ࡱ> #% !"M bjbj== WWhclD7778$282??(B?B?B?B?R??$͌ @?B?B???@CB?B?UCCC?:B?B?C?C6CKjmB?? {&37?4Nm&m\k0tmJ.@mCtrauma scores and scoring systems In principle, scoring systems can be divided into: Physiological Scoring Systems. Anatomical Scoring Systems. Outcome Analysis Systems. Introduction Estimates of the severity of injury or illness are fundamental to the practice of medicine. The earliest known medical text, the Smith Papyrus, classified injuries into three grades, treatable, contentious, and untreatable. Modern trauma scoring methodology uses a combination of an assessment of the severity of anatomical injury with a quantification of the degree of physiological derangement to arrive at scores that correlate with clinical outcomes. Trauma scoring systems are designed to facilitate pre-hospital triage, identify trauma patients suitable for quality assurance audit, allow accurate comparison of different trauma populations, and organize and improve trauma systems. Physiological Scoring Systems Glasgow Coma Scale The Glasgow Coma Scale (GCS), devised in 1974, was one of the first numerical scoring systems (Figure 1). The GCS has been incorporated into many later scoring systems, emphasizing the importance of head injury as a triage and prognostic indicator. Figure 1. The Glasgow coma scale.ParameterResponseScore Eye openingNil1To pain2To speech3Spontaneously4 Motor responseNil1Extensor2Flexor3Withdrawal4Localising5Obeys command6 Verbal responseNil1Groans2Words3Confused4Orientated5 Revised Trauma Score Introduced by Champion et al, the Revised Trauma score (RTS) evaluates blood pressure, Glasgow Coma Scale, and respiratory rate to provide a scored physiological assessment of the patient. The RTS can be used for field triage and enables pre-hospital and emergency care personnel to decide which patients should receive the specialized care of a trauma unit. A RTS (11 is suggested as the triage point for patients requiring at least Level 2 trauma centre status (surgical facilities, 24 hour X-ray etc.). A RTS of (10 carries a mortality of up to 30% and these patients should be moved to a Level 1 institution. The difference between RTS on arrival and best RTS after resuscitation will give a reasonably clear picture of prognosis. By convention the RTS on admission is the one documented. The RTS (non-triage) is designed for retrospective outcome analysis. Weighted co-efficients are used, which are derived from trauma patient populations and provide more accurate outcome prediction than the raw RTS (Figure 2). Since a severe head injury carries a poorer prognosis than a severe respiratory injury, the weighting is therefore heavier. The RTS thus varies from 0 (worst) to 7.8408 (best). The RTS is the most widely used physiological scoring system in the trauma literature. Figure 2. Revised Trauma Score (RTS). The values for the three parameters are summed to give the Triage-RTS. Weighted values are summed for the RTS.Clinical ParameterCategoryScorex weight Respiratory rate (Breaths per minute)10-294 0.2908>2936-921-5100 Systolic blood Pressure>894 0.732676-89350-7521-49100 Glasgow Coma Scale13-154 0.93689-1236-824-5130 Paediatric Trauma Score The Paediatric Trauma Score (PTS) (Figure 3) has been designed to facilitate triage of children. The PTS is the sum of six scores, and values range from 6 to +12, with a PTS of (8 being recommended as a trigger to send to a trauma centre. The PTS has been shown to accurately predict risk for severe injury or mortality, but is not significantly more accurate than the RTS and is a great deal more difficult to measure. Figure 3. Paediatric Trauma Score (PTS). The values for the six parameters are summed to give the overall PTS.Clinical ParameterCategoryScore Size (kg)>20210-201<10-1 AirwayNormal2Maintainable1Unmaintainable-1 Systolic blood pressure (mmHg)>90250-901<50-1 Central Nervous SystemAwake2Obtunded / LOC1Coma / decerebrate-1 Open woundNone2Minor1Major/penetrating SkeletalNone2Closed fracture1Open/multiple fractures-1 Anatomical Scoring Systems Abbreviated Injury Scale The Abbreviated Injury Scale (AIS) was developed in 1971. The AIS grades each injury by severity from 1 (least severe) to 5 (survival uncertain), within six body regions (head/neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. The AIS has been periodically upgraded and AIS-90 is currently being revised. In 1974, Baker et al created the Injury Severity Score (ISS) to relate AIS scores to patient outcomes. ISS body regions are listed in Figure 4. The ISS is calculated by summing the square of the highest AIS scores in the three most severely injured regions. ISS scores range from 1-75 (since the highest AIS score for any region is 5). By convention, an AIS score of 6 (defined as a non-survivable injury) for any region becomes an ISS of 75. Figure 4. ISS body regions. Number Region Head & Neck Face Thorax Abdomen Extremities External The ISS only considers the single, most serious injury in each region, ignoring the contribution of injury to other organs within the same region. Diverse injuries may have identical ISS but markedly different survival probabilities (ISS of 25 may be obtained with isolated severe head injury or by a combination of lesser injuries across different regions). Also, ISS does not have the power to discriminate between the impact of similarly scored injuries to different organs and therefore cannot identify, for example, the different impact of cerebral injury over injury to other organ systems. In response to these limitations, in 1997, the ISS was modified to become the New