structures. 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
2,3
combined categories. 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
6,8
use where possible. each body region) and add the squares together. The ISS has a good
Anatomic Injury Scoring Systems predictive power and correlates well with mortality, morbidity, length of
hospital stay, and other measures of severity. The minimum score is 1
Anatomic injury scoring systems clearly characterise the degree of anatom- and the maximum possible score is 75, with higher scores reflecting an
2
ic disruption but fail to delineate organ system derangements. Examples 9
increased injury severity and mortality. 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 of 75 is automatically assigned. Injury Severity Scores higher than 15
6
2
(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- hospital or trauma centre care. However, it is inappropriate to use this as
4
1
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.
2
The AIS was first introduced in 1969 as an anatomic scoring system to There are several disadvantages to using the ISS. For example, the
5
categorise automobile victims for epidemiological purposes. 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 injury (Table trauma mortality, length of hospital stay, and length of intensive care unit
6
7
26.1). The AIS scores can be found in the AIS Dictionary Manual, a stay, and it may have usefulness in predicting morbidity. It is currently the
1,9
compendium of more than 1200 injuries. An AIS score ≥3 is considered most widely used injury scoring system. 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, 2
but only to score an individual injury. Its other limitation is that it does ISS = ∑ [(AIS of most severe injury in ISS region)
not provide a comprehensive measure of severity of injury because it + (AIS score of next most severe injury in another
2
focuses on singular but not combined injuries of the patient. ISS region)
+ (AIS score of most severe injury in any remaining
2
ISS region) ]