Triage scoring systems, severity of illness measures, and mortality prediction models in pediatric trauma

Comparison of Scoring Systems for Mortality Prediction in Pediatric Multitrauma Patients

The aim of this study was to compare scoring systems for mortality prediction and determine the threshold values of these scoring systems in pediatric multitrauma patients. A total of 57 multitrauma patients referred to the pediatric intensive care unit from January 2020 to August 2021 were included. The pediatric trauma score (PTS), injury severity score (ISS), base deficit (B), international normalized ratio (I), Glasgow coma scale (G) (BIG) score, and pediatric risk of mortality 3 (PRISM 3) score were analyzed for all patients. Of the study group, 35% were female and 65% were male with a mean age of 72 months (interquartile range: 140). All groups' mortality ratio was 12.2%. All risk scores based on mortality prediction were statistically significant. Cutoff value for PTS was 3.5 with 96% sensitivity and 62% specificity; for the ISS, it was 20.5 with 92% sensitivity and 43% specificity; threshold of the BIG score was 17.75 with 85.7% sensitivity and 34% specificity; and 12.5 for PRISM 3 score with 87.6% sensitivity and 28% specificity. PTS, ISS, BIG score, and PRISM 3 score were accurate risk predictors for mortality in pediatric multitrauma patients. ISS was superior to PTS, PRISM 3 score, and BIG score for discrimination between survivors and nonsurvivors.

Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study

Hereby, we aimed to comprehensively compare different scoring systems for pediatric trauma and their ability to predict in-hospital mortality and intensive care unit (ICU) admission. The current registry-based multicenter study encompassed a comprehensive dataset of 6709 pediatric trauma patients aged ≤ 18 years from July 2016 to September 2023. To ascertain the predictive efficacy of the scoring systems, the area under the receiver operating characteristic curve (AUC) was calculated. A total of 720 individuals (10.7%) required admission to the ICU. The mortality rate was 1.1% (n = 72). The most predictive scoring system for in-hospital mortality was the adjusted trauma and injury severity score (aTRISS) (AUC = 0.982), followed by trauma and injury severity score (TRISS) (AUC = 0.980), new trauma and injury severity score (NTRISS) (AUC = 0.972), Glasgow coma scale (GCS) (AUC = 0.9546), revised trauma score (RTS) (AUC = 0.944), pre-hospital index (PHI) (AUC = 0.936), injury severity score (ISS) (AUC = 0.901), new injury severity score (NISS) (AUC = 0.900), and abbreviated injury scale (AIS) (AUC = 0.734). Given the predictive performance of the scoring systems for ICU admission, NTRISS had the highest predictive performance (AUC = 0.837), followed by aTRISS (AUC = 0.836), TRISS (AUC = 0.823), ISS (AUC = 0.807), NISS (AUC = 0.805), GCS (AUC = 0.735), RTS (AUC = 0.698), PHI (AUC = 0.662), and AIS (AUC = 0.651). In the present study, we concluded the superiority of the TRISS and its two derived counterparts, aTRISS and NTRISS, compared to other scoring systems, to efficiently discerning individuals who possess a heightened susceptibility to unfavorable consequences. The significance of these findings underscores the necessity of incorporating these metrics into the realm of clinical practice.

Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry

INTRODUCTION

Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values.

METHODS

We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention.

RESULTS

A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention.

CONCLUSION

The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.

Development and validation of a pediatric model predicting trauma-related mortality

OBJECTIVES

To develop a prediction model of mortality in pediatric trauma-based injuries. Our secondary objective was to transform this model into a translational tool for clinical use.

STUDY DESIGN

A retrospective cohort study of children ≤ 18 years was derived from the National Trauma Data Bank between the years of 2007 to 2015. The goal was to identify clinical or physiologic variables that would serve as predictors for pediatric death. Data was split into a development cohort (80%) to build the model and then tested in an internal validation cohort (20%) and a temporal cohort. The area under the receiver operating characteristic curve (AUC) was assessed for the new model.

RESULTS

In 693,192 children, the mortality rate was 1.4% (n = 9,785). Most subjects were male (67%), White (65%), and incurred an unintentional injury (92%). The proposed model had an AUC of 96.4% (95% CI: 95.9%-96.9%). In contrast, the Injury Severity Score yielded an AUC of 92.9% (95% CI: 92.2%-93.6%), while the Revised Trauma Score resulted in an AUC of 95.0% (95% CI: 94.4%-95.6%).

CONCLUSION

The TRAGIC + Model (Temperature, Race, Age, GCS, Injury Type, Cardiac-systolic blood pressure + Mechanism of Injury and Sex) is a new pediatric mortality prediction model that leverages variables easily obtained upon trauma admission.

Analysis of the efficacy and safety of conservative treatment of blunt abdominal trauma in children: retrospective study. Conservative treatment of blunt abdominal trauma in children

INTRODUCTION

in Brazil, trauma is responsible for 40% of deaths in the age group between 5 and 9 years old, and 18% between 1 and 4 years, and bleeding is the leading cause of preventable death in the traumatized child. Conservative management of blunt abdominal trauma with solid organs injury - started in the 60s - is the current world trend, with studies showing survival rates above 90%. The objective was to assess the efficacy and safety of conservative treatment in children with blunt abdominal trauma treated at the Clinical Hospital of the University of Campinas, in the last five years.

METHODS

retrospective analysis of medical records of patients classified by levels of injury severity, in 27 children.