Injury Severity Score (NISS) as the simple sum of the squares of the three highest AIS scores regardless of body region. NISS is able to predict survival outcomes better than ISS. Anatomic Profile The Anatomic Profile (AP) was introduced in 1990 to overcome some of the limitations of the ISS. AIS scoring is used, but four body regions were chosen (head/brain/spinal cord, thorax/neck, all other serious injury, and all non-serious injury). The AP score is the square root of the sum of the squares of all the AIS scores in a region, thus enabling the impact of multiple injuries within that region to be recognised. Component values for the four regions are summed to constitute the AP score. A modified Anatomic Profile (mAP) has recently been introduced, which is a four number characterization of injury. The four component scores are the maximum AIS score and the square root of the sum of the squares of all AIS values for serious injury (AIS (3) in specified body regions (Figure 5). This leads to an Anatomic Profile Score, the weighted sum of the four mAP components. The coefficients are derived from logistic regression analysis of admissions to four Level 1 trauma centres (the controlled sites) in the Major Trauma Outcome Study. Figure 5. Component definitions of the modified Anatomic Profile.ComponentBody regionAIS severitymAHead/brain3-6Spinal cord3-6mBThorax3-6Front of neck3-6mCAll other3-6mA, mB, mC scores are derived by taking the square root of the sum of the squares for all injuries defined by each component A limitation of the use of AIS-derived scores is their cost. International Classification of Disease (ICD) taxonomy is a standard used by most hospitals and other health care providers to classify clinical diagnoses. Computerized mapping of ICD-9CM rubrics into AIS body regions and severity values has been used to compute ISS, AP and NISS scores. Despite limitations, ICD-AIS conversion has been useful in population-based evaluation when AIS scoring from medical records is not possible. Severity scoring systems also have been directly derived from ICD coded discharge diagnoses. Most recently, the ICD-9 Severity Score (ICISS) has been proposed, which is derived by multiplying survival risk ratios associated with individual ICD diagnoses. Neural networking has been employed to further improve ICISS accuracy. ICISS has been shown to be better than ISS and to outperform TRISS in identifying outcomes and resource utilization. However, modified-AP scores, AP and NISS appear to outperform ICISS in predicting hospital mortality. There is some confusion as to which anatomic scoring system should be used; however, currently, NISS probably should be the system of choice for AIS-based scoring. Organ Injury Scaling (OIS) is a scale of anatomic injury within an organ system or body structure. The goal of OIS is to provide a common language between trauma surgeons and to facilitate research and continuing quality improvement. It is not designed to correlate with patient outcomes. The OIS tables can be found on the American Association for the Surgery of Trauma (AAST) web site, or at the end of this Chapter. Penetrating Abdominal Trauma Index (PATI) Moore and colleagues facilitated identification of the patient at high risk of post-operative complications when they developed the Penetrating Abdominal Trauma Index (PATI) scoring system for patients whose only source of injury was penetrating abdominal trauma. A complication risk factor was assigned to each organ system involved, and then multiplied by a severity of injury estimate. Each factor was given a value ranging from 1 to 5. The complication risk designation for each organ was based on the reported incidence of post-operative morbidity associated with the respective injury. The severity of injury was estimated by a simple modification to the Abbreviated Injury Scale, where 1 = minimal injury to 5 = maximal injury. The sum of the individual organ score times risk factor comprised the final Penetrating Abdominal Trauma Index (PATI). If the PATI is 25 or less, the risk of complications is reduced (and where it was 10 or less, there were no complications), where if it is greater than 25, the risks are much higher. In a group of 114 patients with gunshot wounds to the abdomen they showed that a PATI score >25 dramatically increased the risk of postoperative complications (46% of patients with a PATI score of >25 developed serious postoperative complications compared to 7% of patients with a PATI of <25). Further studies have validated the PATI scoring system. Outcome Analysis Glasgow Outcome Scale For head-injured patients, the level of coma on admission or within 24 hours expressed by the Glasgow Coma Scale was found to correlate with outcome. The Glasgow Outcome Scale was an attempt to quantify outcome parameters (Figure 6) for head-injured patients. Figure 6. Death (D) Persistent vegetative state (PVS) Severe disability (SD) Moderate disability (MD) Good recovery (GR) The grading of depth of coma and neurological signs was found to correlate strongly with outcome, but the low accuracy of individual signs limits their use in predicting outcomes for individuals (Figure 7). Figure 7. Outcome related to signs in the first 24 hours of coma after injury. Outcome scale as described by Glasgow group.   