Points to keep in mind:
Why to Use
The GCS score is an adopted standard for mental status assessment in the acutely ill trauma and nontrauma patient and assists with predictions of neurological outcomes (complications, impaired recovery) and mortality.
When to Use
Next Steps
Daniel Runde, MD
Although it has been adopted widely and in a variety of settings, the GCS score is not intended for quantitative use. Clinical management decisions should not be based solely on the GCS score in the acute setting.
The modified GCS (the 15-point scale that has been widely adopted, including by the original unit in Glasgow, as opposed to the 14-point original GCS) was developed to be used in a repeated manner in the inpatient setting to assess and communicate changes in mental status and to measure the duration of coma (Teasdale 1974).
The evidence presented in 53 published reports on the reproducibility of the GCS was synthesized in a systematic review by Reith et al in 2016. Eighty-five percent of the findings in the studies identified as high quality showed substantial reliability of the GCS as judged by the standard criterion of a kappa statistic > 0.6. Reproducibility of the total GCS score was also high, with kappa > 0.6 in 77% of the observations. Education and training on usage of the GCS resulted in a clear beneficial effect on reliability (Reith 2016).
In its most common usage, the 3 sections of the scale are often combined to provide a summary of severity. The authors themselves have explicitly objected to the score being used in this way, and analysis has shown that patients with the same total score can have huge variations in outcomes, specifically mortality. A GCS score of 4 predicts a mortality rate of 48% if calculated 1 + 1 + 2 for eye, verbal, and motor components, respectively, and a mortality rate of 27% if calculated 1 + 2 + 1, but a mortality rate of only 19% if calculated 2 + 1 + 1 (Healey 2014).
The modified GCS provides a nearly universally-accepted method of assessing patients with acute brain damage. Summation of its components into a single overall score loses information and provides only a rough guide to severity. In some circumstances, such as early triage of severe injuries, assessment of only a contracted version of the motor component of the scale (as in the SMS) can perform as well as the GCS and is less complicated. However, the scores like the SMS may be less informative in patients with lesser injuries.
Sir Graham Teasdale, MBBS, FRCP
Original/Primary Reference
Validation References
Other References
Why to Use
Due to the heterogeneous nature of trauma patients, standardizing the severity of traumatic injuries allows for comparison of much larger sample populations in trauma research studies.
When to Use
The ISS attempts to standardize the severity of injuries sustained during trauma. This standardization allows for more accurate study and prediction of morbidity and mortality outcomes after traumatic injuries.
Next Steps
As the ISS is intended primarily as a research tool, the score should not affect the initial management of a patient with traumatic injuries.
Max Berger, MD
Alexandra Ortego, MD
First, the most severe injury from each of 6 body systems is assigned an AIS score on a scale of 0 (no injury) to 6 (unsurvivable injury). Next, those scores are used to determine the 3 most injured body systems. Finally, the ISS is calculated by squaring the AIS score for each of the 3 most injured body systems, then adding up the 3 squared numbers (A2 + B2 + C2 = ISS, where A, B, and C are the AIS scores of the most severe injury in each of the 3 most severely injured body systems). Patients with an AIS of 6 in any body system are automatically assigned an ISS of 75, the maximum possible score.
The ISS is used primarily in research settings, so calculation of the score should not delay initial management of patients with traumatic injuries.
The ISS was derived by Baker et al (1974) by taking the previously used AIS (American Medical Association Committee on Medical Aspects of Automotive Safety 1971) and adding the squared value of each of the 3 most severely injured body systems, in an effort to add increasing importance to the most severe injuries. The top 3 most severe injuries were used to calculate the final score because it had been shown that injuries that would not necessarily be life-threatening in isolation could have a significant effect on mortality when they occurred in combination with other severe injuries. The derivation study included only injuries sustained from motor vehicle collisions, including the occupants of the vehicles and any pedestrians involved.
Further studies have validated the ISS to include other mechanisms of injury. A study by Beverland et al (1983) of 875 patients with gunshot wounds showed that an increasing ISS was associated with increasing mortality (chi-squared = 83.31, P < .001). A study by Bull (1978) confirmed the correlation between increasing ISS and increasing mortality in road traffic accidents, and showed correlation between increasing ISS and increasing mean hospital length of stay.
