CRITICAL CARE SCORING

I. GLASGOW COMA SCALE

-based on the GCS Scale and the
- The most widely used status of the cardiovascular and
instrument for quantifying respiratory system.
neurologic impairment
- Useful for prehospital triage and A.BPs B.RR C.Resp Effort D.Capil E.G F.Cod
also for the assessment of ys lary CS ed
patient progress after arrival Refill Value
>90 10-24 14- 4
and during critical care 15
admission 70-90 25-35 11- 3
- Before scoring a patient, first 13
50-69 >35 N 8-10 2
consider interfering factors such <50 <10 N Delayed 5-7 1
as: 0/not 0/Apn Shallow/Retrac None 3-4 0
Hearing loss or speech palpab ea tions
le
impairment
Intubation or
Tracheostomy
INTERPRETATION:
Trauma Score Survival
** Since intubation or tracheostomy
Probability
makes it impossible to test a patient’s verbal 1-5 0%
response, a letter “T” is often written with 6-7 10%
the GCS score to indicate the presence of a 8-9 22-37%
tube. 10 55%
(Ex: GCS: 5T) 11 71%
12 83%
EYE VERBAL MOTOR SCORE >=13 90%
OPENING RESPONSE
Obeys 6
Commands -found to underestimate the importance of
Oriented Localized 5 head injuries.
Pain -the authors also acknowledged that
Spontaneou Confused Withdrawal 4 respiratory effort and capillary refill were
s
To Speech Inappropriate Decorticate 3 difficult to assess, thus this system was
Words revised.
To Pain Incomprehensiv Decerebrate 2
e Words III. REVISED TRAUMA SCORE
None No Response Flaccid/ No 1
Response
-now the most widely used physiologic
trauma scoring tool
GCS Scores of:
-based on the GCS, BPsys, and RR.
12-15: Don’t require ICU admission
9-12: Indicate a significant insult with
a moderate coma
<9: Severe Coma; typically requires
endotracheal intubation for airway protection
and ventilator assistance.

II. TRAUMA SCORE

 1-8 Minor
9-15 Moderate
16-24 Serious
25-49 Severe
50-74 Critical
75 Maximum

***The trauma score, RTS, and ISS are

used as pre-hospital admission scoring
**RTS < 4 proposed for transfer to trauma
systems.
center

***Triage-refers to the evaluation and

categorization of the sick or wounded
IV. INJURY SEVERITY SCORE (ISS)
when there are insufficient resources
for medical care of everyone at once
 an anatomical scoring system that
Color of tags used in triage:
provides an overall score for patients
with multiple injuries
 Black Tag- (expectant) are used for
the deceased and for those whose
BODY REGIONS SCORED: injuries are so extensive that they will
 head and neck not be able to survive given the care
 face that is available
 chest  Red Tags- (immediate) are used to
label those who cannot survive
 abdomen
without immediate treatment but who
 extremities have a chance of survival.
 external  Yellow tags- (observation) for those
who require observation (and possible
SCORING PER BODY REGION: later re-triage). Their condition is
stable for the moment and, they are
not in immediate danger of death.
0- No Injury
These victims will still need hospital
1- Minor care and would be treated
2- Moderate immediately under normal
3- Serious circumstances.
4- Severe  Green Tags- (wait) are reserved for
5- Critical the "walking wounded" who will need
6- Unsurvivable medical care at some point, after more
critical injuries have been treated.
 White tags - (dismiss) are given to
ISS= A2+B2+C2 those with minor injuries for whom a
Where A, B, and C are distinct body doctor's care is not required.
regions possessing the highest 3 severity
scores. V. CRAMS SCALE

**If an injury is assigned an AIS of 6 -used to decide which patients require

(unsurvivable injury), the ISS score is triage to a trauma center.
automatically assigned as 75.

INTERPRETATION:
 the first 32 hours following ICU
admission. The CHE component
classified patients into 4 categories
(A for excellent health, to D for
severely failing health).
 Criticisms/ Limitations: The large
number of variables (34) needed to
calculate scores, making it difficult to
use clinically, as well as the
restrictive time frame of 32 hours
allowed for data collection.
 Its use isn’t longer recommended
because of its outdated database.

B. APACHE II
 released in 1985 and incorporated a number
of changes from the original APACHE:
 These included a reduction in
the number of variables to 12.
Scores less than or equal to 8 indicate major  The weighting of other
trauma, and scores greater than or equal to variables were altered; Each
9 indicate minor trauma. variable is weighted from 0 to
4, with higher scores denoting
VI. ACUTE PHYSIOLOGY, AGE,
an increasing deviation from
CHRONIC HEALTH EVALUATION
normal.
(APACHE) SCORING SYSTEM
- COMPONENTS:
A. APACHE I 1. Acute Physiology Score
 Temperature
 The original APACHE score was first
 Mean Arterial Pressure
used in 1981 and consisted of 2
parts:  Heart Rate
 Respiratory Rate
 The acute physiology
 Oxygenation
score (APS) which
 Arterial pH
indicated the degree of
physiologic  Sodium level
derangement,  Potassium Level
 Creatinine Level
 A chronic health
evaluation (CHE) which  Hematocrit
was considered an  WBC Count
indicator of physiologic  GCS
reserve before the acute
2. Age Points
illness onset.
Less than or equal to 44 0
 Thirty-four physiological variables
45-54 2
were selected (by expert panel) and
55-64 3
assigned relative weights, using the 65-74 5
worst value for each variable within More than or equal to 75 6