Dead or vegetative, % Moderate disability or good recovery, % Pupils: reacting non - reacting 39 91 50 4Eye movements intact absent / bad 33 90 56 5Motor response Normal Abnormal 36 74 54 16 Major Trauma Outcome Study (MTOS) In 1982, the American College of Surgeons Committee on Trauma began the ongoing Major Trauma Outcome Study (MTOS), a retrospective, multi-centre study of trauma epidemiology and outcomes. MTOS uses Trauma Score and Injury Severity Score Analysis (TRISS) methodology to estimate the probability of survival, or P(s), for a given trauma patient. P(s) is derived according to the formula: P(s) = 1/(1 + e-b), where e is a constant (approximately 2.718282) and b = b0 + b1(RTS) + b2(ISS) +b3(age factor). The b coefficients are derived by regression analysis from the MTOS database (Figure 8). Figure 8. Coefficients from major trauma outcome study database. Blunt Penetrating bo = -1.2470 -0.6029 b1 = 0.9544 1.1430 b2 = -0.0768 -0.1516 b3 = -1.9052 -2.6676 The P(s) values range from zero (survival not expected) to 1.000 for a patient with a 100% expectation of survival. Each patients values can be plotted on a graph with ISS and RTS axes (Figure 9) The sloping line represents patients with a probability of survival of 50%; these PRE charts (from PREliminary) are provided for those with blunt vs. penetrating injury and for those above vs. below 55 years of age. Survivors whose coordinates are above the P(s)50 isobar and non-survivors below the P(s)50 isobar are considered atypical (statistically unexpected) and such cases are suitable for focused audit. In addition to analysing individual patient outcomes, TRISS allows comparison of a study population with the huge MTOS database. The Z-statistic identifies if study group outcomes are significantly different from expected outcomes as predicted from MTOS. Z is the ratio: (A E)/S, where A = actual number of survivors, E = expected number of survivors, and S = scale factor that accounts for statistical variation. Z may be positive or negative, depending on whether the survival rate is greater or less than predicted by TRISS. Absolute values of Z >1.96 or <-0.96 are statistically significant (P<0.05). The so-called M-statistic is an injury severity match allowing comparison of the range of injury severity in the sample population with that of the main database (i.e. the baseline group). The closer M is to 1, the better the match, the greater the disparity, the more biased Z will be. This bias can be misleading, for example, an institution with a large number of patients with low-severity injuries can falsely appear to provide a better standard of care than another institution that treats a higher number of more severely injured patients. The W-statistic calculates the actual numbers of survivors greater (or fewer) than predicted by MTOS, per 100 trauma patients treated. The Relative Outcome Score (ROS) can be used to compare W-values against a perfect outcome of 100% survival. The ROS may then be used to monitor improvements in trauma care delivery over time. TRISS has been used in numerous studies. Its value as a predictor of survival or death has been shown to be from 75-90% as good as a perfect index, depending on the patient data set used. A Severity Characterisation of Trauma (ASCOT) A Severity Characterization of Trauma (ASCOT), introduced by Champion et al in 1990, is a scoring system that uses the Anatomic Profile to characterize injury in place of ISS. Different coefficients are used for blunt and penetrating injury and the ASCOT score is derived from the formula: P(s) = 1/(1 + e-k). The ASCOT model coefficients are shown in Figure 10. ASCOT has been shown to outperform TRISS, particularly for penetrating injury. Figure 10. Coefficients derived from MTOS data for the ASCOT probability of survival, P(s). k-CoefficientsType of injuryBluntPenetratingk1-1.157-1.135k2 (RTS GCS value)0.77051.0626k3 (RTS SBP value)0.65830.3638k4 (RTS RR value)0.2810.3332k5 (AP head region value)-0.3002-0.3702k6 (AP thoracic region value)-0.1961-0.2053k7 (AP other serious injury value)-0.2086-0.3188k8 (age factor)-0.6355-0.8365 Summary Traumas scoring systems and allied methods of analysing outcomes after trauma are steadily evolving and have become increasingly sophisticated over recent years. Trauma scoring systems are designed to facilitate pre-hospital triage, identify trauma patients whose outcomes are statistically unexpected for quality assurance analysis, allow accurate comparison of different trauma populations, and organize and improve trauma systems. They are vital for the scientific study of the epidemiology and the treatment of trauma and may even be used to define resource allocation and reimbursement in the future. Trauma scoring systems that measure outcome solely in terms of death or survival are at best blunt instruments. Despite the existence of several scales (Quality of Well-being Scale, Sickness Impact Profile, etc.), further efforts are needed to develop outcome measures that are able to evaluate the multiplicity of outcomes across the full range of diverse trauma populations. Despite the profusion of acronyms, scoring systems are a vital component of trauma care-delivery systems. The effectiveness of well-organized, centralized, multidisciplinary trauma centres in reducing the mortality and morbidity of injured patients is well documented. Further improvement and expansion of trauma care can only occur if developments are subjected to scientifically rigorous evaluation. Thus, trauma scoring systems play a central role in the provision of trauma care today and for the future. References American Association for the Surgery of Trauma web site: www.aast.org Boyd CR, Tolson MA, Opes WS. Evaluating Trauma Care: the TRISS method. J Trauma. 1987;27:370-377. Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. J Trauma 1989;29(5):623-629. Champion HR, Copes WS, Sacco WJ, Frey CF, Holcroft JW, Hoyt DB, Weigelt JA. Improved predictions from a severity characterization of trauma (ASCOT) over Trauma and Injury Severity Score (TRISS): results of an independent evaluation. J Trauma. 1996;40(1):42-48. Moore EE, Dunn EL, Moore JB, Thompson JS. Penetrating Abdominal Trauma Index. J Trauma. 1981;21(5):439-444. Osler T, Baker SP, Long W. A modification of the Injury Severity Score that both improves accuracy and simplifies scoring. J Trauma. 1997;43(6):922-926. Tepas JJ 3rd, Ramenofsky ML, Mollitt DL, Gans BM, DiScala C. The Paediatric Trauma Score as a predictor of injury severity: an objective assessment. J Trauma. 1988;28(4):425-429. Scaling system for organ specific injuries Table 1 Cervical vascular organ injury scale Table 2 Chest wall injury scale Table 3 Heart injury scale Table 4 Lung injury scale Table 5 Thoracic vascular injury scale Table 6 Diaphragm injury scale Table 7 Spleen injury scale Table 8 Liver injury scale Table 9 Extrahepatic biliary tree injury scale Table 10 Pancreas injury scale Table 11 Oesophagus injury scale Table 12 Stomach injury scale Table 13 Duodenum injury scale Table 14 Small bowel injury scale Table 15 Colon injury scale Table 16 Rectum injury scale Table 17 Abdominal vascular injury scale Table 18 Adrenal organ injury scale Table 19 Kidney injury scale Table 20 Ureter injury scale Table 21 Bladder injury scale Table 22 Urethra injury scale Table 23 Uterus (non-pregnant) injury scale Table 24 Uterus (pregnant) injury scale Table 25 Fallopian tube injury scale Table 26 Ovary injury scale Table 27 Vagina injury scale Table 28 Vulva injury scale Table 29 Testis injury scale Table 30 Scrotum injury scale Table 31 Penis injury scale Table 32 Peripheral vascular organ injury scale Table 1 Cervical vascular organ injury scale Grade  Description of injury ICD-9 AIS-90 I II III IV V  Thyroid vein Common facial vein External jugular vein Non-named arterial/venous branches External carotid arterial branches (ascending pharyngeal, superior thyroid, lingual, facial, maxillary, occipital, posterior auricular) Thyrocervical trunk or primary branches Internal jugular vein External carotid artery Subclavian vein Vertebral artery Common carotid artery Subclavian artery Internal carotid artery (extracranial) 900.8 900.8 900.81 900.9 900.8 900.8 900.1 900.02 901.3 900.8 900.01 901.1 900.03 1-3 1-3 1-3 1-3 2-3 3-4 2-4 3-5 3-4 3-5 *Increase one grade for multiple grade III or IV injuries involving more than 50% vessel circumference. *Decrease one grade for less than 25% vessel circumference disruption for grade IV or V. From Moore et al. with permission. Table 2 Chest wall injury scale Grade Injury Type Description of Injury  ICD-9 AIS-90 I II III IV V  Contusion Laceration Fracture Laceration Fracture Laceration Fracture Laceration Fracture Fracture Any size Skin & subcutaneous < 3 ribs, closed; non displaced clavicle closed Skin, subcutaneous and muscle >3 adjacent ribs, closed Open or displaced clavicle Non displaced sternum, closed Scapular body, open or closed Full thickness including pleural penetration Open or displaced sternum Flail sternum Unilateral flail segment (<3 ribs) Avulsion of chest wall tissues with underlying rib fractures Unilateral flail chest (>3 ribs) Bilateral flail chest (>3 ribs on both sides) 911.0/922.1 875.0 807.01 / 807.02 810.00 / 810.03 875.1 807.03/ 807.08 810.10/ 810.13 807.2 811.00 / 811.18 862.29 807.2 807.3 807.4 807.10 / 807.18 807.4 807.4 1 1 1-2 2 2 1 2-3 2 2 2 2 2 3-4 4 3-4 5 *This scale is confined to the chest wall alone and does not reflect associated internal or abdominal injuries. Therefore, further delineation of upper versus lower or anterior versus posterior chest wall was not considered, and a grade VI was not warranted. Specifically, thoracic crush was not used as a descriptive term; instead, the geography and extent of fractures and soft tissue injury were used to define the grade. *Upgrade by one grade for bilateral injuries. From Moore et al. [2]; with permission. Table 3 Heart injury scale Grade  Description of injury ICD-9 AIS-90 I II III IV V VI  Blunt cardiac injury with minor ECG abnormality (non-specific ST or T wave changes, premature arterial or ventricular contraction or persistent sinus tachycardia) Blunt or penetrating pericardial wound with out cardiac injury, cardiac tamponade, or cardiac herniation Blunt cardiac injury with heart block (right or left bundle branch, left anterior fascicular, or atrioventricular) or ischaemic changes (ST depression or T wave inversion) without cardiac failure Penetrating tangential myocardial wound up to, but not extending through endocardium, without tamponade Blunt cardiac injury with sustained (>6 beats/min) or multifocal ventricular contractions Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion without cardiac failure Blunt pericardial laceration with cardiac herniation Blunt cardiac injury with cardiac failure Penetrating tangential myocardial wound up to, but extending through, endocardium, with tamponade Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion producing cardiac failure Blunt or penetrating cardiac injury with aortic mitral valve incompetence Blunt or penetrating cardiac injury of the right ventricle, right atrium, or left atrium Blunt or penetrating cardiac injury with proximal coronary arterial occlusion Blunt or penetrating left ventricular perforation Stellate wound with < 50% tissue loss of the right ventricle, right atrium, or of left atrium Blunt avulsion