12

Scandinavian Journal of Surgery 91: 1222, 2002

H. R. Champion

TRAUMA SCORING
H. R. Champion
Surgery and Military & Emergency Medicine, Uniformed Services University of the Health Sciences,
Bethesda, Maryland, U.S.A.

ABSTRACT

Severity scales to characterize the nature and extent of injury are important adjuncts to
trauma care systems, trauma research and many of the elements of a complete public
health approach to injury. This article provides a brief overview of severity scale development over the past 30 years during which the science to support such initiatives has
matured substantially.
Anatomical, physiological, intensive care, composite and complex scales and models
now abound and are being applied to a variety of tasks with increasing precision. Trauma registries enable the meaningful aggregation of data for the development and testing of models. Future challenges are identified as are potentially fruitful avenues of
research.
Key words: Trauma; trauma scores; injury scoring; Injury Severity Score; TRISS

INTRODUCTION
Measurement and tabulation of the severity of injury
is an essential prerequisite both to effective trauma
care and clinical research. Furthermore, programmatic and public policy issues related to injury are
not easily addressed without understandable renditions of the epidemiology and the nature and severity of the problem. Also, both civilian mass casualty
contingency planning and military expeditionary
medical resourcing benefit immensely from knowledge of the number, nature and severity of anticipated casualties. Several trauma severity scales are used
to quantify injury severity and describe patient severity casemix. Once injury is thus characterized, the
results can be applied to triage, resourcing, research,
and quality of care assessment. In many cases, indices facilitate precise communication about often complex problems.
Severity classifications can be nominal, ordinal or
interval in nature. Many injury severity characteriCorrespondence:
Howard. R. Champion, M.D.
954 Melvin Road
Annapolis, Maryland 21403, U.S.A.
Email: HRCHAMPION@aol.com

zations are nominal scales where verbal definitions

are used to place injuries in various dissimilar bins
of severity or complexity. They are valuable in facilitating communication between interested parties
and allowing for consistent casemix definitions to be
adopted by a variety of investigators. Ordinal scales
(Ordinal: any positive whole number defining a
things place in a series) assign a number to states of
severity. Most cancer classifications are ordinal
scales. In injury, many classifications of fractures (1)
are examples, as is the Glasgow Coma Scale (2).
Triage classifications and many orthopaedic, neurosurgical and general injury classifications fall into
this group. Interval scales also assign numbers, but
there is an implicit expectation of some consistency
in the intervals between the numbers. The Abbreviated Injury Scale (AIS) describes anatomical injury,
but the 5 in head has a different outcome from a 5 in
the abdomen and the interval between a 2 and a 3 or
a 3 and a 4 also varies from body area to body area.
Few if any injury scoring systems are truly consistent
interval scales. A score is the number, grade or rating. A scale is the system of measurement. Thus, both
the Trauma Score and the Pediatric Trauma Score
should have been named as scales as the Glasgow
Coma Scale was so correctly identified.

Trauma scoring

A model is created when a scale or score is used

to predict or correlate with an outcome measure,
e.g., survival. Models refine the ability of scores or
scales to be used for comparison of groups of patients or in determining thresholds which allow patients to be placed in various bins for the purpose
of treatment, triage or comparative analysis. Although each scale in and as of itself may also be
used as a predictive model, injury, in its complex
involvement of many organs and anatomical areas
with time dependent physiological sequelae after
anatomical rearrangement requires more than a single, simple descriptor for its characterization. Models may be logistic regression based, Bayesian or
Hybrid. Many neural nets have complex bases for
models, e.g., back propagation, radial, etc. Composite models such as AIS derivatives (see below) plus
the Trauma Score (3), e.g., (TRISS) (4) are often used
to fashion a predictive model and are composed of
the determinants deemed important in predicting
the outcome measure being used. It is important to
understand that such predictive models are not deterministic for individual outcome. They give the
probability of an outcome for a given patient. Thus,
a patient may have a probability of death Pd of .6 or
60 % risk of dying. For every 10 identical patients,
6 will die and 4 will live if it is a perfect model.
But which group does this patient fall into: the
60 % dead or the 40 % alive? Only chance determines the answer.
Probabilistic models require different statistical
approaches to deterministic models. Probabilistic
models should always be evaluated for their discrimination and their calibration. Discrimination refers to
the ability of the model to distinguish between outcomes e.g. survivors from deaths. Measures of discrimination are shown in Table 1. Perfect discrimination would assign a 1 to all those that died and 0
to those that did not. Calibration measures how accurately the model predicts the probability of death
of given interval sets. A perfectly calibrated model
would give the same probability of death for any given group of cases as the observed proportion of
deaths.
Concordance is often used as a measure of discrimination. Each survivor/non-survivor pair is assigned
a score of 1 where a survivor has probability of survival strictly greater than that of the non-survivor,
0,5 where the survival probabilities are equal and 0
where the non-survivor has a greater probability of
survival than the survivor. The concordance is the
sum of these values divided by the total number of
survivor/non-survivor pairs. A perfectly discriminating model has a concordance of 1.
Data sets can be compared using concordance by
using test/design set methodologies or by bootstrapping techniques.
Data sets can be compared for calibration using
calibration curves and the Hosmer-Lemshow statistic (5). The H-L statistic is a single summary measure of the calibration of a model. It is based on comparing the observed and estimated probability outcome of patients grouped by estimated mortality or
decile. The resulting statistic has a chi-square distri-

