Autor: Dr. Luiz Carlos von Bahten

Doctor em Cirurgia UNICAMP

Technical Diretor Hospital Universitário Cajuru







In the contemporary society the interpersonal violence has been taking over highlight roll. Either it takes place in the wars or guerrillas battles field or in the urban environment; the violence victimizes men, women, children and senior, burdens the government and pledges the population’s future.


World Health Organization (WHO) defines violence as the “intentional use of the physical force or of power, real or a menace, against himself, against other person, or against a group or a community, that results or have great possibility to result in lesion, death, psychological damage, development or privation deficiency”, therefore a public health’ problem.


Probably the biggest clinical-surgical afflictions arise at the assistance moment to a trauma victim due to her complexity and diversity. The evaluation of the necessary resources for the assistance of a patient would be restricted to the experience acquired by the doctors or EMT (Emergency Medical Technicians) that help the victim. There is the need to a method that assists it to predict the gravity, the resources and the necessary management for each patient. It’s necessary to organize the medical assistance and the decisions regarding the assistance center choice.


We should remind that the only essential ingredient to reach that ideal assistance is, in the most of the time, a properly trained professional, that knows how to establish conducts through clinical protocols that prioritize important situations in the assistance.


The outcome in the trauma depends on: the trauma gravity, the period of time between trauma and the definitive treatment, the patient's general conditions and of the assistance quality


Trauma Scores 

They are quantitative measures to evaluate the trauma severity. They allow an emergency service to prepare adequately the necessary therapeutic resources before the patient’s arrival to a hospital. It is possible to evaluate the changes in the patient's state for a certain period, to anticipate and analyze different outcomes. Trauma scores allow even to evaluate and compare the assistance quality in different services.


The trauma indices started to be described in the 20th century, arising initially as the called anatomical indices. In 1967, the World Health Organization published the International Code of the Diseases, allowing specifying the lesion nature and location, however, without quantifying its gravity2.


1.Anatomical indices 

AIS Abbreviated Injury Scale 

In 1971, it was published the Abbreviated Injury Scale (AIS), an used as anatomical index in the current days3. (COMMITEE ON MEDICAL ASPECTS OF AUTOMOTIVES SAFETY, 1971.) It is a list that contains several lesions of all the corporal segments, divided by the gravity. The corporal segments are in number of 6: Head and neck, face, thorax, abdomen, members and external lesions. Each lesion receives a value, with increasing gravity, that varies of 1 (minimum lesion) to 6 (maybe fatal lesion). In spite to of not being used separately, its importance is in serving as base for other outcome indices. A criticism to the method would be the multiple injury patients' evaluation.



ISS Injury Severity Score  

Described by BAKER et al in 1974, it is used to quantify the trauma gravity4. The human body is divided into six segments: Head and neck, face, thorax, abdomen and pelvis, pelvis extremities and bones and external surface. In each one of these segments,  the lesion receives a score from 1 to 6, having as base the AIS criteria, where: 1 smaller lesion, 2 moderated lesion, 3 larger or serious lesion, 4 severe lesion, 5 critical lesion and 6 fatal lesion. In each segment it considers only the most serious lesion. Afterwards, they select the three corporal segments that present the higher score level lesions, elevate it to the square, then with the sum of the squared scores resulting the ISS. The index has a minimum value of 1 and maximum of 75. The larger be the value,  the bigger the mortality probability. Lesions greater than 25 are considered serious traumas. Patient that present fatal lesion, they correspond for AIS 6, and automatically, will have an ISS of 75.Críticism to that method are the patients who present in the same corporal segment more than one lesion.


NISS (New Injury Severity Score) was described by OSLER et al, in 1997, in order to improve for ISS's accuracy5. NISS is obtained by the squares sum of the three more serious lesions of the AIS, independent of injured corporal segment. Patients that present associated serious injuries at the same corporal segment, what is relatively frequent in penetrating traumas, can be considered to NISS evaluation.


2.   Physiologic indices


RTS Revised Trauma Score

This index is due to studies that compared injured patients from different institutions5. For the calculation it uses absolute values them of the Coma Scale of Glasgow (GCS), of the systolic arterial pressure (PAS) and of the respiratory frequency (FR) that are converted in a gravity scale from 0 to 4 as in the picture below.


Quadro 1. – Variáveis do Escore de Trauma Revisado (RTS)





13 -15


10 -29


9 -  12

76 -89

> 29


6 – 8

50 - 75

6 - 9


4 - 5

1 - 49

1 - 5











After multi center studies it was agreed the graduation of the gravity of each parameter through constants:

RTS = 0,9368 X GCS + 0,7326 X PAS + 0,2908 X FR

Thus RTS varies from 0 to almost 8 (7,8408).

RTS is a practical physiologic index and should be calculated in the patient's admission in hospital. However, he is not a predictor of complications6,7.).


3.   Mixed indices



 It is an index that evaluates the surviving probability8. In a practical manner, it is calculated using the values obtained from RTS and of ISS, the patient's age (< 54 years or 54 >) and traumatism type (blunt or penetrating ). These values are applied in a table TRISSCAN (Picture 2) that easily determines the surviving probability and its importance in results.  By RTS's Intersection and of ISS it obtains in the TRISSCAN a picture with four values in which the values to the left represent the surviving probability of a blunt trauma victim and to the right  the values to penetrating trauma. The superior values represent the surviving probability of patients with less than 54 years and the inferior with more than 54 years.


Bibliographical References


  1. Organização Mundial de Saúde. Classificação Mundial de Saúde.  Classificação Estatística Internacional das Doenças e de Problemas Relacionados à Saúde, 1995, décima revisão, Genebra.

  2. Word Health Organization. Manual of the Internacional Statistical Classification of Diseases, Injuries and Causes of  Death, 196, Word Health Organization, 1967.

  3. Committee on Medical Aspects of Automotive Safety. Rating the severety of tissue damage I, The Abbreviated Scale. JAMA, 1971, 215: 277-80.

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  18. Coimbra RSM. Prefácio Trauma Guia de Escores de Lesão Orgânica e Índices de Severidade. In Porcides RD, Nimer NY, Jardim Neto JCM, Gus J. Trauma Guia de Escores de Lesão Orgânica e Índices de Severidade. Editora Evangraf, 2003, Porto Alegre.

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  27. Moore EE, Gogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ Injury Scaling: Spleen an liver (1994 Revision) J.Trauma, 1995, 38: 323-4.

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