RESULTS

only one child underwent surgery for initial failure of conservative treatment (persistent hemodynamic instability), resulting in a 96% overall success rate of the conservative treatment. Five other children (22%) developed late complications that required elective surgery: a bladder injury, two cases of infected perirenal collections (secondary to injury of renal collecting system), a pancreatic pseudocyst and a splenic cyst. Resolution of the complications was attained in all children, with anatomical and functional preservation of the affected organ. There were no deaths in this series.

CONCLUSION

the conservative initial approach in the treatment of blunt abdominal trauma was effective and safe with high resolution and low rate of complications leading to a high preservation rate of the affected organs. Level of evidence III - prognostic and therapeutic study.

Análise de eficácia e segurança do tratamento conservador do trauma abdominal contuso em crianças: estudo retrospectivo. Tratamento conservador de trauma abdominal contuso em crianças

RESUMO Introdução: no Brasil, o trauma é responsável por 40% dos óbitos na faixa etária entre 5 e 9 anos, e 18% entre 1 e 4 anos, e o sangramento é a principal causa de prevenção morte na criança traumatizada. O manejo conservador de trauma abdominal contuso com lesão de órgãos sólidos - iniciado na década de 60 - é a tendência mundial atual, com estudos mostrando taxas de sobrevivência acima de 90%. O objetivo do presente trabalho foi avaliar a eficácia e segurança do tratamento conservador em crianças com trauma abdominal contuso tratado no Hospital das Clínicas da Universidade de Campinas, nos últimos cinco anos. Métodos: análise retrospectiva de prontuários de pacientes classificados por níveis de gravidade da lesão, em 27 crianças. Resultados: apenas uma criança foi submetida a cirurgia por falha inicial do tratamento conservador (instabilidade hemodinâmica persistente), resultando em uma taxa de sucesso global de 96% do tratamento conservador inicial. Outras cinco crianças (22%) desenvolveram complicações tardias que exigiram cirurgias eletivas: lesão na bexiga, dois casos de coleção perirenal infectada (secundária à lesão de sistema de coleta renal), um pseudocisto pancreático e um cisto esplênico. Resolução da complicação foi atingida em todas as crianças, com preservação anatômica e funcional do órgão afetado. Não houve mortes nesta série. Conclusão: a abordagem inicial conservadora no tratamento de trauma abdominal contundente foi eficaz e segura com alta resolução e baixa taxa de complicações levando a uma alta taxa de preservação dos órgãos afetados. Nível de evidência III - estudo prognóstico e terapêutico.

Severity of Illness Scoring for Pediatric Interfacility Transport: A North American Survey

OBJECTIVE

Severity of illness scoring during pediatric critical care transport may provide objective data to determine illness trajectory and disposition and contribute to quality assurance data for pediatric transport programs. The objective of this study was to ascertain the breadth of severity of illness scoring tool application among North American pediatric critical care transport teams.

METHODS

A cross-sectional quantitative survey using REDCap was distributed to 137 North American pediatric transport programs. Baseline team characteristics were established along with questions related to severity of illness tool application.Descriptive statistics were used for analysis.

RESULTS

There were 55 responses (40%), and of those, 13 (24%) use a severity of illness scoring tool within their practice. A variety of tools were used including: Transport Risk Index of Physiologic Stability, Children's Hospital Medical Center Cincinnati, Canadian Triage and Acuity Score, Transport Risk Assessment in Pediatrics, Pediatric Early Warning Scores, Levels of Acuity, Transport Pediatric Early Warning Scores, and an unspecified tool. The timing of scoring, team personnel who applied the score, and the frequency of analysis varied between transport programs.

CONCLUSIONS

Severity of illness scoring is not consistently performed by pediatric interfacility transport programs in North America. Among the programs that use a scoring tool, there is variability in its application. There is no universally accepted or performed severity of illness scoring tool for pediatric interfacility transport.Future research to validate and standardize a pediatric transport severity of illness scoring tool for North America is necessary.

The International Classification of Disease Critical Care Severity Score demonstrates that pediatric burden of injury is similar to that of adults: Validation using the National Trauma Databank☆

BACKGROUND/PURPOSE

Resource-based severity of injury (SOI) measures, such as the International Classification of Disease (ICD) Critical Care Severity Score (ICASS), may characterize traumatic burden better than standard mortality-based measures. The purpose of this study was to validate the ICASS in a representative national-level trauma cohort and compare SOI measures between children and adults.

METHODS

The National Trauma Databank was used to derive (2008-12) and validate (2013-15) ICASS and ICD Injury Severity Scores (ICISS, standard mortality-based SOI measure). SOI metrics and outcomes were compared between pediatric, adult, and elderly age groups. Logistic regression modeling evaluated predictors of critical care resource utilization.

RESULTS

Derivation and validation cohorts consisted of 3.90 and 1.97 million patients, respectively. ICASS strongly predicted actual critical care utilization (OR 1.04, 95% CI 1.04-1.04, p<0.0001). Mean ICASS was 24.4 for children and 33.0 for adults (ratio 0.74), indicating predicted critical care utilization in children was three-quarters that of adults. In contrast, predicted pediatric mortality was less than half that of adults.

CONCLUSIONS

Mortality-based SOI measures underestimate pediatric burden of injury. This study validates ICASS and demonstrates that pediatric resource-based SOI is more similar to that of adults. ICASS is easily calculated without a trauma registry and complements mortality-based measures. Level of evidence III, retrospective comparative study.

Performance of the BIG Score in Predicting Mortality in Normotensive Children With Trauma

OBJECTIVES

Children have a larger reserve for traumatic hemorrhagic shock, requiring a score that uses physiologic variables other than hypotension. Recently, the BIG score comprising admission base deficit, international normalized ratio, and the Glasgow Coma Scale has been reported to predict traumatic mortality. We aimed to validate the performance of the BIG score in mortality prediction of normotensive children with trauma.

