Severity of Illness Scoring
First Things First
First Things First
First Things First
- Combines clinical observations and statistical theory to create a single metric of the patient’s condition and associated outcome (e.g., mortality, length of hospital stay, etc.)
History and Physical (assess for the following)
History and Physical (assess for the following)
History and Physical (assess for the following)
- Scoring systems are calibrated based on a logistic regression analysis of variables from large observational studies.
- Regression analysis results must be considered in light of the facilities and inclusion criteria of the original study and may not apply to all institutions.
- Epidemiological tools that cannot be used to determine an individual patient’s outcome
- Can be subdivided to particular condition and population studied, such as:
- Trauma vs. non-trauma surgical vs. medical vs. cardiac populations, etc.
- Can evaluate multiple aspects of the patient’s condition (e.g., APACHE II) or can be organ-specific (e.g., Glasgow Coma Scale [GCS])
- Performed at the time of admission or at intervals throughout hospital stay
Diagnostic Tests
Diagnostic Tests
Diagnostic Tests
- Have to be individualized to the particular scoring system employed
General Management Principles
General Management Principles
General Management Principles
- Scoring systems typically incorporate elements of:
- Anatomic injury (mainly in trauma-specific scoring systems)
- Physiological derangement
- Effects of comorbidities
- Allow for between-facility comparison in the quality and efficacy of intensive care
- Increasingly used to determine risk/benefit of applying particular therapies (e.g., drotrecogin alpha)
Specific Treatment
Specific Treatment
Specific Treatment
General severity of illness scoring methods for adult ICU admissions
Acute Physiology and Chronic Health Evaluation (APACHE II; 1985)
- Incorporates 2/3 scoring elements of physiologic derangement, and comorbid diseases
- Score is based on the initial data collection at the time of admission and includes:
- 12 physiological measurements
- Age
- Previous health status
- Score ranges from 0-71 points
- Benefits
- Drotrecogin alpha may be considered for the treatment of sepsis based on the presence of both:
- Sepsis-induced multiple organ failure, septic shock, or sepsis-induced acute respiratory distress syndrome [ARDS]) and,
- An APACHE II score >25
- Allows for adjustment in scores based upon a multitude of comorbidity modifiers
- Limitations
- Lacks anatomic injury component and therefore less useful in trauma patients
- APACHE III (1992) is intended to rectify trauma limitation but the system is proprietary
- More complex than other commonly available ICU admission scoring systems
Simplified Acute Physiology Score (SAPS II; 1993)
- Similar to APACHE II
- 12 routine physiological measurements during the first 24 hours, age, and prior health status
- Score ranges from 0-24
- Benefits
- Most commonly used severity of illness scoring system
- Limitations
- Also lacks an anatomic injury component
- Uses only 3 chronic health conditions in scoring (metastatic or hematologic malignancy, AIDS)
Sequential Organ Failure Assessment (SOFA; 1996)
- Uses only 6 physiologic measurements and no chronic health or age-related modifiers
- Score ranges from 0-24
- Benefits
- Ease of use
- Uses common and readily available variables
- Can be performed on a daily basis
- Limitations:
- Also lacks an anatomic injury component
- Fails to take into account preexisting comorbidity modifiers
MODS (Multiple Organ Dysfunction Score)
- Similar criteria and scoring system as SAPS II, with the same benefits/limitations
Severity of illness scoring methods for adult trauma admissions
Abbreviated Injury Scale (AIS)
- Measures anatomic injury only
- Originally intended for documentation of motor vehicle accidents
- Comprises a lexicon of six-digit coded injuries (>2,000 listed) based on:
- Region
- Type of anatomic structure
- Specific structure
- Level of injury
- Injuries are assigned a severity value of 1 (minor) to 6 (fatal)
- Uses maximum AIS score based on the highest AIS severity among a set of injuries
- Benefits
- Most advanced and comprehensive trauma-specific coding system
- Limitations
- Uses only the single worst injury for a single area to provide the maximum AIS
- Ineffective in the multiply injured patient
- Proprietary system that requires specially trained coding personnel
- Assigned values are subjective
- Does not include comorbidities or physiological variables
Injury Severity Score (ISS; 1974)
- Summation of AIS scores from the squared values of the three most severely injured body areas
- Scores range from 0-75
- Benefits: includes more injuries in its score derivation
- Limitations
- Same as AIS scoring, with the exception of number of injuries scored
- Recognizes only the 3 most severe injuries
- Includes only 1 injury from each area
Trauma-Related Injury Scoring System (TRISS; 1987)
- Overcomes the lack of comorbid conditions and physiologic variables missing from AIS/ISS
- Incorporates ISS, age, and 3 physiological variables
- Final modifying equation is applied depending on whether the trauma was blunt or penetrating
- Benefits
- Has become the most accepted means of estimating trauma-related survival probabilities
- Overcomes the ISS limitations of lack of physiological and comorbid disease data
- Limitations
- Same as AIS scoring
- Only 3 physiological variables included
Revised Trauma Score (RTS)
- Measures physiologic derangement
- Combines coded values for systolic BP (SBP), respiratory rate (RR) & GCS
- Coded values are given for each GCS, SBP, RR
- GCS
- 13-15 = 4
- 9-12 = 3
- 6-8 = 2
- 4-5 = 1
- 3 = 0
- SBP
- >89mmHg=4
- 76-89 mmHg = 3
- 50-75 mmHg = 2
- 1-49 mmHg = 1
- 0 mmHg = 0
- RR
- 10-29 bpm = 4
- >29bpm=3
- 6-9 bpm = 2
- 1-5 bpm = 1
- 0 bpm = 0
- Coded values can be added for score of 0-12 for use in pre-hospital triage.