13
TABLE 1
Some measures of discrimination.

Sensitivity
Specificity
False Positive Rate
False Negative Rate
Positive Predictive Power
Misclassification Rate
Area under receiver operating characteristic curve
Concordance

bution with degrees of freedom equal to 2 less than

the number of groups. The smaller the H-L statistic
the better the fit.
Another thing to consider when evaluating scores
and models is their validity: face, concurrent, construct, content and predictive.
Since there are a wide variety of applications for
injury severity scoring systems, it is important that
the choice of the severity score scale, index, or model accurately match the application. Thus, for triage,
which places a patient in one or three or four bins of
severity, a relatively simple tool may be all that is
required. For controlling for casemix and comparing
outcomes over time or in different centers or in therapeutic arms of a study, a more scientifically robust
tool might be in order. Misapplication of a simple
tool to a complex task creates an opportunity for unwarranted extrapolations and poor science.
ANATOMICAL INDICES
AIS, ISS, AP, NISS, MAP AND OTHERS

Indices that score anatomic injury severity have been

widely applied in epidemiologic studies. When used
alone, their correlation with outcome is lower than
when combined with measures of physiologic states.
The Abbreviated Injury Scale (AIS) (6) was developed by engineers to rate and compare blunt injuries from road vehicle accidents and has undergone
several modifications since its introduction in 1971.
We are currently updating AIS -95 (1998 version). It
is called AIS 2000, but may not be out until 2003.
The AIS scores individual injuries and classifies them
into one of six categories, each with an associated severity score: minor [1], moderate [2], serious [3] severe [4] critical [5], and fatal [6]. The AIS has been
shown to relate to risk of death in each body region.
The severity scores were subjectively assigned by experts thus, there is some internal inconsistency, e.g.,
a 3 for one body region does not have the same risk
of death as a 3 in another region.
The Injury Severity Score (ISS) (7) was derived to
summarize the severity of the condition of multiply
injured patients. The ISS is the sum of squares of the
highest AIS grades in each of the three most severely injured body regions.
ISS = a2 + b2 + c2

14

H. R. Champion
TABLE 2
Measures for each index (Ref. 19).
Discrimination

Calibration

Concordance
(Area Under
ROC Curve)

H-L Statistica

ISS
NISS
mAP
APS

86
86
87
87

384
040
029
070

ICSS (NCTR)
ICISS (PTOS)

87
88

244
370

ICD/ISS
ICD/NISS
ICD/mAP
ICD/APS

82
84
85
85

283
133
097
094

Measures

H-L statistic computed by comparing predicted versus observed

number of survivors across strata defined by equal range fixed
Ps cut-off values (e.g., 0.00.09; 0100.19, etc.)

ISS
NISS
mAP
APS

Injury Severity Score

New Injury Severity Score
Maximum Anatomical Profile Score
Anatomical Profile Score

xx When prefixed by ICD means ICDMAP and ICD-10CM code

were used to derive ISS
ICD derived ISS NCTR. North Carolina Dataset
ICISS & ICD based ISS PTOS dataset
(Table 2 is published with permission from Lippincott Williams
& Wilkins, Baltimore, MD, USA)

Limitations of the ISS have been described (8). These

limitations result from the use of a one-dimensional
score to represent the spectrum of injury locations
and severities and from the ISS definition that excludes all but the most serious injury in any body
region. The ISS also considers equal serious injuries
of the same AIS severity to any body region. Thus,
the ISS does not provide a reliable basis for characterizing injury severity, inflates the variability of outcome estimates, and obscures comparisons of certain
patient populations. It is particularly frail for ballistic
penetrating injury where there are many injuries in
a single body area, e.g., gunshot to abdomen, and in
populations with high proportions of head injuries.
Nevertheless, the ISS was the first widely used scale
to capture multiple injuries. It is still widely used.
Because of ISS limitations, a multidimensional
characterization was sought that considers the
number, location, and severity of anatomic injuries
and their influence on outcome. The Anatomic Profile characterization uses four variables to describe a
patients injuries: A, B, and C summarizes serious
(AIS = 3) injuries to the head and neck, thorax, and
other body regions respectively, and D describes all
nonserious injuries to any body region. The scores
are combined using an Euclidean Distance Model viz.
the square root of the sum of the squares