of the heart; penetrating wound producing > 50% tissue loss of a chamber  861.01 861.01 861.12 861.01 861.01 861.01 861.12 861.12 861.03 861.03 861.13 861.03 861.13  3 3 3 3-4 3-4 3-4 3 3 5 5 5 5 6 *Advance one grade for multiple wounds to a single chamber or multiple chamber involvement. From Moore et al.; with permission. Table 4 Lung Injury Scale Grade* Injury Type Description of Injury ICD-9 AIS-90 I II III IV V VI Contusion Contusion Laceration Contusion Laceration Haematoma Laceration Haematoma Vascular Vascular Vascular Unilateral, <1 lobe Unilateral, single lobe Simple pneumothorax Unilateral, > 1 lobe Persistent (> 72 hrs) air leak from distal airway Nonexpanding intraparenchymal Major (segmental or lobar) air leak Expanding intraparenchymal Primary branch intrapulmonary vessel disruption Hilar vessel disruption Total uncontained transection of pulmonary hilum 861.12/ 861.31 861.20/ 861.30 860.0 / 1 / 4 / 5 861.20/ 861.30 860.0 / 1/ 4 / 5 862.0 / 861.30 862.21 / 861.31 901.40 901.41 / 901.42 901.41/ 901.42  3 3 3 3 3-4 4-5 3-5 4 4  *Advance one grade for bilateral injuries up to grade III. Haemothorax is scored under thoracic vascular injury scale. From Moore et al [3]; with permission.  Table 5 Thoracic Vascular Injury Scale Grade* Description of injury ICD-9 AIS-90 I II III IV V VI  Intercostal artery/vein Internal mammary artery/vein Bronchial artery/vein Oesophageal artery/vein Hemiazygos vein Unnamed artery/vein Azygos vein Internal jugular vein Subclavian vein Innominate vein Carotid artery Innominate artery Subclavian artery Thoracic aorta, descending Inferior vena cava (intrathoracic) Pulmonary artery, primary intraparenchymal branch Pulmonary vein, primary intraparenchymal branch Thoracic aorta, ascending and arch Superior vena cava Pulmonary artery, main trunk Pulmonary vein, main trunk Uncontained total transection of thoracic aorta or pulmonary hilum 901.81 901.82 901.89 901.9 901.89 901.9 901.89 900.1 901.3 901.3 900.01 901.1 901.1 901.0 902.10 901.41 901.42 901.0 901.2 901.41 901.42 901.0 901.41/ 901.42 2-3 2-3 2-3 2-3 2-3 2-3 2-3 2-3 3-4 3-4 3-5 3-4 3-4 4-5 3-4 3 3 5 3-4 4 4 5 4  *Increase one grade for multiple grade III or IV injuries if more than 50% circumference. Decrease one grade for grade IV injuries if less than 25% circumference. From Moore et al [3]; with permission Table 6 Diaphragm injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion Laceration <2cm Laceration 2-10cm Laceration >10 cm with tissue loss < 25 cm2 Laceration with tissue loss > 25 cm2 862.0 862.1 862.1 862.1 862.1 2 3 3 3 3 *Advance one grade for bilateral injuries up to grade III. From Moore et al. [3]; with permission Table 7 Spleen injury scale (1994 revision) Grade* Injury type Description of injury ICD-9 AIS-90 I II III IV V  Haematoma Laceration Haematoma Laceration Haematoma Laceration Laceration Laceration Vascular Subcapsular, <10% surface area Capsular tear, <1cm parenchymal depth Subcapsular, 10%-50% surface area; intraparenchymal, <5 cm in diameter Capsular tear, 1-3cm parenchymal depth that does not involve a trabecular vessel Subcapsular, >50% surface area or expanding; ruptured subcapsular or parenchymal Haematoma; intraparenchymal Haematoma > 5 cm or expanding >3 cm parenchymal depth or involving trabecular vessels Laceration involving segmental or hilar vessels producing major devascularisation (>25% of spleen) Completely shattered spleen Hilar vascular injury with Devascularised spleen 865-01/ 865.11 865.02/ 865.12 865.01 / 865.11 865.02/ 865.12 865.03 865.13 865.04 865.14 2 2 2 2 3 3 4 5 5 *Advance one grade for multiple injuries up to grade III. From Moore et al. [4]; with permission Table 8 Liver injury scale (1994 revision) Grade* Type of Injury Description of injury ICD-9 AIS-90 I II III IV V VI  Haematoma Laceration Haematoma Laceration Haematoma Laceration Laceration Laceration Vascular Vascular Subcapsular, <10% surface area Capsular tear, <1cm parenchymal depth Subcapsular, 10% to 50% surface area: intraparenchymal <10 cm in diameter Capsular tear 1-3 parenchymal depth, <10 cm in length Subcapsular, >50% surface area of ruptured subcapsular or parenchymal Haematoma; intraparenchymal Haematoma > 10 cm or expanding 3 cm parenchymal depth Parenchymal disruption involving 25% to 75% hepatic lobe or 1-3 Couinauds segmentswithin a single lobe. Parenchymal disruption involving >75% of hepatic lobe or >3 Couinauds segments within a single lobe Juxtahepatic venous injuries; i.e., retrohepatic vena cava/central major hepatic veins Hepatic avulsion 864.01/ 864.11 864.02 / 864.12 864.01 / 864.11 864.03 / 864.13 864.04 / 864.14 864.04/ 864.14 864.04 / 864.14 864.04 / 864.14 2 2 2 2 3 3 4 5 5 5 *Advance one grade for multiple injuries up to grade III From Moore et al. [4]; with permission Table 9 Extrahepatic biliary tree injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Gallbladder contusion/Haematoma Portal triad contusion Partial gallbladder avulsion from liver bed; cystic duct intact Laceration or perforation of the gallbladder Complete gallbladder avulsion from liver bed Cystic duct laceration Partial or complete right hepatic duct laceration Partial or complete left hepatic duct laceration Partial common hepatic duct laceration (<50%) Partial common bile duct laceration (<50%) >50% transection of common hepatic duct >50% transection of common bile duct Combined right and left hepatic duct injuries Intraduodenal or intrapancreatic bile duct injuries 868.02 868.02 868.02 868.12 868.02 868.12 868.12 868.12 868.12 868.12 868.12 868.12 868.12 868.12 2 2 2 2 3 3 3 3 3 3 3-4 