METHODS

We reviewed 1046 injured children (<18 years) who visited a Korean academic hospital from 2010 to 2018, excluding those with age-adjusted hypotension. In-hospital mortality, the BIG score and its predicted mortality, Revised Trauma Score, and Pediatric Trauma Score were calculated. We compared areas under the curve (AUCs) for in-hospital mortality of the 3 scores and did in-hospital and BIG-predicted mortalities.

RESULTS

Of the 1046 children, 554 were enrolled with a 4.9% in-hospital mortality rate. The median BIG score was higher in the nonsurvivors (6.4 [interquartile range, 4.4-9.2] vs 20.1 [16.5-24.8]; P < 0.001). The AUC of the BIG score was 0.94 (95% confidence interval [CI], 0.92-0.96), which was higher than that of Pediatric Trauma Score (0.87 [95% CI, 0.84-0.90]; P < 0.001). The AUC of the BIG score tended to be higher than that of Revised Trauma Score without statistical significance (0.90 [95% CI, 0.87-0.92]; P = 0.130). We noted a parallel between in-hospital and BIG-predicted mortalities. The hemorrhage-related nonsurvivors showed higher median base deficit and BIG score than did the isolated traumatic brain injury-related ones.

CONCLUSIONS

The BIG score can predict mortality with excellent accuracy in normotensive children with trauma.

Novel Trauma Composite Score is superior to Injury Severity Score in predicting mortality across all ages

BACKGROUND

Injury Severity Score (ISS) is a widely used metric for trauma research and center verification; however, it does not account for age-related physiologic parameters. We hypothesized that a novel age-based injury severity metric would better predict mortality.

METHODS

Adult patients (≥18 years) sustaining blunt trauma (BT) or penetrating trauma (PT) were abstracted from the 2010 to 2016 National Trauma Data Bank. Admission vitals, Glasgow Coma Scale, ISS, mechanism, and outcomes were analyzed. Patients with incomplete/non-physiologic vital signs were excluded. For each age: (1) a cut point analysis was used to determine the ISS with the highest specificity and sensitivity for predicting mortality and (2) a linear discriminant analysis was performed using ISS, ISS greater than 16, Trauma and Injury Severity Score, and Revised Trauma Scale to compare each scoring system's mortality prediction. A novel injury severity metric, the trauma component score (TCS), was developed for each age using significant (p < 0.05) variables selected from Abbreviated Injury Scale scores, Glasgow Coma Scale, vital signs, and gender. Receiver operator curves were developed and the areas under the curve were compared between the TCS and other systems.

RESULTS

There 777,794 patients studied (BT, 91.1%; PT, 8.9%). Blunt trauma patients were older (53.6 ± 21.3 years vs. 34.4 ± 13.8 years), had higher ISS scores (11.1 ± 8.5 vs. 8.5 ± 8.9), and lower mortality (2.9% vs. 3.4%) than PT patients (p < 0.05). When assessing the entire PT and BT cohort the optimal ISS cut point was 16. The optimal ISS was between 20 and 25 for BT younger than 70 years. For those older than 70 years, the optimal BT ISS steadily declined as age increased PT's cut point was 16 or less for all ages assessed. When the injury metrics were compared by area under the curve, our novel TCS more accurately predicted mortality across all ages in both BT and PT (p < 0.001).

CONCLUSION

Injury Severity Score is a poor mortality predictor in older patients and those sustaining penetrating trauma. The age-based TCS is a superior metric for mortality prediction across all ages.

LEVEL OF EVIDENCE

Clinical outcomes, Level IV.

Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic

BACKGROUND AND OBJECTIVES

The Covid-19 pandemic has forced mass closures of childcare facilities and schools. While these measures are necessary to slow virus transmission, little is known regarding the secondary health consequences of social distancing. The purpose of this study is to assess the proportion of injuries secondary to physical child abuse (PCA) at a level I pediatric trauma center during the Covid-19 pandemic.

METHODS

A retrospective review of patients at our center was conducted to identify injuries caused by PCA in the month following the statewide closure of childcare facilities in Maryland. The proportion of PCA patients treated during the Covid-19 era were compared to the corresponding period in the preceding two years by Fisher's exact test. Demographics, injury profiles, and outcomes were described for each period.

RESULTS

Eight patients with PCA injuries were treated during the Covid-19 period (13 % of total trauma patients), compared to four in 2019 (4 %, p < 0.05) and three in 2018 (3 %, p < 0.05). The median age of patients in the Covid-19 period was 11.5 months (IQR 6.8-24.5). Most patients were black (75 %) with public health insurance (75 %). All injuries were caused by blunt trauma, resulting in scalp/face contusions (63 %), skull fractures (50 %), intracranial hemorrhage (38 %), and long bone fractures (25 %).

CONCLUSIONS

There was an increase in the proportion of traumatic injuries caused by physical child abuse at our center during the Covid-19 pandemic. Strategies to mitigate this secondary effect of social distancing should be thoughtfully implemented.