A2 + B2 + C2 + D2
allowing for decreasing influence of injuries as the

number of injuries increases. Using the A, B, C, D

methodology, survival probabilities can be estimated by multiple logistic regression or from the percentage of survivors among clusters of patients
with similar injury constellations. This anatomic injury score is called the Anatomic Profile (AP). The
maximum AP(mAP) (9) double scores the maximum
AIS injury score allowing for its dominant effect in
multiple injuries.
Another improvement has been the development
of the new Injury Severity Score (NISS) which overcomes some of the shortcomings of the Injury Severity Score (ISS) allowing severe injuries in multiple
body areas to be counted (10).
Anatomic injury scales have also been based on
versions of the International Classification of Diseases (ICD) used throughout the world as the prime
nomenclature system for disease and injury. ICD 9CM (CM stands for Clinical Modification) (11) has
many discrete definitions of, for instance fractures,
and relatively poor definition for vascular and solid
organ injuries, e.g., liver injuries to which are a major cause of early death after injury thus it lacks
face validity.
There have been several attempts to circumnavigate the lack of discrimination in the ICD nominal
system and the labor intensive duplicative coding
that developing AIS requires. Codes based on the
ICD 9-CM have included the Estimated Survival
Probability Index (12), the Anatomic Index and ICISS
(13, 14). The PEBL Code provides greater specificity
for penetrating injuries. It was derived from data on
3,600 Vietnam combat casualties and remains the
most detailed anatomic code (15), but is not used.
A computerized conversion (ICDMAP) (16) has
been developed that assigns ICD 9-CM diagnoses to
AIS-90 and then AIS-95 severity scores, although the
conversion has some limitations primarily because of
the range of severities associated with some ICD 9CM codes. It is widely used to convert administrative data sets coded in ICD-9CM into AIS and ISS.
ICD 10 is now in use. Its clinical modification will
be available soon. Severity models based on this will
follow. ICD-10CM is much more detailed than ICD9CM and may improve the ability of ICD to be used
as an element in models predicting outcome, and in
a fashion that does not require the labor intensive AIS
coding system.
Recent years have seen competitive claims from the
various authors of various anatomical injury severity
scoring methodologies (17, 18). We, therefore, compared a number of different offerings ICD-based and
non-ICD-based, AIS generated scores (19) (Table 2).
These data show a general difference in the discrimination measure between ICD-based scores and AIS
coded scores. The former also showed poor calibration. The new ISS (NISS) and Anatomic Profile (AP
and MAP) scales are the best. Researchers continue to
identify limitations with existing formulae, but replacements have yet to get traction (20, 21, 22).

Trauma scoring

15

TABLE 3
Revised Trauma Score variables (Ref. 28).
Glasgow Coma Score

Systolic BP (mmHg)

Resp. rate (min)

Coded Value

8> 89
7689
5075
0149
0

1029
8> 29
69
15
0

4
3
2
1
0

1315
0912
068
045
03

(Published with permission from Lippincott Williams & Wilkins, Baltimore, MD, USA)

PHYSIOLOGICAL SCALES
TRAUMA SCORE, REVISED TRAUMA SCORE, CRAMS SCALE

If anatomic scores characterize the static component

of injury, then physiologic scores measure the acute
dynamic component. This is important since most
deaths from injury occur within hours (23), and are
due to exsanguinations, brain or spinal cord injury
or respiratory failure.
In 1980, consensus physician peer review of severity indices resulted in the Trauma Score. The Trauma Score modified the Triage Index (24) to include
systolic blood pressure and respiratory rate and used
the Glasgow Coma Scale (GCS) to assess the degree
of coma. The Trauma Score ranged from 1 (worst
prognosis) to 16 (best prognosis) and is computed by
summing points assigned to component variables.
The Trauma Score was a useful predictor of outcome
for patients with blunt or penetrating injuries (25).
Field assessments determined that the Trauma Score
user had high inter-rater reliability (26). It was tested
in the military (27).
The Revised Trauma Score (RTS) (28) (Table 3) was
developed to mitigate limitations of the Trauma
Score. Field use of the Trauma Score revealed that
capillary refill and respiratory expansion were difficult to assess, especially at night, and that retractive
respiratory expansion was always difficult to observe. Furthermore, dichotomous variables have limited utility. When retrospectively correlated with patient outcome, the Trauma Score was also found to
underestimate the severity of the condition of some
head-injured patients (i.e., the GCS was underweighted). In developing the RTS, measurement
scales for systolic blood pressure and respiratory rate
were divided into five intervals, chosen so that their
associated survival probabilities approximated those
of the widely used Glasgow Coma Scale intervals. A
value from 0 to 4 was assigned each interval. For
triage, coded values of Glasgow Coma Scale, systolic blood pressure, and respiratory rate are added to
yield the triage version (labeled T-RTS) of the RTS.
T-RTS takes on integer values from 0 to 12. The
American College of Surgeons triage guidelines,
which identify patients to be triaged to trauma centers whose sum of RTS coded variable values is less
than or equal to 11, demonstrate a substantial gain
in sensitivity with only a modest loss in specificity
when compared with the previously recommended

