What is the clinical significance and management of an abnormal Revised Trauma Score (RSS)?

Clinical Significance and Management of an Abnormal Revised Trauma Score (RTS)

An abnormal Revised Trauma Score (RTS) has been removed from current trauma triage guidelines due to its limited sensitivity and high rates of undertriage, and clinicians should instead rely on individual physiologic parameters and newer scoring systems for trauma patient assessment and management. 1

Understanding the Revised Trauma Score

The Revised Trauma Score (RTS) is a physiological scoring system that was developed to assess trauma severity based on three parameters:

• Glasgow Coma Scale (GCS)
• Systolic Blood Pressure (SBP)
• Respiratory Rate (RR)

Each parameter is assigned a coded value from 0-4, which is then multiplied by weighted coefficients to calculate the RTS (range: 0-12).

Limitations of the RTS

The RTS has significant limitations that have led to its removal from current trauma triage guidelines:

• Poor sensitivity: Studies show that using RTS as a sole criterion would miss substantial injury in 8-36% of seriously injured patients 1
• High undertriage rates: RTS <12 had a 25.2% rate of undertriage (predicting minor injury when ISS was >15) 1
• Poor correlation with anatomical injury: The correlation between scene RTS and Injury Severity Score (ISS) is poor (-0.29) 2
• Limited predictive accuracy: The RTS has been determined to be an insensitive triage criterion 1

Current Recommendations for Trauma Assessment

Individual Physiologic Parameters

Instead of relying on composite RTS scores, current guidelines recommend focusing on individual physiologic parameters:

• Respiratory Rate:

  • Adults and children >1 year: <10 or >29 breaths per minute
  • Infants <1 year: <20 breaths per minute 1

• Glasgow Coma Scale: Score ≤13 1

• Systolic Blood Pressure:

  • <90 mmHg for younger patients
  • <110 mmHg for patients aged 65 or older 1

Alternative Assessment Tools

Several newer scoring systems have demonstrated superior performance:

1. Geriatric Trauma Outcome Score (GTOS):

   • Formula: [age] + [2.5 × ISS] + 22 (if packed red blood cells transfused ≤24h)
   • AUC of 0.82-0.86 for predicting in-hospital mortality 1

2. Delta Shock Index (ΔSI):

   • Measures change in shock index (heart rate/systolic blood pressure)
   • ΔSI >0.1 associated with 31% increased likelihood of death 3
   • Superior predictive ability compared to traditional vital signs 3

3. MGAP Score:

   • Includes mechanism of injury, GCS, age, and blood pressure
   • Higher sensitivity and specificity for mortality prediction (AUROC 0.96) 2

Management Algorithm for Patients with Abnormal Physiologic Parameters

1. Initial Assessment:

   • Evaluate individual physiologic parameters (GCS, SBP, RR)
   • Calculate alternative scores (GTOS, Delta Shock Index) if available

2. Triage Decision:

   • Transport to Level I trauma center if any physiologic abnormalities are present
   • Consider age-adjusted parameters for elderly patients (SBP <110 mmHg, etc.)

3. Early Interventions:

   • Initiate damage control resuscitation for patients with physiologic derangements
   • Early surgical consultation for patients with severe injuries who progress to systemic toxicity 1

4. Ongoing Monitoring:

   • Frequent reassessment of physiologic parameters
   • Recalculation of scores at regular intervals while patient remains in ED 4

5. Special Considerations for Elderly Patients:

   • Lower threshold for aggressive management
   • Early involvement of palliative care team when appropriate 1
   • Evaluation of frailty using validated tools (FRAIL Questionnaire, Palliative Performance Scale) 1

Pitfalls and Caveats

• Relying solely on RTS: The RTS should not be used as the only criterion for triage decisions due to its high undertriage rate 1
• Failing to adjust for age: Elderly patients may have "normal" vital signs that actually represent significant physiologic derangement 1
• Overlooking medication effects: Beta-blockers and other medications can mask physiologic responses to trauma 3
• Delayed reassessment: Trauma scores should be recalculated at frequent intervals as patient condition may change rapidly 4
• Assuming alcohol is the only cause of altered mental status: Always consider traumatic brain injury in patients with depressed consciousness 4

By focusing on individual physiologic parameters and utilizing newer, more accurate scoring systems, clinicians can improve trauma triage decisions and optimize patient outcomes.