Trauma Scores and Their Prognostic Value for the Outcome Following Pediatric Polytrauma

Purpose: The management and prognostic assessment of pediatric polytrauma patients can pose substantial challenges. Trauma scores developed for adults are not universally applicable in children. An accurate prediction of the severity of trauma and correct assessment of the necessity of surgical procedures are important for optimal treatment. Several trauma scores are currently available, but the advantages and drawbacks for use in pediatric patients are unclear. This study examines the value of the trauma scores Injury Severity Score (ISS), Pediatric Trauma Score (PTS), National Advisory Committee for Aeronautics (NACA), and Glasgow Coma Score (GCS) for the assessment of the polytraumatized child. Methods: In a retrospective study, 97 patients aged 0-17 years who presented with polytrauma and an ISS ≥16 in the trauma bay were included in the study. Patient records including radiological studies were analyzed. Pathological imaging findings and emergency surgery were assessed as outcome variables and the predictive value of the trauma scores were analyzed using receiver operator characteristic (ROC) curves. Statistical significance was set at an alpha level of P ≤ 0.05. Results: In this study, 35 of the 97 studied children had pathological cranial computed findings. These either underwent craniectomy or trepanation or a parenchymal catheter was placed for intracranial pressure monitoring. Abdominal trauma was present in 45 patients, 16 of which were treated surgically. Forty-three patients arrived with thoracic injuries, 10 of which received a thoracic drainage. One child underwent an emergency thoracotomy. Predictive accuracy for emergency surgery calculated using receiver-operator characteristic (ROC) curves was highest for ISS and NACA scores (0,732 and 0.683, respectively), and lower for GCS (0.246) and PTS (0.261). Conclusion: In our study cohort, initial ISS and NACA scores better predicted operative interventions and outcome than PTS or GCS for polytraumatized pediatric patients.

Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan

BACKGROUND

Pediatric casualties account for a notable proportion of encounters in the deployed setting based on the humanitarian medical care mission. Previously published data demonstrates that an age-adjust shock index may be a useful tool in predicting massive transfusion and death in children. We seek to determine if those previous findings are applicable to the deployed, combat trauma setting.

METHODS

We queried the Department of Defense Trauma Registry (DODTR) for all pediatric subjects admitted to US and Coalition fixed-facility hospitals in Iraq and Afghanistan from January 2007 to January 2016. This is a secondary analysis of casualties seeking to validate previously published data using the shock index, pediatric age-adjusted. We then used previously published thresholds to determine patients outcome for validation by age grouping, 1-3 years (1.2), 4-6 years (1.2), 7-12 years (1.0), 13-17 years (0.9).

RESULTS

From January 2007 through January 2016 there were 3439 pediatric casualties of which 3145 had a documented heart rate and systolic pressure. Of those 502 (16.0%) underwent massive transfusion and 226 (7.2%) died prior to hospital discharge. Receiver operating characteristic (ROC) thresholds were inconsistent across age groups ranging from 1.0 to 1.9 with generally limited area under the curve (AUC) values for both massive transfusion and death prediction characteristics. Using the previously defined thresholds for validation, we report sensitivity and specificity for the massive transfusion by age-group: 1-3 (0.73, 0.35), 4-6 (0.63, 0.60), 7-12 (0.80, 0.57), 13-17 (0.77, 0.62). For death, 1-3 (0.75, 0.34), 4-6 (0.66-0.59), 7-12 (0.64, 0.52), 13-17 (0.70, 0.57). However, negative predictive values (NPV) were generally high with all greater than 0.87.

CONCLUSIONS

Within the combat setting, the age-adjusted pediatric shock index had moderate sensitivity and relatively poor specificity for predicting massive transfusion and death. Better scoring systems are needed to predict resource needs prior to arrival, that perhaps include other physiologic metrics. We were unable to validate the previously published findings within the combat trauma population.

Inclusion of lactate level measured upon emergency room arrival in trauma outcome prediction models improves mortality prediction: a retrospective, single-center study

Background

This study aimed to develop a model for predicting trauma outcomes by adding arterial lactate levels measured upon emergency room (ER) arrival to existing trauma injury severity scoring systems.

Methods

We examined blunt trauma cases that were admitted to our hospital during 2010– 2014. Eligibility criteria were cases with an Injury Severity Score of ≥9, complete Trauma and Injury Severity Score (TRISS) variable data, and lactate levels that were assessed upon ER arrival. Survivor and non-survivor groups were compared and lactate-based prediction models were generated using logistic regression. We compared the predictive performances of traditional prediction models (Revised Trauma Score [RTS] and TRISS) and lactate-based models using the area under the curve (AUC) of receiver operating characteristic curves.

Results

We included 829 patients, and the in-hospital mortality rate among these patients was 21.6%. The model that used lactate levels and age provided a significantly better AUC value than the RTS model. The model with lactate added to the TRISS variables provided the highest Youden J statistic, with 86.0% sensitivity and 70.8% specificity at a cutoff value of 0.15, as well as the highest predictive value, with a significantly higher AUC than the TRISS.

Conclusions

These findings indicate that lactate testing upon ER arrival may help supplement or replace traditional physiological parameters to predict mortality outcomes among Korean trauma patients. Adding lactate levels also appears to improve the predictive abilities of existing trauma outcome prediction models.

Comparison of Injury Severity Score, Glasgow Coma Scale, and Revised Trauma Score in Predicting the Mortality and Prolonged ICU Stay of Traumatic Young Children: A Cross-Sectional Retrospective Study

Introduction

The purpose of this study was to examine the capacity of commonly used trauma scoring systems such as the Glasgow Coma Scale (GCS), Injury Severity Score (ISS), and Revised Trauma Score (RTS) to predict outcomes in young children with traumatic injuries.