Trauma-Score-based guidelines. The T-RTS also

triages nearly all deaths (97.2 percent) to trauma
centers.
Another simplification of the Trauma Score was
developed for field triage and added information on
torsal injury. The CRAMS Scale (29), measures five
components: circulation, respiration, abdominal injury, and motor and speech responses. In CRAMS, a
value is assigned to each variable, depending on
whether it is normal (2), mildly abnormal (1), or severely abnormal (0). Scores of 9 or 10 are defined as
minor trauma, e.g., patient discharged home, and
scores of 8 or less are defined as major trauma, e.g.,
patient died in emergency department or went to the
operating room for general surgery or neurosurgery.
In field tests, CRAMS accurately discriminated between major and minor trauma, with 92 percent sensitivity and 98 percent specificity (i.e., two bin discrimination).
Comparisons of physiologic scores for triage have
had varying results and have been strongly influenced by differing case severity mixes, inconsistent
triage cut-off points, and varying definitions of patients needing trauma center treatment. An analysis
of triage scales has shown that the Trauma Score and
CRAMS have similar predictive values. Both, however, were found to have high false-negative triage
rates. As a tool for prehospital triage, the effectiveness of the Trauma Score is enhanced when it is used
with additional information, e.g., on mechanism of
injury, and extent and location of identifiable anatomic injury. American College of Surgeons Committee on Trauma guidelines (Fig. 1) emphasize the importance of evaluating anatomic damage, even in the
presence of normal physiology, and factors such as
age (< 5 and > 55) and pre-existing disease that might
lower the threshold at which patients should be
triaged to a trauma center.
A Pediatric Trauma Score (PTS) (30) has been developed that grades six components commonly seen
in pediatric trauma. A 0 percent mortality has been
found in patients with a PTS higher than 8, whereas
mortality increases to 30 percent for patients with a
PTS lower than or equal to 8. PTS triage guidelines
recommend that a child with a PTS lower than or
equal to 8 should be triaged to a level I trauma center, as defined by the American College of Surgeons.
An examination of the utility of the PTS found significant correlations with survival, Injury Severity
Score and other measures, although it demonstrated

16

H. R. Champion

Fig. 1. Field triage decision scheme (from Resources for optimal care of the injured 1999, with permission from American College of
Surgeons).

Trauma scoring

no advantages over the Revised Trauma Score in

pediatric patients (31).
As with anatomical scales, greater precision continues to be sought with physiologic scales.
The reaction level scale (RLS 85) was developed
by Starmark et al. (32) RLS 85 is an 8 point scale
which removes the redundancy in the Glasgow
Coma Scale between best verbal and best motor response. It compares favorably when tested against
the Glasgow Coma Scale (33, 34).
The PolyTrauma Score (PS) was developed in 1983
in Hanover. It was based on an analysis of 696 trauma patients treated between 1975 and 1986. The revised version used data from 389 patients treated between 1984 and 1990. The revised (PS) adds up to 90
points. It includes physiological data, the Glasgow
Coma Scale, PaO2, FiO2, base excess and anatomical
information on injuries to abdomen, extremities, thorax and pelvis. Each injury receives a specific score.
Age is also factored into the PolyTrauma Score. Patients with a score of less than 20 are considered to
have a mortality risk of less than 10 %. Patients with
a score between 21 and 34 have a mortality risk of
20 %. Patients with a score of 35 to 48.7, 38 % and
injuries beyond 48 % have a mortality risk of 65 %.
The PS represented a system of practical reliable scoring for estimating mortality and morbidity of blunt
trauma patients in the emergency room (35).
COMBINATION INDICES/MODELS
TRAUMA SCORE-INJURY SEVERITY SCORE METHODOLOGY

