Use of the BIG score to predict mortality in pediatric trauma

Validation of motor component of Glasgow coma scale in lieu of total Glasgow coma scale as a pediatric trauma field triage tool

INTRODUCTION

Prehospital trauma triage and disability assessment of pediatric patients can be challenging on the field, especially in the pre-verbal age group. It would be useful if the same triage tool and criteria can be used for both adults and children to risk-stratify the need of higher acuity of trauma care.

STUDY OBJECTIVE

We aimed to investigate if using only the motor component of Glasgow Coma Scale (mGCS), as a quick field trauma triage tool, was non-inferior to total GCS (tGCS), and if mGCS <6 was non-inferior to tGCS <14, in predicting the need for intensive care or mortality in the pediatric population.

METHODS

We performed a retrospective review of patients <18-years-old, who presented to our emergency department (ED) with moderate (Injury Severity Score (ISS) 9-15) to severe (ISS > 15) traumatic injuries from January 2012 to December 2021. Using ED triage data, mortality and the need for intensive care unit (ICU) admission were used as surrogate outcomes to investigate if mGCS <6 was non-inferior to tGCS <14, and the area-under-the-receiver-operating-characteristic curve (AUROC) was used as a measure of comparability.

RESULTS

Among 582 included for analysis, the median age was 7-years-old (2-12), and most were male (63.4%). 22.4% patients demised or required ICU care. mGCS <6 had an AUROC of 0.75 (95% CI 0.70 to 0.79), which was non-inferior to tGCS <14; AUROC 0.76, (95% CI 0.72 to 0.81), for identifying children requiring ICU management or demised. The results shown here were based on the AUROCs that were used to evaluate the discriminatory ability of tGCS <14 and mGCS <6 in prediction of mortality and the need for ICU care.

CONCLUSION

Our study showed that mGCS was significantly associated with tGCS, and was non- inferior to the latter as a triage tool in pediatric trauma. It validated the use of mGCS <6 in lieu of tGCS <14 in the pre-hospital field triage of pediatric patients, in identification of children at risk of death or requiring ICU care. Larger prospective, observational studies using on-scene data would be required for more robust validation and determine optimal cut-offs.

How significant is the BIG score in childhood traumatic brain injury?

BACKGROUND

This study aims to evaluate the reliability of the BIG score in predicting mortality in children with traumatic brain injury (TBI) and to compare it with the literature and other scoring systems.

METHODS

Patients who were followed up in the Pediatric Intensive Care Unit (PICU) for TBI between 2014 and 2019 in a tertiary reference hospital were evaluated retrospectively.

RESULTS

One hundred fifty-nine patients met the inclusion criteria. The most common injury mechanisms were falling from a height (39.6%). The mortality rate was 12.6% (n = 20). The mean BIG score, ISS, and PRISM III were statistically significantly higher in the mortality group (p < 0.001). The AUC values found in the ROC analysis in the whole study group, respectively, 0.962 (CI 0.920-0.986) for the BIG score, 0.952 (CI 0.906-0.979) for the ISS, 0.957 (CI 0.913-0.983) for the GCS, and 0.981 (CI 0.946-0.996) for the PRISM III. In the patients with isolated TBI, the AUC value for the BIG score was 0.988 (0.967-1.000) and higher than the ISS and PRISM 3 [0.983 (0.956-1.000), 0.969 (0.932-1.000) respectively]). The cut-off point for the BIG score in the whole group was 19 (sensitivity 95%, specificity 88%, positive predictive value 0.58, negative predictive value 0.99). In logistic regression model, we found that BIG score is an independent variable for mortality (AOR:1.4, 95%CI 1.22-1.63).

CONCLUSION

In children with traumatic brain injury, the BIG score is simple, quickly calculated, and a good predictor of mortality and disease severity. Prospective studies with more extensive series are needed on this subject.

Polytrauma in Children

BACKGROUND

Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room.

METHODS

This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered.

RESULTS

Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial.

CONCLUSION

4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

From Death Triad to Death Tetrad-The Addition of a Hypotension Component to the Death Triad Improves Mortality Risk Stratification in Trauma Patients: A Retrospective Cohort Study

The death triad, including coagulopathy, hypothermia, and acidosis, is shown to be a strong predictor of mortality in trauma patients. We aimed to investigate whether the inclusion of hypotension, defined as systolic blood pressure (SBP) < 60 mmHg, as a fourth factor in the death triad would comprise a death tetrad to help stratify mortality risk in trauma patients. A total of 3361 adult trauma patients between 1 January 2009 and 31 December 2019 were allocated into groups to investigate whether hypotension matters in determining the mortality outcome of trauma patients who possess 1−3 death triad components compared to those without any component. Hypotension was added to the death tetrad, and the adjusted mortality outcome was compared among groups with 0−4 death tetrad components. Herein, we showed that SBP < 60 mmHg could be used to identify patients at risk of mortality among patients with one or two death triad components. Patients with one, two, and three death tetrad components had respective adjusted mortality rates of 3.69-, 10.10-, and 40.18-fold, determined by sex, age, and comorbidities. The mortality rate of trauma patients with all the four death tetrad components was 100%. The study suggested that hypotension, defined as an SBP < 60 mmHg, may act as a proper death tetrad component to stratify the mortality risk of trauma patients.

Ten-year in-hospital mortality trends among Japanese injured patients by age, injury severity, injury mechanism, and injury region: A nationwide observational study

The Injury Severity Score (ISS) is widely used in trauma research worldwide. An ISS cutoff value of ≥16 is frequently used as the definition of severe injury in Japan. The mortality of patients with ISS ≥16 has decreased in recent years, owing to the developing the trauma care system. This study aimed to analyze the prevalence, in-hospital mortality, and odds ratio (OR) for mortality in Japanese injured patients by age, injury mechanism, injury region, and injury severity over 10 years. This study used the Japan Trauma Data Bank (JTDB) dataset, which included 315,614 patients registered between 2009 and 2018. 209,290 injured patients were utilized. This study evaluated 10-year trends of the prevalence and in-hospital mortality and risk factors associated with in-hospital mortality. The overall in-hospital mortality was 10.5%. During the 10-year study period in Japan, the mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases (p <0.001). Moreover, the mortality risk of patients with ISS ≥26 was significantly higher than that of patients with ISS 0–15 and 16–25 (p <0.001, OR = 0.05 and p<0.001, OR = 0.22). If we define injured patients who are expected to have a mortality rate of 20% or more as severely injured, it may be necessary to change the injury severity definition according to reduction of trauma mortality as ISS cutoff values to ≥26 instead of ≥16. From 2009 to 2018, the in-hospital mortality trend among all injured patient groups with ISS 0–15, 16–25, and ≥26 showed significant decreases in Japan. Differences were noted in mortality trends and risks according to anatomical injury severity.