Treating trauma patients require stringent planning and therapeutic resource allocation to provide optimal levels of care for injured patients. A standardized rapid assessment model not only assists with triaging injured patients but also 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. Multiple assessment tools exist and are available at this time, but the Trauma Score (TS) was initially developed to produce an accurate representation of an injured patient’s injury severity. 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. Components of the TS include respiratory rate, respiratory effort, systolic blood pressure, capillary refill time, and the Glasgow Coma Scale (GCS). Researchers found that by adding the respiratory rate and systolic blood pressure to the TS, it increased attending physicians’ suitability of the tool to assist in triaging injured patients. Multiple studies have already verified the reliability, reproducibility, and effectiveness of the TS.
Application of the TS demonstrated benefits in proper triage and mortality prediction. Accurate triage was defined as severely injured patients (those with an injury severity score [ISS] of 16 or more) transported and treated at a trauma center and mildly injured patients (those with an ISS of 15 or less) transported and treated at a nearby hospital. The TS was able to accurately triage 66% of patients who experienced blunt injuries with an overtriage rate of 8% and 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. However, the in-depth analysis revealed that if the classification of mild injury was lower (an ISS of 14 or less), there was an increase in the overtriage rates (13.6%), but there was also an inverse reduction in the undertriage rates (16.7%). Furthermore, researchers found the TS to be an accurate predictor of survival among such injured patients. While the original TS demonstrated benefits regarding the ability to accurately triage patients and predict mortality, limitations associated with the original TS provided ample room to further revise the scoring system.
Multiple studies found few disadvantages associated with the inclusions of capillary refill and respiratory expansion within the scoring system. 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 lead to the formulation of the Revised Trauma Scale (RTS), which removed the capillary refill and respiratory expansion. Additionally, there were two versions of the RTS created; one was developed specifically for triage (T-RTS) and the other for outcome evaluations and controlling for injury severity (RTS). 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.
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. Using the RTS as a triage tool assisted in reducing the treatment errors from 21 out of 36 patients (58%) to 14 out of 54 patients (26%). Additionally, researchers found that the RTS was an effective measure of predicting mortality for patients with an RTS greater than seven. Furthermore, the RTS was most useful in predicting the survival rates among patient with head injuries compared to patients with penetrating or blunt traumas.
When using the RTS to predict geriatric trauma mortality, the recommended cutoff value was identified as 7.108 with a sensitivity of 97% and a specificity of 80%. There were statistically significant differences regarding the receiving operator characteristics (ROC) curve between ISS, New Injury Severity Score (NISS),, and the Trauma and Injury Severity Score (TRISS), in predicting geriatric mortality. The measurement tool that best predicted elderly mortality, based on the ROC, was the TRISS, but the RTS was also an appropriate measurement tool to predict the same. When patients transported via Helicopter Emergency Medical Services (HEMS) were assessed using the RTS, 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 regarding the same.