TRISS
Development of the Trauma Score-Injury Severity
Score (TRISS) in 1981 gave clinicians a way to identify major trauma patients with unexpected outcomes
and to compare patient outcomes among institutions
while controlling for differences in injury severity.
TRISS, a severity index based on the patients Revised Trauma Score at admission to the emergency
department, ISS, patient age and mechanism of injury is the basis of the Major Trauma Outcome Study
methodology. TRISS has been adapted for assessing
the impact of aeromedical emergency and prehospital care, for comparing outcomes in both adult and
pediatric populations, and for documenting improvement of trauma patient outcomes over time or between countries and states.
The key mathematical element of TRISS is the logistic function
[1] Ps = 1/(1 + eb)
where Ps is an estimate of a patients survival probability and
[2] b = bo + b1(RTS) + b2(ISS) + b3(AGE)
and
RTS = the admission Revised Trauma Score,
ISS = the Injury Severity Score
and
AGE = 0 for age less than 55 years,
AGE = 1 for age greater than or equal to 55.

17
TABLE 4
TRISS Calculation.

A 25 year old male with a GSW to the chest received the

following injuries: (coded in AIS-98).
GSW to the chest

AIS-98

Perforation RLL, LLL lung

Perforation diaphragm
Bilateral hemopneumothorax

441450.4
4
440604.3
3
included in lung
injury code

Through and through laceration

of liver
Lacerated duodenum
GSW R thigh
ISS = 16 + 9 + 1 = 26

541824.3
541020.2
816002.1

ISS Body
region

3
2
1

Physiologic variables on admission were:

SBP 80 mmHg
RR 28/min
GCS 15
RTS = 6.8174
Probability of Survival = 92.7 %

The bs are regression coefficients. For a patient

group, e.g., adults over 15 years old with blunt injuries, equation [1] is used to assign a survival probability to each combination of RTS, ISS, and AGE.
For outcome evaluation, the RTS is computed from
coded values (04) of the Glasgow Coma Scale (GCS),
systolic blood pressure (SBP), and respiratory rate
(RR) (see Table 3). Regression weights were derived
for the coded RTS variables using data from the Major Trauma Outcome Study patients. Those weights
are:
GCS: 0.9368 / SBP: 0.7326 / RR: 0.2908.
The RTS is the sum of the product of the weights
above and the coded values of the associated variables. The RTS takes on values between 0 and (approximately) 8. Evaluations have shown that the RTS is a
more reliable predictor of survival and death than the
Trauma Score. The weight given to the Glasgow
Coma Scale attests to the importance of coma to outcome.
The TRISS coefficients for equation [2] are (again
based on MTOS data)
Blunt
Penetrating

Constant (b0) RTS (b1)

0.4499
0.8085
2.5355
0.9934

ISS (b2)
0.0835
0.0651

Age (b3)
1.7430
1.1360

Examples of TRISS calculations are shown in Tables

4 and 5.
The Major Trauma Outcome study utilized equation [1] in two ways to evaluate patient outcomes.
The first method, PRE, supports quality assurance
activities. Fig. 2 shows a PRE chart, a scattergram for
a set of patients (all in the same age group) characterized by RTSs (ordinate) and ISSs (abscissa). Survivors and nonsurvivors are indicated by Ls and Ds,
respectively. Patients whose ISS-RTS coordinates are

18

H. R. Champion

Fig. 2. Sample PRE

chart.

TABLE 5
TRISS Calculation.
65 year old female in MVA received the following injuries:
AIS-98
ISS
Multiple cerebral contusions
LOC 1 hour
Maxilla fracture
Fractured R ribs #4, 5, 6
R hemothorax
Bilateral femur fractures
ISS = 9 + 9 + 9 = 27

140611.3
3
included in cerebral
contusion code
250800.2
2
450222.3
3
included in rib fracture
code
851800.3
3

Physiologic variables on admission were:

SBP 60 mmHg
RR 20 min
GCS 13
RTS = 6.376
Probability of Survival = 67.2 %

on the diagonal line have an estimated survival probability of 0.50. This P50 line is determined by setting
b = 0 in equation [2]. Ls (survivors) above the line
and Ds (no survivors) below it represent patients
with unexpected outcomes worthy of review. Not
all such patients are therapeutic successes or failures.
Because of limitations in its component indices (particularly ISS), such estimates of survival probability
must be reviewed by clinicians. A systematic review
of the unexpected outcomes leads not only to suggestions for improvement in trauma care but also to
potential improvements in severity scores.