Methods

This retrospective study was conducted for the period from 2009 to 2016 in Kaohsiung Chang Gung Memorial Medical Hospital, a level I trauma center. We included all children under the age of 6 years admitted to the hospital via the emergency department with any traumatic injury and compared the trauma scores of GCS, ISS, and RTS on patients' outcome. The primary outcomes were mortality and prolonged Intensive Care Unit (ICU) stay, with the latter defined as an ICU stay longer than 14 days. The secondary outcome was the hospital length of stay (HLOS). Receiver operating characteristic (ROC) analysis was also adopted with the value of the area under the ROC curve (AUC) for comparing trauma score prediction with patient mortality. Cutoff values from each trauma score for mortality prediction were also measured by determining the point along the ROC curve where Youden's index was maximum.

Results

We included a total of 938 patients in this study, with a mean age of 3.1 ± 1.82 years. The mortality rate was 0.9%, and 93 (9.9%) patients had a prolonged ICU stay. An elevated ISS (34 ± 19.9 vs. 5 ± 5.1, p=0.004), lower GCS (8 ± 5.0 vs. 15 ± 1.3, p=0.006), and lower RTS (5.58 ± 1.498 vs. 7.64 ± 0.640, p=0.006) were all associated with mortality. All three scores were considered to be independent risk factors of mortality and prolonged ICU stay and had a linear correlation with increased HLOS. With regard to predicting mortality, ISS has the highest AUC value (ISS: 0.975; GCS: 0.864; and RTS: 0.899). The prediction cutoff values of ISS, GCS, and RTS on mortality were 15, 11, and 7, respectively.

Conclusion

Regarding traumatic injuries in young children, worse ISS, GCS, and RTS were all associated with increased mortality, prolonged ICU stay, and longer hospital LOS. Of these scoring systems, ISS was the best at predicting mortality.

Severity of Illness Measures for Pediatric Inpatients

INTRODUCTION

Severity of illness (SOI) measures are commonly used in adults for comparison of treatment and outcomes in similar populations. Less is known about the psychometric properties of measures available to providers and healthcare systems caring for pediatric patients. The purpose of this study was to (1) identify SOI measures used for pediatric patients admitted to acute care hospitals and (2) compare the ability of two SOI measures to predict mortality and length of stay (LOS).

METHODS

Twelve instruments were identified through literature search and one, the pediatric chronic complex condition (CCC), was retained. The CCC and the Charlson/Deyo comorbidity score were applied to an 8-year retrospective, multi-institutional data set using logistic and zero-truncated negative binomial regression models.

RESULTS

Records from 199,001 children were examined. The CCC performed better for predicting mortality (odds ratio = 3.36; 95% confidence interval [CI]: 3.20-3.53) and LOS (incidence rate ratio = 2.24; 95% CI: 2.22-2.26).

CONCLUSIONS

The CCC may be preferable for predicting outcomes among pediatric inpatients. Pediatric SOI measures are not extensively developed and tested nor widely and freely available. The use of the CCC can predict mortality and LOS to guide care, resource allocation, and research for the pediatric population.

Characterizing injury severity in nonaccidental trauma: Does Injury Severity Score miss the mark?

BACKGROUND

Children suffering nonaccidental trauma (NAT) are at high risk of death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as Injury Severity Score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared with accidental trauma (AT).

METHODS

Pediatric patients younger than 16 years from the Pennsylvania state trauma registry 2000 to 2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients. Similar models were performed for head Abbreviated Injury Scale (AIS). Sensitivity analysis examined impaired functional independence at discharge as an alternate outcome.

RESULTS

Fifty thousand five hundred seventy-nine patients were included with 1,866 (3.7%) NAT patients. Nonaccidental trauma patients had a similar rate of mortality at an ISS of 13 as an ISS of 25 for AT patients. Nonaccidental trauma patients also have higher mortality for a given head AIS level (range, 1.2-fold to 5.9-fold higher). Injury Severity Score was a significantly greater predictor of mortality in AT patients (adjusted odds rations [AOR], 1.14; 95% confidence interval [CI], 1.13-1.15; p < 0.01) than NAT patients (AOR, 1.09; 95% CI, 1.07-1.12; p < 0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR, 3.48; 95% CI, 1.54-8.32; p < 0.01) than AT patients (AOR, 1.21; 95% CI, 0.95-1.45; p = 0.12). Nonaccidental trauma patients had a higher rate of impaired functional independence at any given ISS or head AIS level than AT patients.

CONCLUSION

Nonaccidental trauma patients have higher mortality and impaired function at a given ISS/head AIS than AT patients. Conventional ISS thresholds may underestimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking efforts that rely on ISS for injury characterization.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Assessment of memory functioning over two years following severe childhood traumatic brain injury: results of the TGE cohort

The aims of this study were (1) to prospectively measure memory functioning following severe childhood Traumatic Brain Injury (TBI), and its evolution over 2 years; (2) to assess demographic and medical factors associated with memory function and recovery; (3) to explore relations between memory and other TBI outcomes. Methods: Children (aged 0-15 years; n= 65) consecutively admitted in a single trauma center over a 3-year period, who survived severe non-inflicted TBI, were included in a prospective longitudinal study. Memory was assessed in 38 children aged 5-15 years at injury, using the Children's Memory Scale at 3, 12, and 24 months post-injury. Results: Mean general memory score was low at 3 months (M = 90.2, SD = 20.3) but within the normal range at 12 and 24 months (M = 100.6, SD = 23.1 and M = 108.6, SD = 24.1, respectively), with high variability. Improvement was stronger for immediate visual memory than for other memory indices. Lower general memory score was associated with higher injury severity, lower intellectual ability and functional status, higher overall disability, and ongoing education. Conclusion: Memory functioning is highly variable following severe childhood TBI, related to injury severity and functional, cognitive and educational outcomes; improvement is significant during the first-year post-injury, but varies according to the type of memory.

