Tools
Revised Trauma Scale
Definition/Introduction
Treating trauma patients requires stringent planning and therapeutic resource allocation to provide optimal levels of care for injured patients.[1] A standardized rapid assessment model assists with triaging injured patients and provides a standardized process that can be applied across different settings to ensure similar treatment decisions are made pertaining to a patient’s level of care.[1] Multiple assessment tools exist and are available now, but the Trauma Score (TS) was initially developed to represent an injured patient’s injury severity accurately.[1][2] The TS was designed to assist with field triage to reduce the risk of overtriage, which can contribute to the high cost of regional trauma care or undertriage, which can put injured patients at higher risk for mortality.[1] Components of the TS include respiratory rate, respiratory effort, systolic blood pressure, capillary refill time, and the Glasgow Coma Scale (GCS).[1][3] Researchers found that adding the respiratory rate and systolic blood pressure to the TS increased attending physicians’ suitability of the tool to assist in triaging injured patients.[1][3] Multiple studies have already verified the reliability, reproducibility, and effectiveness of the TS.
Application of the TS[1] demonstrated benefits in proper triage and mortality prediction.[1][2][4][5][5] Accurate triage was defined as severely injured patients (those with an injury severity score [ISS] of ≥16) transported and treated at a trauma center, and mildly injured patients (those with an ISS of ≤15) transported and treated at a nearby hospital.[4][6] The TS was able to accurately triage 66% of patients who experienced blunt injuries with an overtriage rate of 8% and an undertriage rate of 25.2%, as determined by mildly injured patients transported to a trauma center and severely injured patients transported to the nearest hospital, respectively.[4] However, the in-depth analysis revealed that if the classification of mild injury was lower (an ISS of ≤14), there was an increase in the over-triage rates (13.6%). Still, there was also an inverse reduction in the undertriage rates (16.7%).[4] Furthermore, researchers found that TS accurately predicted survival among such injured patients.[2][5] While the original TS demonstrated benefits regarding the ability to triage patients and predict mortality accurately,[5] limitations associated with the original TS provided ample room to revise the scoring system further.[1][2][4][7][2]
Multiple studies found few disadvantages associated with including capillary refill and respiratory expansion within the scoring system.[7] First responders shared challenges observing the capillary refill and respiratory expansion during dark settings or at night. Another group coordinated through the American College of Surgeons Committee on Trauma found that the TS may underestimate head injury severity among such cohorts. These factors led to the formulation of the Revised Trauma Scale (RTS), which removed the capillary refill and respiratory expansion. Additionally, 2 versions of the RTS were created; one was developed specifically for triage (T-RTS), and the other was developed for outcome evaluations and controlling for injury severity (RTS).[7] When providers utilize the RTS for triage, they use raw values, and when using the assessment tool for outcome evaluations, the coded values are weighted and summed.[7]
Numerous studies demonstrated the benefits of utilizing the RTS. Researchers found that after implementation of the RTS, there was no difference in the error rate for diagnosis and investigation compared to not utilizing the RTS; however, there was a statistically significant improvement concerned with the appropriateness of the formulated treatments.[7][8] Using the RTS as a triage tool reduced the treatment errors from 21 out of 36 patients (58%) to 14 out of 54 patients (26%).[8] Additionally, researchers found that the RTS effectively predicted mortality for patients with an RTS greater than 7.[9] Furthermore, the RTS was most useful in predicting the survival rates among patients with head injuries compared to patients with penetrating or blunt traumas.[9]
When using the RTS to predict geriatric trauma mortality, the recommended cutoff value was 7.108, with a sensitivity of 97% and a specificity of 80%.[7][10] There were statistically significant differences regarding the receiving operator characteristics (ROC) curve between ISS,[6] New Injury Severity Score (NISS),[11], and the Trauma and Injury Severity Score (TRISS),[12] in predicting geriatric mortality.[10] The measurement tool that best predicted elderly mortality, based on the ROC, was the TRISS,[12] but the RTS was also an appropriate measurement tool to predict the same.[10] When patients transported via Helicopter Emergency Medical Services (HEMS) were assessed using the RTS,[7] the optimal cutoff score to predict trauma patients at risk for a major complication during a HEMS mission was 11.5. The researchers reported a sensitivity of 84% and a specificity of 90.5%, thereby validating the usefulness of the RTS as an appropriate assessment tool.[13]
Issues of Concern
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Issues of Concern
Although the merits of the RTS have been demonstrated, other assessment tools may also be useful.[7] As previously shared, research showed the TRISS as the best predictor of geriatric mortality.[10] After conducting a metaanalysis, researchers found the Kampala Trauma Score (KTS) had better sensitivity (0.88), which was higher than that of the RTS (0.82), in its ability to predict mortality accurately.[14][15] However, the RTS resulted in a better specificity (0.91) and ROC (0.93) curve than the KTS during the same meta-analysis.[7][14][16] While researchers found the RTS to have acceptable psychometrics, there still may be room for future improvements and developments.[7][9]
Clinical Significance
According to the Centers for Disease Control and Prevention (CDC), unintentional injuries were the leading cause of death in people from birth through 44 years of age in the United States. With the high prevalence rates of injuries, a simple and standardized assessment tool to identify injury severity is critical for clinicians. There are various metrics to evaluate the severity of a patient’s injuries. ISS, NISS, and TRISS have retrospectively measured indexes, whereas TS and RTS have their basis on patient characteristics at the time of initial evaluation.[6][11][12] Furthermore, the TS-based metrics can be reevaluated in real time to assess changes in patient status for re-triage. Thus, TS and RTS can be used for triage, whereas the ISS-based metrics are used to evaluate the effectiveness of triage or to cohort patients for proper dichotomization.