The second method, DEF, is a statistical assessment

of patient outcome. Imagine lines parallel to the PRE
P50 line covering every decile with L&D patients
lying between all the lines. DEF compares a study
population to a baseline population by counting
the L/D ratio between the lines. Unlike PRE, DEF
accounts explicitly for differences in patient injury
severity mix and for the statistical significance of the
comparison. In DEF, the statistic z compares the
number of survivors in a sample (hospital) to that
expected from a baseline population or norm. The
statistic z is the ratio (A E)/S, where A and E are
the actual and expected numbers of survivors for the
study sample, and S is a scale factor that accounts
for statistical variation. E is computed as Pi, where
Pi is the survival probability for in the ith patient in
the study population. Pi is computed from the logistic TRISS model (equation [1]) based on the data from
the baseline population. The scale factor S is given
by Pi (I Pj). Depending on whether the survival
rate in the study sample is greater or less than that
predicted by TRISS from the baseline data, z may be
positive or negative. Absolute values of z greater
than 1.96 are statistically significant (p < 0.05).
Nonsignificant z scores can result from either small
sample sizes for which the z statistic has limited statistical power or from outcomes that are indistinguishable from the norm. For large samples, high (in
absolute value) and statistically significant z values
can result from small and clinically insignificant departures from expectations. Thus, institutional performance cannot be inferred from the magnitude of
statistically significant z scores. W quantifies the clin-

Trauma scoring

ical significance of statistically meaningful differences between the actual (A) and expected (E)
number of survivors: W = 100 (A E)/N where A and
E are defined as in z, and N is the number of patients
in the institutions sample. For institutions with significant positive (negative) z scores, W is the average increase (decrease) in the number of survivors
per 100 patients treated compared with norm expectations. Statistics z and W provided a more balanced
description of patient outcomes in the context of an
institutions contemporaries.
TRISS has been the pre-eminent trauma outcome
prediction model for the past 20 years. It is used
throughout the world to compare patient outcomes
in a consistent fashion. Its greatest frailty is related
to the Injury Severity Score (ISS). For that reason, ISS
was replaced in the TRISS formulation by AP to create ASCOT. ASCOT not only replaces the ISS with
Anatomical Profile (AP), but changes age from being a dichotomous to a continuous variable (36).
When comparing ASCOT and TRISS, the ASCOT
performs much better on outcome prediction than
TRISS. However its complexity has deterred many
from implementing it and TRISS still remains the
mainstay of comparative analysis of trauma patients.
A study reporting the replacement of ISS with NISS
in TRISS would be a worthwhile contribution.
OUTCOMES
DISABILITY OUTCOMES

Only a small proportion of injured patients are at risk

of dying certainly less than 10 % of those hospitalized. Depending on the nature and type of injuries,
however, disabilities and impairments can persist for
many years. Thus, scales that relate to outcomes
other than mortality are important in evaluating the
public health impact of injury. For obvious reasons,
most such scales focus on central nervous system and
musculoskeletal injuries.
The Glasgow Outcome Score (GOS) (37) has been
widely used since its development in 1975, despite
its recognized inadequacy to quantitatively reflect
subtle changes during recovery from severe head injury. The Disability Rating Scale has been advocated
as a single instrument to chart the progress of severely head injured patients from coma to community. The Admission Disability Rating Scale has been
related to clinical outcome 1 year after injury and to
electrophysiologic measures of brain dysfunction.
Non-trauma related factors (e.g., educational level,
type of employment, income, and family support)
have also been shown to affect the functional recovery of general trauma patients.
In 1983, the Functional Independent Measure
(FIM) was developed to assess the assistance required for a disabled person to effectively perform
self-care, sphincter management, mobility, locomotion, communication, and social and cognitive skills.
The Functional Independent Measure was pilot-tested by clinicians in 50 United States facilities in 1985.
The scale was assessed for ease of use and utility as

19

well as for its measurement properties, such as standardization, discriminatory power, reliability, and validity. The FIM was found to have face validity and
to be reliable. Three of its assessments (feeding, locomotion, and expression) are included in the Major
Trauma Outcome Study database.
Other non-mortality scales include the widely used
SF 36 scale. This has been modified by adding measures of cognitive function for its application to injury patient populations.
For the past decade a number of attempts to develop a disability scale have been lead by Mackenzie
et al. Efforts to develop the Functional Capacity Index (FCI) are ongoing. In this case, severity of a limitation of function is defined in terms of its impact
and overall functioning in everyday living. Thus, the
FCI looks at eating, excretory and sexual function,
walking, hand and arm movement, bending, lifting,
vision, hearing, speech and cognitive function. Such
a validated scale would be of great value in crafting
comprehensive health care approaches to injury.