In a study of 8852 trauma patients from the Illinois Trauma Program (including both vehicular and nonvehicular trauma), Semmlow et al (1976) had similar findings to Baker et al regarding the relationship between ISS and mortality. They also found that the ISS correlated with hospital length of stay.
Susan P. Baker, MPH
Original/Primary Reference
Validation References
Why to Use
The SIPA is more accurate than the SI at differentiating severely injured children from children with mild injury. In the original study (Acker 2015), an elevated SIPA was shown to identify approximately 25% of the most severely injured children, regardless of age, while an SI > 0.9 has been shown to identify anywhere from 32% to 71% of injured children, depending on age. Being able to accurately identify severely injured children is critical in reducing the overtriage of children who have sustained injuries. An elevated SIPA is associated with the following outcomes (Acker 2015; Nordin, Coleman, Shi, et al 2017):
When to Use
The SIPA can be used for patients aged 4 to 16 years who have sustained blunt trauma. The SIPA should not be used for young infants, toddlers, or patients with penetrating trauma.
Next Steps
The general management of pediatric blunt abdominal trauma includes performing the primary and secondary surveys and determining the extent, type, and severity of injury.
A thorough abdominal examination is ex-tremely important because abdominal injuries are often not apparent on physical examination. Depending on the examination findings, the use of imaging may be warranted.
Christian Hietanen, DO
Patients who present with an elevated SIPA for age have a higher risk of morbidity and mortality following blunt trauma. Early recognition and treatment of these patients, including a possible decision to transfer to a higher level of care, will improve outcomes.
There is no value or finding that necessarily defines shock, and children can compensate more readily than adults. Hypotension is often a late finding in children with hypovolemic shock.
The SIPA was originally developed by researchers at the Children’s Hospital of Colorado to help identify severely injured children following blunt trauma (Acker 2015). Mechanism alone has been found to be a poor predictor of injury severity in children (Qazi 1998). Clinical and physiologic parameters are better indicators (Wang 2001) and previous studies (Rousseaux 2013; Yasaka 2013) have shown that the shock index (SI) helps identify a higher risk of mortality versus using heart rate and blood pressure alone. The SIPA furthers builds on those findings by using specific vital sign cutoffs by age group.
Realizing that pediatric vital signs vary with age and that the SI might not be as useful in children, Acker et al (2015) sought and defined maximum normal heart rate and minimum normal systolic blood pressure using reference ranges from 2 pediatric textbooks and the United States Department of Health and Human Services’ Pediatric Basic and Advanced Life Support guidelines. The authors used these numbers to determine the maximum normal SI for 3 age groups, and then conducted a retrospective review of 543 children aged 4 to 16 years who had been admitted between January 2007 and June 2013 to 2 Colorado trauma centers following blunt trauma and with injury severity scores > 15.
An elevated SI was present in 49% of the children, while an elevated SIPA was present in only An elevated SI was present in 49% of the children, while an elevated SIPA was present in only 27.6% of the children, all of whom had the same adverse outcomes that were identified by using the SI. The SIPA demonstrated improved discrimination of severe injury compared to the SI in the following categories:
The authors concluded that the SIPA misses fewer children with severe injury while also minimizing overtriage.
A multicenter prospective observational study of 386 patients aged 4 to 16 years (Linnaus 2017) validated the original study with level II-quality evidence.
In 2017, Nordin, Coleman, and Shi, et al, developed SIPA cutoff values for patients aged 1 to 3 years and found the SIPA to be a significantly better predictor than the SI of transfusion needs, injury severity, intensive care unit admission, ventilator use, and mortality following blunt and penetrating trauma.
The authors of the original SIPA study conducted a follow-up study (Acker 2017) and found the SIPA to be superior to age-adjusted hypotension in identifying injured children who required trauma team activation. The criteria used as indicators included early blood transfusion, endotracheal intubation, and emergency operation.
A comparison of the accuracy of the SIPA, SI, and the revised trauma score for predicting outcomes in pediatric trauma patients was presented at the 2017 annual meeting of the Pediatric Trauma Society; the presenters found that the SIPA outperformed the SI and compared favorably to the revised trauma score (Nordin, Shi, Wheeler 2017).
Manuel Mutschler, MD
Original/Primary Reference
Validation Reference
Other References
Nicole Schacherer, MD;Jill Miller, MD; Kelli Petronis, MD
Lara Zibners, MD, MMed, FAAP, FACEP
January 15, 2020
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