Prehospital Versus Trauma Center Glasgow Coma Scale in Pediatric Traumatic Brain Injury Patients

BACKGROUND

Traumatic brain injury (TBI) is a major source of morbidity and mortality in children. The Glasgow Coma Scale (GCS) can be challenging to calculate in pediatric patients. Our objective was to determine its reproducibility between prehospital providers and pediatric trauma hospital personnel.

MATERIALS AND METHODS

The institutional trauma database for a level 1 pediatric trauma center was queried for patients aged ≤18 y who presented with a TBI. Demographics, mechanism, prehospital GCS, and trauma center GCS were collected. Agreement was evaluated with weighted kappa (κ) coefficients (0 = agreement no better than that expected by chance alone, 1 = perfect agreement).

RESULTS

The inclusion criteria were met by 1711 patients, 263 of whom were aged <3 y. Prehospital GCS and trauma center GCS differed in 766 patients (44.8%). Agreement between prehospital GCS and trauma center GCS was moderate for all patients (κ = 0.61, 95% confidence interval [CI] 0.57-0.64). Agreement was slightly better than chance alone in patients with trauma center GCS between 9 and 12 y (κ = 0.09, 95% CI 0.03-0.15) and was lower for children aged 0-2 y (κ = 0.51, 95% CI 0.42-0.61) than for those aged between 3 and 18 y (κ = 0.63, 95% CI 0.59-0.66). Younger children were more likely to have score differences of at least 3 points (21.3% versus 13.6% of 3- to 18-y-olds, P < 0.001).

CONCLUSIONS

Prehospital and trauma center GCS scores frequently disagree in children, particularly in TBI patients aged <3 y and those with moderate TBI. Centers should consider the inconsistency of the pediatric GCS when triaging TBI patients.

Local vs. national: Epidemiology of pedestrian injury in a mid-Atlantic city

OBJECTIVE

Understanding pedestrian injury trends at the local level is essential for program planning and allocation of funds for urban planning and improvement. Because we hypothesize that local injury trends differ from national trends in significant and meaningful ways, we investigated citywide pedestrian injury trends to assess injury risk among nationally identified risk groups, as well as identify risk groups and locations specific to Baltimore City.

METHODS

Pedestrian injury data, obtained from the Baltimore City Fire Department, were gathered through emergency medical services (EMS) records collected from January 1 to December 31, 2014. Locations of pedestrian injuries were geocoded and mapped. Pearson's chi-square test of independence was used to investigate differences in injury severity level across risk groups. Pedestrian injury rates by age group, gender, and race were compared to national rates.

RESULTS

A total of 699 pedestrians were involved in motor vehicle crashes in 2014-an average of 2 EMS transports each day. The distribution of injuries throughout the city did not coincide with population or income distributions, indicating that there was not a consistent correlation between areas of concentrated population or concentrated poverty and areas of concentrated pedestrian injury. Twenty percent (n = 138) of all injuries occurred among children age ≤14, and 22% (n = 73) of severe injuries occurred among young children. The rate of injury in this age group was 5 times the national rate (Incident Rate Ratio [IRR] = 4.81, 95% confidence interval [CI], [4.05, 5.71]). Injury rates for adults ≥65 were less than the national average.

CONCLUSIONS

As the urban landscape and associated pedestrian behavior transform, continued investigation of local pedestrian injury trends and evolving public health prevention strategies is necessary to ensure pedestrian safety.

Validation of the age-adjusted shock index using pediatric trauma quality improvement program data

PURPOSE

In adults, shock index (SI; heart rate/systolic blood pressure) >0.9 predicts injury severity and trauma outcomes. However, age-adjusted shock index (SIPA) out-performs SI in blunt trauma patients 4-16years old. We sought to confirm these findings and expand this tool to include penetrating trauma and children aged 1-4years.

METHODS

We developed cutoff values for patients 1-3years old using age-based vital signs and queried the 2014 Pediatric Trauma Quality Improvement Program (TQIP) database for patients aged 1-16years sustaining blunt or penetrating trauma. Outcomes measured included injury severity, transfusion within 24h, intensive care unit (ICU) and hospital length of stay (LOS), and mortality. SI and SIPA were compared using Student's t-test and chi-square tests.

RESULTS

We identified 22,344 blunt and 613 penetrating trauma patients. SI was elevated in 41.3% and 40.0% of these groups, respectively, whereas SIPA was elevated in 15.6% and 19.4% of patients. SIPA was a significantly better predictor of transfusion needs, injury severity, ICU admission, ventilator use, and mortality for both blunt and penetrating trauma.

CONCLUSION

SIPA identifies severe injury and predicts transfusion needs and mortality more effectively than SI for both blunt and penetrating pediatric trauma. Further investigation should evaluate its use as a triage tool.

TYPE OF STUDY

Prognosis Study.

LEVEL OF EVIDENCE

II.

Retrospective evaluation of the BIG score to predict mortality in pediatric blunt trauma

OBJECTIVES

This study's objective was to measure the criterion validity of the BIG score (a new pediatric trauma score composed of the initial base deficit [BD], international normalized ratio [INR], and Glasgow Coma Scale [GCS]) to predict in-hospital mortality among children admitted to the emergency department with blunt trauma requiring an admission to the intensive care unit, knowing that a score <16 identifies children with a high probability of survival.

METHODS

This was a retrospective cohort study performed in a single tertiary care pediatric hospital between 2008 and 2016. Participants were all children admitted to the emergency department for a blunt trauma requiring intensive care unit admission or who died in the emergency department. The primary analysis was the association between a BIG score ≥16 and in-hospital mortality.