3-4 3-4 3-4 *Advance one grade for multiple injuries up to grade III. From Moore et al. [5]; with permission Table 10 Pancreas Injury Scale Grade* Type of Injury Description of Injury ICD-9 AIS-90 I II III IV V  Haematoma Laceration Haematoma Laceration Laceration Laceration Laceration Minor contusion without duct injury Superficial laceration without duct injury Major contusion without duct injury or tissue loss Major laceration without duct injury or tissue loss Distal transection or parenchymal injury with duct injury Proximal transection or parenchymal injury involving ampulla Massive disruption of pancreatic head 863.81 / 863.84 863.81 / 863.84 863.92 / 863.94 863.91 863.91 2 2 2 3 3 4 5 *Advance one grade for multiple injuries up to grade III. *863.51,863.91 - head; 863.99,862.92-body;863.83,863.93-tail. *Proximal pancreas is to the patients right of the superior mesenteric vein. From Moore et al. [6]: with permission. Table 11 Oesophagus injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion Laceration Laceration Laceration Tissue Loss Tissue Loss Contusion/Haematoma Partial thickness laceration Laceration <50% circumference Laceration >50% circumference Segmental loss or devascularisation <2cm Segmental loss or devascularisation >2cm 862.22 / 826.32 862.22 / 826.32 862.22 / 826.32 862.22 / 826.32 862.22 / 826.32 862.22 / 826.32 2 3 4 4 5 5 *Advance one grade for multiple lesions up to grade III. From Moore et al [5]; with permission Table 12 Stomach injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion Laceration Laceration Laceration Tissue Loss Tissue Loss Contusion / Haematoma Partial thickness laceration <2cm in Gastro-oesophageal junction or pylorus <5cm in proximal 1/3 stomach <10cm in distal 2/3 stomach >2cm in Gastro-oesophageal junction or pylorus >5cm in proximal 1/3 stomach >10cm in distal 2/3 stomach Tissue loss or devascularisation <2/3 stomach Tissue loss or devascularisation >2/3 stomach 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 863.0 / 863.1 2 2 3 3 3 3 3 3 4 4 *Advance one grade for multiple lesions up to grade III. From Moore et al.[5]; with permission Table 13 Duodenum injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V Haematoma Laceration Haematoma Laceration Laceration Laceration Laceration Vascular Involving single portion of duodenum Partial thickness, no perforation Involving more than one portion Disruption <50% of circumference Disruption 50%-75% of circumference of D2 Disruption 50%-100% of circumference of D1,D3,D4 Disruption >75% of circumference of D2 Involving ampulla or distal common bile duct Massive disruption of duodenopancreatic complex Devascularisation of duodenum 863.21 863.21 863.21 863.31 863.31 863.31 863.31 863.31 863.31 863.31 2 3 2 4 4 4 5 5 5 5  *Advance one grade for multiple injuries up to grade III. D1-first position of duodenum; D2-second portion of duodenum; D3-third portion of duodenum; D4-fourth portion of duodenum From Moore et al. [6]; with permission. Table 14 Small bowel injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V Haematoma Laceration Laceration Laceration Laceration Laceration Vascular Contusion or Haematoma without devascularisation Partial thickness, no perforation Laceration <50% of circumference Laceration > 50% of circumference without transection Transection of the small bowel Transection of the small bowel with segmental tissue loss Devascularised segment 863.20 863.20 863.30 863.30 863.30 863.30 863.30 2 2 3 3 4 4 4  *Advance one grade for multiple injuries up to grade III. From Moore et al. [6]; with permission Table 15 Colon injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V  Haematoma Laceration Laceration Laceration Laceration Laceration Contusion or haematoma without devascularisation Partial thickness, no perforation Laceration <50% of circumference Laceration > 50% of circumference without transection Transection of the colon Transection of the colon with segmental tissue loss 863.40 - 863.44 863.40 - 863.44 863.50 - 863.54 863.50 - 863.54 863.50 - 863.54 863.50 - 863.54 2 2 3 3 4 4 *Advance one grade for multiple injuries up to grade III. *863.40 / 863.50 = Non-specific site in colon. 863.41 / 863.51 = Ascending. 863.42 / 863.52 = Transverse. 863.43 / 863.53 = Descending. 863.44 / 863.54 = Sigmoid. From Moore et al. [6]; with permission Table 16 Rectum injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V Haematoma Laceration Laceration Laceration Laceration Vascular Contusion or haematoma without devascularisation Partial-thickness laceration Laceration < 50% of circumference Laceration > 50% of circumference Full-thickness laceration with extension into the perineum Devascularised segment 863.45 863.45 863.55 863.55 863.55 863.55 2 2 3 4 5 5  *Advance one grade for multiple injuries up to grade III. From Moore et al. [6]; with permission Table 17 Abdominal vascular injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Non-named superior mesenteric artery or superior mesenteric vein branches Non-named inferior mesenteric artery or inferior mesenteric vein branches Phrenic artery or vein Lumbar artery or vein Gonadal artery or vein Ovarian artery or vein Other non-named small arterial or venous structures requiring ligation Right, left, or common hepatic artery Splenic artery or vein Right or left gastric arteries Gastroduodenal artery Inferior mesenteric artery / trunk, or inferior mesenteric vein / trunk Primary named branches of mesenteric artery (e.g., ileocolic a.) or mesenteric vein Other named abdominal vessels requiring ligation or repair Superior