TRIAGE AND TRAUMA SCORING

The triage of trauma patients is necessary when a
small proportion of hospitals receive victims of major injury in a regional trauma system. The triage decision involves determination of the threshold of injury severity that merits prompt access to the special
resources of a trauma center care. The other application of triage is the priority determination of mass
casualties and effective matching of their needs with
the limited available resources.
A significant proportion of patients with severe
injuries and at risk of dying can be identified at the
scene of the accident by their abnormal physiology.
There have been many attempts to aggregate the various physiologic parameters into a single entity. The
Trauma Score has been widely applied and field-tested for this purpose. Simpler versions, such as the
CRAMS score, have also been advocated. The Revised Trauma Score physiologic threshold variables
identifies 10 percent mortality on arrival at trauma
centers.
A far more difficult problem in triage is the identification of patients with significant anatomic injury
whose physiologic status is close to normal at the
scene shortly after an accident. There have been
many attempts to refine tools that would provide accurate triage. The tool developed by the authors for
the American College of Surgeons Guidelines has
stood the test of time for nearly 20 years (Fig. 1).

SEVERITY SCALES FOR SEVERELY ILL

PATIENTS
About the same time that injury severity indices were
being developed for hospitalized injured patients
similar efforts were underway to provide outcome
based characterization of seriously ill patients in the
intensive care setting. The challenges in this patient

20

H. R. Champion

population are somewhat different to but in no way

less than those of providing adequate models to characterize hospitalized injured patients in general.
The intensive care environment provides care for
a variety of medical and surgical patients. Some of
the surgical patients are trauma patients. The dynamics of care of surgical and medical patients are somewhat different in that surgical intervention often provides a watershed event for improving the patients
trajectory towards wellness (or death).
In 1981, the Acute, Physiological And Chronic
Health Evaluation (APACHE) scoring system was
introduced by Knaus et al (38). It consisted of 34
physiological variables each awarded a value between 0 and 4 depending on the severity of the disturbance. The sum of the worse value at each variable during the initial 24 hours after ICU admission
yielded the acute physiologic score (APS). The system was complex to use and was not found to track
surgical or trauma patients very well. APACHE II
was derived by summing a 12-variable acute physiologic score (APS) and points awarded for age and
chronic health problems. APACHE II has been widely used to control for casemix in intensive care units.
Its value in surgical and trauma patients is still questioned.
APACHE III is a proprietary prognostic system
developed from APACHE II. The number of physiological variables was extended from 12 to 17. The variable ranges were adjusted and weighted.
The APACHE III was proposed as a system to
serve as a frame of reference to assess quality of ICU
care. Some institutions use it to track outcome in this
fashion.
Other scoring systems in use for ICU patients include the Sepsis Score described in 1983 by Elebute
and Stoner (39),the Sepsis Severity Score described
by Stevens (40), the Multiple Organ Failure score introduced by Goris in 1985 (41) and the Multiple Organ Dysfunction score developed by Marshall et al
in 1995 (42). Most of these systems score different organ system functions and aggregate them on some
mathematical basis to prognosticate for individual
patients or predict outcome for overall sets of patients.
In addition to these multiple organ scales, there are
specific scales used to score pulmonary function. Few
have been validated and have limited value in predicting outcome.

Numerous institutional, local, and statewide registries have been developed to monitor hospital
trauma care, to help make decisions about allocation
of hospital resources, and to provide information to
county and local accrediting agencies. Existing registries vary greatly in the data they contain, the training of the personnel who record and enter data, the
sophistication and versatility of the system, and the
reports and information they can generate. Often the
quality and completeness of the data raise serious
questions regarding their value for anything, let
alone as a research tool.
The Major Trauma Outcome Study (MTOS)
opened the way to interinstitutional collaboration in
trauma indices. Since that time, many states or counties have obligatory or local registries from their trauma centers. In addition, similar registries have developed in the U.K., Germany, Austria, Norway,
Australia and a number of other countries. The
American College of Surgeons has assumed the mantel of pooling data from trauma centers in the United States and has the TRACS and the National Trauma Databases.
Trauma indices and their applications are an essential element of a public health approach to injury
and will continue to evolve in their accuracy and usefulness. Indices of injury severity are central to triage,
to outcome evaluation and quality assurance. With
the growing importance of their applications, severity scales are being more closely scrutinized for their
accuracy and validity. Limitations discovered
through analyses of registry data have motivated the
development of improved measures. However, further improvements are needed. For example, more
streamlined physiologic scores for triage, which
maintain or improve the predictive power of current
indices perhaps by trending data would be of great
value. TRISS requires values for all component variables to derive survival probability estimates. However, it is frequently not possible to obtain best verbal response or respiratory rate from intubated patients, who must then be excluded from an institutions PRE and DEF analyses. Those exclusions can
seriously bias outcome evaluations and reduce the
benefit derived for quality assurance activities.
Alternative means for quantitatively evaluating
such patients are needed. TRISS coefficients based on
NISS should be developed. Continued injury research can lead to the needed refinements in indices
and methods and, thus, in their applications to triage,
outcome evaluation, and quality assurance activities.