RESULTS

Twenty-eight children died among the 336 who met the inclusion criteria. Two hundred eighty-four children had information on the three components of the BIG score, and they were included in the primary analysis. A BIG score ≥16 demonstrated a sensitivity of 0.93 (95% confidence interval [CI]: 0.76-0.98) and specificity of 0.83 (95% CI: 0.78-0.87) to identify mortality. Using receiver operating characteristic curves, the area under the curve was higher for the BIG score (0.97; 95% IC: 0.95-0.99) in comparison to the Injury Severity Score (0.78; 95% IC: 0.71-0.85).

CONCLUSION

In this retrospective cohort, the BIG score was an excellent predictor of survival for children admitted to the emergency department following a blunt trauma.

Comparison of ISS, NISS, and RTS score as predictor of mortality in pediatric fall

Background

Studies to identify an ideal trauma score tool representing prediction of outcomes of the pediatric fall patient remains elusive. Our study was undertaken to identify better predictor of mortality in the pediatric fall patients.

Methods

Data was retrieved from prospectively maintained trauma registry project at level 1 trauma center developed as part of Multicentric Project—Towards Improving Trauma Care Outcomes (TITCO) in India. Single center data retrieved from a prospectively maintained trauma registry at a level 1 trauma center, New Delhi, for a period ranging from 1 October 2013 to 17 February 2015 was evaluated. Standard anatomic scores Injury Severity Score (ISS) and New Injury Severity Score (NISS) were compared with physiologic score Revised Trauma Score (RTS) using receiver operating curve (ROC).

Results

Heart rate and RTS had a statistical difference among the survivors to nonsurvivors. ISS, NISS, and RTS were having 50, 50, and 86% of area under the curve on ROCs, and RTS was statistically significant among them.

Conclusions

Physiologically based trauma score systems (RTS) are much better predictors of inhospital mortality in comparison to anatomical based scoring systems (ISS and NISS) for unintentional pediatric falls.

The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury?

BACKGROUND

The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS greater than 15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and Abbreviated Injury Scale (AIS) to predict mortality and define optimal thresholds of severe injury in pediatric trauma.

METHODS

Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as younger than 16 years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cutoff for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated the association between mortality and maximum AIS in each body region, controlling for age, mechanism, and nonaccidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed.

RESULTS

Included were 352,127 adults and 50,579 children. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cutoff in children was ISS greater than 25 and had a positive predictive value of 19% and negative predictive value of 99% compared to a positive predictive value of 7% and negative predictive value of 99% for ISS greater than 15 to predict mortality. In single-system-injured children, mortality was associated with head (odds ratio, 4.80; 95% confidence interval, 2.61-8.84; p < 0.01) and chest AIS (odds ratio, 3.55; 95% confidence interval, 1.81-6.97; p < 0.01), but not abdomen, face, neck, spine, or extremity AIS (p > 0.05). For multisystem injury, all body region AIS scores were associated with mortality except extremities. Sensitivity analysis demonstrated ISS greater than 23 to predict need for full trauma activation, and ISS greater than 26 to predict impaired functional independence were optimal thresholds.

CONCLUSION

An ISS greater than 25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system-injured children. These findings should be considered in benchmarking and performance improvement efforts.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma

OBJECTIVE

The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma.

METHODS

This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes.

RESULTS

We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI.

CONCLUSIONS

The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Outcome Rating Scales for Pediatric Head Injury

Intensivists, surgeons, neurologists, and others involved in pediatric intensive care units (PICUs) have an important investment in both short-and long-term outcomes of children and adolescents with head injury who are treated under their care. Outcomes are most often documented by either single-or multiple-item rating scales and are implemented both during and after hospital care. For this review, the authors have organized the content of rating scales into 6 general classes: (1) mortality prediction, (2) severity, (3) global recovery, (4) activity restrictions, (5) secondary adverse conditions, and (6) limitations in participation, quality of life, and health status. Rating scales that describe the outcomes of children and adolescents after head injury are used to monitor medical and functional recovery, guide clinical management, drive quality assurance initiatives, and conduct clinical research. The authors restrict their selective review to rating scales that describe child outcomes (vs family) and that have been reported and applied in the outcome literature. Although head injury is a major cause of mortality and short-and long-term morbidity in children and adolescents, there is no consensus on which rating scales are optimal for hospital care or community follow-up. Major considerations for clinical use are feasibility, type of outcome information needed, content breadth across multiple ages and levels of recovery, and utility in determining the short-term impact of PICU care on long-term outcome.

Pediatric trauma BIG score: Predicting mortality in polytraumatized pediatric patients

BACKGROUND

Trauma is a worldwide health problem and the major cause of death and disability, particularly affecting the young population. It is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children.

AIM OF THE WORK

This study aimed at evaluation of pediatric trauma BIG score in comparison with New Injury Severity Score (NISS) and Pediatric Trauma Score (PTS) in Tanta University Emergency Hospital.

MATERIALS AND METHODS

The study was conducted in Tanta University Emergency Hospital to all multiple trauma pediatric patients attended to the Emergency Department for 1 year. Pediatric trauma BIG score, PTS, and NISS scores were calculated and results compared to each other and to observed mortality.

RESULTS

BIG score ≥12.7 has sensitivity 86.7% and specificity 71.4%, whereas PTS at value ≤3.5 has sensitivity 63.3% and specificity 68.6% and NISS at value ≥39.5 has sensitivity 53.3% and specificity 54.3%. There was a significant positive correlation between BIG score value and mortality rate.