mesenteric vein, trunkand primary subdivisions Renal artery or vein Iliac artery or vein Hypogastric artery or vein Vena cava, infrarenal Superior mesenteric artery, trunk Coeliac axis proper Vena cava, suprarenal and infrahepatic Aorta, infrarenal Portal vein Extraparenchymal hepatic veinonly Extraparenchymal hepatic veins + liver Vena cava, retrohepatic or suprahepatic Aorta suprarenal, subdiaphragmatic 902.20 /.39 902.27/.32 902.89 902.89 902.89 902.81 / 902.82 902.80 902.22 902.23 / 902.34 902.21 902.24 902.27 / 902.32 902.26 / 902.31 902.89 902.31 902.41 / 902.42 902.53 / 902.54 902.51 / 902.52 902.10 902.25 902.24 902.10 902.00 902.33 902.11 902.11 902.19 902.00 NS NS NS NS NS NS NS 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 4 3 3 5 5 4  *This classification system is applicable to extraparenchymal vascular injuries. *If the vessel injury is within 2 cm of the organ parenchyma, refer to specific organ injury scale. *Increase one grade for multiple grade III or IV injuries involving > 50% vessel circumference. *Downgrade one grade if <25% vessel circumference laceration for grades IV or V. NS-not scored. From Moore et al [2]; with permission Table 18 Adrenal organ injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Contusion Laceration involving only cortex (<2 cm) Laceration extending into medulla (> 2 cm) >50% parenchymal destruction Total parenchymal destruction (including massive intraparenchymal haemorrhage) Avulsion from blood supply  868.01/.11 868.01/.11 868.01/.11 868.01/.11 868.01/.11  1 1 2 2 3 *Advance one grade for bilateral lesions up to grade V From Moore et al [1]; with permission Table 19 Kidney injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V Contusion Haematoma Haematoma Laceration Laceration Laceration Vascular Laceration Vascular Microscopic or gross haematuria, urologic studies normal Subcapsular, nonexpanding without parenchymal laceration Nonexpanding perirenal haematoma confined to renal retroperitoneum <1.0 cm parenchymal depth of renal cortex without urinary extravagation >1.0 cm parenchymal depth of renal cortex without collecting system rupture or urinary extravasation Parenchymal laceration extending through renal cortex, medulla, and collecting system Main renal artery or vein injury with contained haemorrhage Completely shattered kidney Avulsion of renal hilum which devascularises kidney 866.01 866.01 866.11 866.11 866.02 / 866.12 866.03 / 866.13 866.04 / 866.14 866.13  2 2 2 2 3 4 4 5 5  *Advance one grade for bilateral injuries up to grade III From Moore et al. [7]; with permission Table 20 Ureter injury scale Grade* Type of injury Description of injury ICD-9 AIS-90 I II III IV V Haematoma Laceration Laceration Laceration Laceration Contusion or haematoma without devascularisation < 50% transection > 50% transection Complete transection with < 2 cm devascularisation Avulsion with > 2 cm of devascularisation 867.2/ 867.3 867.2/ 867.3 867.2/ 867.3 867.2/ 867.3 867.2/ 867.3  2 2 3 3 3 *Advance one grade for bilateral up to grade III. From Moore et al. [2]; with permission Table 21 Bladder injury scale Grade* Injury type Description of injury ICD-9 AIS-90 I II III IV V  Haematoma Laceration Laceration Laceration Laceration Laceration Contusion, intramural Haematoma Partial thickness Extraperitoneal bladder wall laceration <2 cm Extraperitoneal (>2cm) or intraperitoneal (<2cm) bladder wall laceration Intraperitoneal bladder wall laceration >2cm Intraperitoneal or extraperitoneal bladder wall laceration extending into the bladder neck or ureteral orifice (trigone)  867.0 / 867.1 867.0 / 867.1 867.0 / 867.1 867.0/ 867.1 867.0/ 867.1 867.0/ 867.1 2 3 4 4 4 4  *Advance one grade for multiple lesions up to grade III From Moore et al. [2]; with permission Table 22 Urethra injury scale Grade* Injury type  Description of injury ICD-9 AIS-90 I II III IV V Contusion Stretch injury Partial disruption Complete disruption Complete disruption Blood at urethral meatus; urethrography normal Elongation of urethra without extravasation on urethrography Extravasation of urethrography contrast at injury site with visualisation in the bladder Extravasation of urethrography contrast at injury site without visualization in the bladder; <2cm of urethra separation Complete transaction with >2 cm urethral separation, or extension into the prostate or vagina 867.0/ 867.1 867.0/ 867.1 867.0/ 867.1 867.0/ 867.1 867.0/ 867.1 2 2 2 3 4 *Advance one grade for bilateral injuries up to grade III From Moore et al. [2]; with permission Table 23 Uterus (non-pregnant) injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion/Haematoma Superficial laceration (<1 cm) Deep laceration (> 1 cm) Laceration involving uterine artery Avulsion/devascularisation 867.4 / 867.5 867.4 / 867.5 867.4 / 867.5 902.55 867.4 / 867.5 2 2 3 3 3 *Advance one grade for multiple injuries up to grade III From Moore et al. [5]; with permission Table 24 Uterus (pregnant) injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Contusion or Haematoma (without placental abruption) Superficial laceration (<1cm) or partial placental abruption <25% Deep laceration (>1cm) occurring in second trimester or placental abruption >25% but <50% Deep laceration (>1cm) in third trimester Laceration involving uterine artery Deep laceration (>1cm) with >50% placental abruption Uterine rupture Second trimester Third trimester Complete placental abruption  867.4 / 867.5 867.4/ 867.5 867.4 / 867.5 867.4 / 867.5 902.55 867.4 / 867.5 867.4 / 867.5 867.4 / 867.5 867.4 / 867.5 2 3 3 4 4 4 4 5 4-5 *Advance one grade for multiple