USE OF SEVERITY SCORING IN TRAUMA

REGISTRIES
USE OF SEVERITY SCORING IN RESEARCH
Although organized systems of medical reporting of
injury have been in use since the early l980s, no comprehensive data source has evolved for the epidemiologic study of injury and resultant impairment. Such
information has been found to be severely lacking
and must be acquired from many sources such as
hospital records, police reports, and governmental
and research organizations. Inherent inconsistencies
and inadequacies of these data sources limit their use
for injury research.

The heterogeneity of trauma patient populations severely hampers both retrospective and prospective
studies. Injury severity scores together with tight use
of operational definitions for entry and exclusion criteria to studies can be of significant value in study
design and thus enhance the ability of such studies
to draw valid and generalizable conclusions.
The TRISS methodology in particular has been
used in numerous studies as a means of controlling

Trauma scoring

for casemix differences in different populations or

over time and thus to normalize for injury severity
and control for its effect on outcome. It is not perfect
at this task, but it is more widely used than any tool
other than tight case definition criteria which severely limit the populations. TRISS has been used
throughout the world in this fashion and allows for
a reasonably effective mechanism by which anatomy,
physiology, age and mechanism of injury can be taken into account as to their influence on outcome
when some other independent variable is being
studied.
The demands of acute care research and the difficulties in implementing research protocols in nocturnal weekend hours are primary factors in why acute
care resuscitation research has attracted so little effort. This is so even though substantial research questions require to be answered not the least of which
include the optimum resuscitation fluids, appropriate early resuscitation therapeutic endpoints and the
value of blood substitute hemoglobin solutions in
early acute resuscitation. Studies on patients in shock
following injury require definition of a homogenous
target population within this highly heterogenous
subset of trauma patients. Without such attempts research in this domain will often be an exercise in futility.
CHALLENGES
The major challenges of trauma registries and injury
severity scoring are as follows:
1. Unavailable data. It is particularly difficult to
measure the GCS in patients who are intubated
or paralyzed. This situation has led to approximations, few of which are valid. Thus, a number of
researchers are exploring ways of measuring coma
on intubated patients.
2. Missing data. It is notoriously difficult to get accurate and complete data in the early phases of
care of the acutely injured individuals both in the
prehospital and inhospital phases of care. Conventions for handling missing data and approximating their effect need to be developed. It is unfortunate that the largest sources of missing data are
always the most critical patients.
3. Development and implementation of outcome
measures other than death. It is hoped that Functional Capacity Index under development will address this problem.
4. Complex and military injuries. The current conventions for scoring anatomic injury do not relate
well to the multiple etiologies and multiple injuries encountered in combat. War is estimated to
be the 8th leading cause of death and disability of
all diseases and injuries by the year 2020. Efforts
are underway at the present time to develop an
International Early Conflict Care database.
If lessons learned from its civilian counterparts hold
true, this latter effort will provide tremendous insight
into the nature and severity of injuries, outcome and
time dependency of theses injuries. However, be-

21

cause of the epidemiological and etiological differences of injury and the challenges of providing care
in a tactical setting, substantial differences are likely
to be encountered. This international collaborative
effort should provide information to many countries.
THE FUTURE
Trauma severity scales albeit imperfect have established themselves in the patina of health care delivery as an essential tool for many research and public
health initiatives. Severity scoring systems are a natural partner, with trauma registries and other databases designed to aggregate information on injured
patients for a variety of applications, and provide the
large numbers from which to develop valid models
and statistically valid analyses. As the accuracy of
injury severity scoring systems improves, they will
have increased applications in risk assessment and
decision support.
It has already been determined that the risk of
multiple organ failure sequelae of major injury increases with increasing injury severity. Combinations
of anatomical and physiological scales, age and preexisting conditions are important in general classification of injury severity against survival probability.
In the future, an identified threshold of injury severity will be used to trigger early assessment of indicators of high risk of serious sequelae of injury.
These indicators may well include a risk model based
on cytokine response and/or shock dose. The latter
would be a measure which takes into account not
only the severity of shock, but the length of time of
hypoperfusion and the residual status after resuscitation as measured by lactate or base deficit. Such a
model would isolate high risk patients allowing for
institution of early prophylaxis against multiple organ failure and other highly lethal consequences of
severe injury. Such models would also enable consistent case definition for studies of subsets of severe
patients and decrease the statistical noise that bedevils much of the research into severely injured patients
at this time.
In conclusion, injury severity scores are an established part of trauma care as are trauma registries.
The two work in conjunction as a basis for probabilistic models for a variety of scientific applications.
Severity scoring systems are a work in process. Future developments will refine them and add scientific precision to their application.
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Received: September 11, 2001