3. Chronic Health Points
if patient has history of severe organ
insufficiency or is immunocompromised,
assign points as follows;
5 points for nonoperative or
emergency postoperative patients
2 points if elective
postoperative patients
**APACHE II Score= Acute Physiology Score
+ Age Points + Chronic Health points
The maximum score is 71.
-A score of 25 represents a predicted
mortality of 50% and a score of over 35
represents a predicted mortality of 80%.
0 to 4 points: 4% non-op, 1% post-op
5 to 9 points: 8% non-op, 3% post-op
10 to 14 points: 15% non-op, 7% post-op
15 to 19 points: 24% non-op, 12% post-op
20 to 24 points: 40% non-op, 30% post-op
25 to 29 points: 55% non-op, 35% post-op
30 to 34 points: Approx 73% both
>34 points: 85% non-op, 88% post-op
- - The performance of the APACHE III severity
Continues to be used more often than other systems.
-To calculate the predicted death rate:
Ln(R/1-R)= -3.517 + (Apache II) *
0.416 + Diagnostic Category Weight +
0.603 if postemergency surgery.
Predicted death rate= eLn(R/1-R)
/(1+eLn(R/1-R)
where “e” is the base of natural
logarithm, 2.718.
-Criticisms: its risk predictions are
based on old data from 1979 to 1982;
the system wasn’t designed to predict
outcome for individual patients and
particular diseases; underestimates
mortality in surgical patients; also
lacks a component to assess
accurately the full extent of acute
trauma-related illness in formerly
healthy individuals, as opposed to
patients with more chronic conditions.
-Designed for illness severity scoring
during the first day of ICU admission.
**** FOR THE APACHE II SCORING
TABLE, REFER TO THE LAST PAGE
C. APACHE III
-released in 1991
- developed with the objectives of improved
statistical power, ability to predict individual
patient outcome, and identify the factors in
ICU care that influence outcome variations.
-The weightings are far more complex than
the two previous scoring systems, but
notably are the addition of HIV and
haematological malignancy (as well as
disseminated malignancy and liver disease)
to the chronic health points.
score is slightly better than that of APACHE
II, but the former has not achieved
widespread acceptance perhaps because the
statistical analysis used to score it is under
copyright control.
- used to produce an equation predicting
hospital mortality after the first day of ICU
treatment
COMPONENTS:
age, major disease category (reason for ICU
admission), acute (current) physiology, and
prior site of healthcare (eg, hospital floor,
emergency room, etc.)
D. APACHE IV
 - Developed in 2006
- Main changes include the
improvement of the accuracy of
physiologic risk by rescaling P/F and
GCS variables, increasing the precision
of disease labeling, and the use of
more advanced statistical methods.
VII. RANCHO LOS AMIGOS- Level of
Cognitive Functioning Scale (LCFS)
**Cognition
- any form of information
processing, mental operation, or intellectual
activity such as thinking, reasoning,
remembering, imagining, or learning
- a widely accepted medical scale used
to describe the cognitive and
behavioural patterns found in brain
injury patients as they recover from
injury
- often used in conjunction with the
Glasgow Coma Scale during the initial
assessment of a brain injury patient.  assist. Uses memory device with intermittent
- However, unlike the Glasgow Coma
Scale, it is used throughout the
recovery period and not limited to the
initial assessment. It takes into
account a patient’s state of
consciousness as well as their reliance
on assistance to carry out their
cognitive and physical functions.
 Level I: No response to pain, touch,
sound or sight.
 Level II: Generalized response
regardless of type of location of
stimuli.
 Level III: Localized response. Blinks to
strong light, turns toward or away
from sound, responds to physical
discomfort, inconsistent response to
commands.
 Level IV: Confused/ agitated. Alert,
very active, aggressive or bizarre
behaviors, non-purposeful motor
movement, short attention span,
inappropriate verbalization.
Level V: Confused/inappropriate/non-
aitated. Gross attention to environment,
distractible, requires continual redirection,
agitated by too much stimuli, inappropriate
social interactions. 
Level VI: Confused/appropriate. Inconsistent
orientation, recent memory attention
impaired, follows simple directions, goal-
directed with assistance, begins to recall
past. Emerging awareness of self.
 
Level VII: Automatic/appropriate. Performs
daily routine in robot-like manner, skills
deteriorate in unfamiliar environment,
unrealistic planning. Superficial awareness.
 
Level VIII: Purposeful/appropriate. Stand-by
assist, over or under estimates abilities,
irritable, self-centered, acknowledges other's
feelings with minimal assist, low frustration
tolerance, carries out familiar tasks with
intermittent assist.
 
Level IX: Purposeful/appropriate. Stand-by
assist on request. Completes familiar tasks
independently, independently shifts between
tasks, self-monitors and anticipates problems
with stand-by assist, uses assitive memory
devices to recall schedule.
Level X: Purposeful/appropriate. Modified
independence. Handles multiple tasks
simultaneously, independently initiates and
carries out unfamiliar routines, anticipates
impact of impairments, independently thinks
about consequences of decisions, social
interaction is consistently appropriate.
References:
Handbook of Respiratory Care, 3rd edition by
Robert L. Chatburn and Eduardo Mireles-
Cabadevila
Harrison’s Principles of Internal Medicine
17th edition by Fauci,Braunwald, Kasper,
Hauser, Longo, Jameson, and Loscalzo
Wilkin’s Clinical Assessment in Respiratory
Care 7th edition by Albert J. Heuer and Craig
Scanlan
Current Critical Care Diagnosis and
Treatment 2nd edition by Frederic S. Bongard
and Darryl Y. Sue