injuries up to grade III From Moore et al. [5]; with permission Table 25 Fallopian tube injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Haematoma or contusion Laceration <50% circumference Laceration >50% circumference Transection Vascular injury; devascularised segment  867.6 / 867.7 867.6 / 867.7 867.6 / 867.7 867.6 / 867.7 902.89 2 2 2 2 2 *Advance one grade for bilateral injuries up to grade III From Moore et al. [5]; with permission Table 26 Ovary injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Contusion or haematoma Superficial laceration (depth <0.5 cm) Deep laceration (depth > 0.5 cm) Partial disruption or blood supply Avulsion or complete parenchymal destruction 867.6 / 867.7 867.6 / 867.7 867.8 / 867.7 902.81 902.81 1 2 3 3 3  *Advance one grade for bilateral injuries up to grade III From Moore et al. [5]; with permission Table 27 Vagina injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion or haematoma Laceration, superficial (mucosa only) Laceration, deep into fat or muscle Laceration, complex, into cervix or peritoneum Injury into adjacent organs (anus, rectum, urethra, bladder) 922.4 878.6 878.6 868.7 878.7 1 1 2 3 3 *Advance one grade for multiple injuries up to grade III From Moore et al. [5]; with permission Table 28 Vulva injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V  Contusion or haematoma Laceration, superficial (skin only) Laceration, deep (into fat or muscle) Avulsion; skin, fat or muscle Injury into adjacent organs (anus, rectum, urethra, bladder) 922.4 878.4 878.4 878.5 878.5 1 1 2 3 3 *Advance one grade for multiple injuries up to grade III From Moore et al. [5]; with permission Table 29 Testis injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Contusion / haematoma Subclinical laceration of tunica albuginea Laceration of tunica albuginea with <50% parenchymal loss Major laceration of tunica albuginea with >50% parenchymal loss Total testicular destruction or avulsion  911.0 - 922.4 922.4 878.2 878.3 878.3  1 1 2 2 2 *Advance one grade for bilateral lesions up to grade V From Moore et al [1]; with permission Table 30 Scrotum injury scale Grade Description of injury ICD-9 AIS-90 I II III IV V  Contusion Laceration <25% of scrotal diameter Laceration >25% of scrotal diameter Avulsion <50% Avulsion >50% 922.4 878.2 878.3 878.3 878.3 1 1 2 2 2 From Moore et al [1]; with permission Table 31 Penis injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Cutaneous laceration / contusion Bucks fascia (cavernosum) laceration without tissue loss Cutaneous avulsion Laceration through glans / meatus Cavemosal or urethral defect <2cm Partial penectomy Cavarnosal or urethral defect > 2 cm Total penectomy  911.0 / 922.4 878.0 878.1 878.1 876.1 1 1 3 3 3 *Advance one grade for multiple injuries up to grade III From Moore et al. [1]; with permission Table 32 Peripheral vascular organ injury scale Grade* Description of injury ICD-9 AIS-90 I II III IV V Digital artery/vein Palmar artery/vein Deep palmar artery/vein Dorsalis pedis artery Plantar artery/vein Non-named arterial/venous branches Basilic / cephalic vein Saphenous vein Radial artery Ulnar artery Axillary vein Superficial/deep femoral vein Popliteal vein Brachial artery Anterior tibial artery Posterior tibial artery Peroneal artery Tibioperoneal trunk Superficial/deep femoral artery Popliteal artery Axillary artery Common femoral artery  903.5 903.4 904.6 904.7 904.5 903.8 / 904.7 903.8 904.3 903.2 903.3 903.02 903.02 904.42 903.1 904.51 / 904.52 904.53 / 904.54 904.7 904.7 904.1 / 904.7 904.41 903.01 904.0 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 1-3 2-3 2-3 2-3 2-3 1-3 1-3 1-3 2-3 3-4 2-3 2-3 3-4 *Increase one grade for multiple grade III or IV injuries involving >50% vessel circumference. Decrease one grade for < 25% vessel circumference disruption for grades IV or V From Moore et al [1]; with permission references 1. Moore EE, Malangoni MA, Cogbill TH, Peterson NE, Champion HR, Shackford SR. Organ Injury Scaling VII: Cervical Vascular, Peripheral Vascular, Adrenal, Penis, Testis and Scrotum. J Trauma: 1996; 41(3) 523-524. 2. Moore EE, Cogbill TH, Jurkovich. Organ Injury Scaling III: chest wall, abdominal vascular, ureter, bladder and urethra. J Trauma 1992; 33: 337-338 3. Moore EE, Malangoni MA, Cogbill TH, Shackford SR, Champion HR, Jurkovich GJ, McAninich JW, Trafton PG. Organ Injury Scaling IV: Thoracic, vascular, lung, cardiac and diaphragm J Trauma 1994; 36(3): 299-300 4. Moore EE, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ Injury Scaling: Spleen and Liver (1994 Revision) J Trauma 1995; 38(3): 323-324 5. Moore EE, Jurkovich GJ, Knudson MM, Cogbill TH, Malangoni MA, Champion HR Shackford SR. Organ Injury Scaling VI: Extrahepatic biliary, oesophagus, stomach, vulva, vagina, uterus (non-pregnant), Uterus (Pregnant), Fallopian tube, and ovary. J Trauma: 1995: 39(6): 1069-1070 6. Moore EE, Cogbill TH, Malangoni MA, Jurkovich GJ, Shackford SR, Champion HR. Organ Injury Scaling: Pancreas, duodenum, small bowel, colon and rectum J Trauma 1990; 30(11): 1427-1429 7. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA, Ramenowsky ML, Trafton PG. Organ Injury Scaling: Spleen, liver and kidney. J Trauma 1989; 29(12): 1664-1666 IATSIC Chapter 12: Page  PAGE 25 revised  DATE \@ "d/MM/yyyy" \* MERGEFORMAT 16/08/2001  Organ Injury Scale of the American Association for the Surgery of Trauma (OIS-AAST). 2000; http://www.aast.org.  Moore EE, Dunn EL, Moore JB et al. Penetrating Abdominal Trauma Index. J Trauma 1981; 21: 439-445. 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