Nursing, Allied Health, and Interprofessional Team Interventions
The RTS is an assessment tool that can be utilized by multiple medical professionals with a variety of experience levels to help triage patients or predict mortalities. Junior residents can assess trauma patients using the RTS, despite their inexperience in making complex medical decisions, to identify severe injuries that may require additional support from a senior resident or attending physician.[8][17] Instances may exist where a medical professional’s background or experience level may impact patient assessment. Comparing two two-person teams, a pair with dual licensure as registered nurses (RN) and paramedics (PM) vs. a single dual-licensed (RN/PM) plus a licensed paramedic, researchers found that there was a statistically significant difference between the teams with the team of 2 RNs/PMs assessing trauma patients at a lower RTS than the 1 RN/PM plus 1 PM team.[15]
Nursing, Allied Health, and Interprofessional Team Monitoring
As previously discussed, the RTS is a tool for triaging patients.[7][8][17] Although initial assessments are essential, there is a good level of evidence to support using the RTS[7] to reassess trauma patients while they are in the emergency department, demonstrating its versatility as an assessment tool for trauma patients.[17] Though most of the literature reviewed focused on physicians, nursing staff, and allied health professionals who may be responsible for reassessing patients, they can also utilize the RTS.[15]
References
Champion HR, Sacco WJ, Carnazzo AJ, Copes W, Fouty WJ. Trauma score. Critical care medicine. 1981 Sep:9(9):672-6 [PubMed PMID: 7273818]
Sacco WJ, Champion HR, Gainer PS, Morelli SA, Fallen S, Lawnick MA. The Trauma Score as applied to penetrating trauma. Annals of emergency medicine. 1984 Jun:13(6):415-8 [PubMed PMID: 6731957]
Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet (London, England). 1974 Jul 13:2(7872):81-4 [PubMed PMID: 4136544]
Long WB,Bachulis BL,Hynes GD, Accuracy and relationship of mechanisms of injury, trauma score, and injury severity score in identifying major trauma. American journal of surgery. 1986 May; [PubMed PMID: 3706634]
Level 2 (mid-level) evidence. Panel: current status of trauma severity indices. The Journal of trauma. 1983 Mar:23(3):185-201 [PubMed PMID: 6834440]
Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. The Journal of trauma. 1974 Mar:14(3):187-96 [PubMed PMID: 4814394]
Champion HR, Sacco WJ, Copes WS, Gann DS, Gennarelli TA, Flanagan ME. A revision of the Trauma Score. The Journal of trauma. 1989 May:29(5):623-9 [PubMed PMID: 2657085]
Fisher RB,Dearden CH, Improving the care of patients with major trauma in the accident and emergency department. BMJ (Clinical research ed.). 1990 Jun 16; [PubMed PMID: 2372624]
Alvarez BD, Razente DM, Lacerda DA, Lother NS, VON-Bahten LC, Stahlschmidt CM. Analysis of the Revised Trauma Score (RTS) in 200 victims of different trauma mechanisms. Revista do Colegio Brasileiro de Cirurgioes. 2016 Sep-Oct:43(5):334-340. doi: 10.1590/0100-69912016005010. Epub [PubMed PMID: 27982326]
Javali RH, Krishnamoorthy, Patil A, Srinivasarangan M, Suraj, Sriharsha. Comparison of Injury Severity Score, New Injury Severity Score, Revised Trauma Score and Trauma and Injury Severity Score for Mortality Prediction in Elderly Trauma Patients. Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine. 2019 Feb:23(2):73-77. doi: 10.5005/jp-journals-10071-23120. Epub [PubMed PMID: 31086450]
Osler T, Hales K, Baack B, Bear K, Hsi K, Pathak D, Demarest G. Trauma in the elderly. American journal of surgery. 1988 Dec:156(6):537-43 [PubMed PMID: 3202269]
Level 2 (mid-level) evidenceBoyd CR, Tolson MA, Copes WS. Evaluating trauma care: the TRISS method. Trauma Score and the Injury Severity Score. The Journal of trauma. 1987 Apr:27(4):370-8 [PubMed PMID: 3106646]
Gałązkowski R, Farkowski MM, Rabczenko D, Marciniak-Emmons M, Darocha T, Timler D, Sterliński M. Additional data from clinical examination on site significantly but marginally improve predictive accuracy of the Revised Trauma Score for major complications during Helicopter Emergency Medical Service missions. Archives of medical science : AMS. 2018 Jun:14(4):865-870. doi: 10.5114/aoms.2016.61884. Epub 2016 Aug 18 [PubMed PMID: 30002706]
Kobusingye OC, Lett RR. Hospital-based trauma registries in Uganda. The Journal of trauma. 2000 Mar:48(3):498-502 [PubMed PMID: 10744292]
Rodenberg H. The revised trauma score: a means to evaluate aeromedical staffing patterns. Aviation, space, and environmental medicine. 1992 Apr:63(4):308-13 [PubMed PMID: 1610343]
Level 2 (mid-level) evidenceManoochehry S, Vafabin M, Bitaraf S, Amiri A. A Comparison between the Ability of Revised Trauma Score and Kampala Trauma Score in Predicting Mortality; a Meta-Analysis. Archives of academic emergency medicine. 2019 Winter:7(1):e6 [PubMed PMID: 30847441]
Level 1 (high-level) evidenceGilpin DA, Nelson PG. Revised trauma score: a triage tool in the accident and emergency department. Injury. 1991 Jan:22(1):35-7 [PubMed PMID: 2030028]