- RTS value < 11 suggests need for transfer to trauma center.
- Values are weighted for in-hospital use as follows:
- RTS = 0.9368 (GCScoded) + 0.7326 (SBPcoded) + 0.2908 (RRcoded)
- Range of values 0-7.84
- RTS >5, >90% survival
- RTS < 3, < 20 % survival
- Used primarily as research tool for outcome assessment & quality assurance
Severity of illness scoring methods for pediatric ICU admissions
Pediatric Risk of Mortality (PRISM; 1988)
- Uses 12 physiologic measurements, papillary response and GCS assessment – similar to APACHE II
- Benefit: comprehensive scoring tool
- Limitation: does not include comorbid disease assessments
Severity of illness scoring methods for pediatric trauma admissions
Pediatric Trauma Score (PTS)
- Combines aspects of anatomic injury, physiologic derangement & physiologic reserve
- Components include pt size, airway, consciousness, SBP, fracture, cutaneous injury
- Used for pre-hospital triage
- Each category is scored -1, +1 or +2.
- Size
- Child >20 kg = +2
- Toddler 11-20 kg = +1
- Infant < 10 kg = -1
- Airway
- Normal = +2
- Assisted w/ oxygen = +1
- Intubated = -1
- Consciousness
- Awake = +2
- Obtunded/lost consciousness = +1
- Unresponsive = -1
- SBP
- >90mmHg=+2
- 51-90 mmHg = +1
- < 50 mmHg = -1
- Fracture
- No fracture = +2
- Single closed fracture = +1
- Multiple or open fracture = -1
- Cutaneous
- No visible injury = +2
- Contusion/abrasion or laceration not through fascia = +1
- Tissue loss, gunshot or stab through fascia = -1
- Total score ranges from -6 to +12
- PTS >8, 0% mortality; PTS < 0, 100% mortality
- PTS < 9 indicates need for transfer to a pediatric trauma center.
Ongoing Assessment
Ongoing Assessment
Ongoing Assessment
Commonly used organ specific scoring methods
- GCS (1974)
- Easily applied and reproducible assessment of level of consciousness
- Based on combined scores for visual, motor, and verbal interaction
- Eye Opening
- Spontaneous = 4
- To Voice = 3
- To Pain = 2
- None = 1
- Verbal Response
- Oriented = 5
- Confused = 4
- Inappropriate words = 3
- Incomprehensible sounds = 2
- None = 1
- Motor Response
- Obeys commands = 6
- Localizes pain = 5
- Withdraws from pain = 4
- Flexor posturing to pain = 3
- Extensor posturing to pain = 2
- None = 1
- Benefits:
- GCS < 9 suggests inability to protect airway
- Can be performed throughout the patient’s hospital course
- Killip classification (1967) of heart failure after acute myocardial infarction
- Stratified according to physiological variables and thoracic auscultation
- Killip class I - no clinical signs of heart failure; 6% mortality
- Killip class II - rales or crackles in the lungs, S3 gallop, and elevated jugular venous pressure; 17% mortality
- Killip class III describes individuals with frank acute pulmonary edema; 38% mortality
- Killip class IV - cardiogenic shock evidence of peripheral vasoconstriction; 81% mortality
- Predictor of all-cause mortality for the following:
- ST and non-ST segment elevation myocardial infarction
- Unstable angina
- Those undergoing percutaneous coronary intervention
- Risk of acute renal failure, Injury to the kidney, Failure of kidney function,Loss of kidney function and End-stage kidney disease (RIFLE; 2007)
- Uses the duration and extent of decline in urine output and creatinine levels or glomerular filtration rate to define the extent of acute kidney injury
- Stratified injury among:
- 3 grades of increasing severity of kidney injury: Risk, Injury, and Failure and
- 2 outcome classes: Loss and End-stage
- Particular stratification predicts mortality across multiple patient populations
- Easily applied and reproducible scoring system
Complications
Complications
Complications
- Avoid extrapolation of mortality prediction model results to individual patients.
- Scoring systems are largely used in the research and quality assurance settings.
- SOFA score and GCS are easily applied and reproducible and can be repeated daily.
Author
Author
Author
- Written by James B. Sampson, MD, and Jeffrey D. Kerby, MD, PhD
- Revised by Patrick F. Allan, MD
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