CONCLUSION

The pediatric BIG score is a reliable mortality-prediction score for children with traumatic injuries; it uses international normalization ratio (INR), Base Excess (BE), and Glasgow Coma Scale (GCS) values that can be measured within a few minutes of sampling, so it can be readily applied in the Pediatric Emergency Department, but it cannot be applied on patients with chronic diseases that affect INR, BE, or GCS.

The comparison of C-proteasome activity in the plasma of children after burn injury, mild head injury and blunt abdominal trauma

PURPOSE

We aimed to evaluate and compare the changes in circulating 20S proteasome activity in the plasma of children suffering from blunt abdominal trauma, thermal injury and mild head injury.

PATIENTS AND METHODS

The study population comprised 40 patients with burns, 35 children admitted due to mild head injury, and 30 children suffering from blunt abdominal trauma, who were admitted to Pediatric Surgery Department of Medical University of Bialystok Poland, between 2010 and 2014, and their parents gave informed consent, were included into the study. Patients were aged 9 months to 17 years (median=5.73±1.91y). The girls to boys ratio was nearly 1:2 (34 girls and 106 boys). Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2-6h, 12-16h, and 48h after the injury. 20 healthy children admitted for planned inguinal hernia repair served as controls.

RESULTS

In our series of patients, the C-proteasome activity was much higher 12-16h after burns, than after mild head injuries, or blunt abdominal injuries, and the difference was statistically significant (p<0.05).

CONCLUSIONS

Circulating 20S proteasome is probably released from damaged tissues in response to the injury and is a biomarker of tissue damage - more severe in the group of burnt patients in comparison to the patients with mild head injury and blunt abdominal trauma. Therefore detection of 20S proteasome may represent a novel marker of immunological activity and cellular degradation in trauma patients.

The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma

OBJECTIVES

To examine the association between in-hospital mortality and the BIG (composed of the base deficit [B], International normalized ratio [I], Glasgow Coma Scale [G]) score measured on arrival to the emergency department in pediatric blunt trauma patients, adjusted for pre-hospital intubation, volume administration, and presence of hypotension and head injury. We also examined the association between the BIG score and mortality in patients requiring admission to the intensive care unit (ICU).

STUDY DESIGN

A retrospective 2001-2012 trauma database review of patients with blunt trauma ≤ 17 years old with an Injury Severity score ≥ 12. Charts were reviewed for in-hospital mortality, components of the BIG score upon arrival to the emergency department, prehospital intubation, crystalloids ≥ 20 mL/kg, presence of hypotension, head injury, and disposition.

RESULTS

50/621 (8%) of the study patients died. Independent mortality predictors were the BIG score (OR 11, 95% CI 6-25), prior fluid bolus (OR 3, 95% CI 1.3-9), and prior intubation (OR 8, 95% CI 2-40). The area under the receiver operating characteristic curve was 0.95 (CI 0.93-0.98), with the optimal BIG cutoff of 16. With BIG <16, death rate was 3/496 (0.006, 95% CI 0.001-0.007) vs 47/125 (0.38, 95% CI 0.15-0.7) with BIG ≥ 16, (P < .0001). In patients requiring admission to the ICU, the BIG score remained predictive of mortality (OR 14.3, 95% CI 7.3-32, P < .0001).

CONCLUSIONS

The BIG score accurately predicts mortality in a population of North American pediatric patients with blunt trauma independent of pre-hospital interventions, presence of head injury, and hypotension, and identifies children with a high probability of survival (BIG <16). The BIG score is also associated with mortality in pediatric patients with trauma requiring admission to the ICU.

Designing optimal mortality risk prediction scores that preserve clinical knowledge

Many in-hospital mortality risk prediction scores dichotomize predictive variables to simplify the score calculation. However, hard thresholding in these additive stepwise scores of the form "add x points if variable v is above/below threshold t" may lead to critical failures. In this paper, we seek to develop risk prediction scores that preserve clinical knowledge embedded in features and structure of the existing additive stepwise scores while addressing limitations caused by variable dichotomization. To this end, we propose a novel score structure that relies on a transformation of predictive variables by means of nonlinear logistic functions facilitating smooth differentiation between critical and normal values of the variables. We develop an optimization framework for inferring parameters of the logistic functions for a given patient population via cyclic block coordinate descent. The parameters may readily be updated as the patient population and standards of care evolve. We tested the proposed methodology on two populations: (1) brain trauma patients admitted to the intensive care unit of the Dell Children's Medical Center of Central Texas between 2007 and 2012, and (2) adult ICU patient data from the MIMIC II database. The results are compared with those obtained by the widely used PRISM III and SOFA scores. The prediction power of a score is evaluated using area under ROC curve, Youden's index, and precision-recall balance in a cross-validation study. The results demonstrate that the new framework enables significant performance improvements over PRISM III and SOFA in terms of all three criteria.

Mortality Risk in Pediatric Motor Vehicle Crash Occupants: Accounting for Developmental Stage and Challenging Abbreviated Injury Scale Metrics

OBJECTIVE

Survival risk ratios (SRRs) and their probabilistic counterpart, mortality risk ratios (MRRs), have been shown to be at odds with Abbreviated Injury Scale (AIS) severity scores for particular injuries in adults. SRRs have been validated for pediatrics but have not been studied within the context of pediatric age stratifications. We hypothesized that children with similar motor vehicle crash (MVC) injuries may have different mortality risks (MR) based upon developmental stage and that these MRs may not correlate with AIS severity.

METHODS

The NASS-CDS 2000-2011 was used to define the top 95% most common AIS 2+ injuries among MVC occupants in 4 age groups: 0-4, 5-9, 10-14, and 15-18 years. Next, the National Trauma Databank 2002-2011 was used to calculate the MR (proportion of those dying with an injury to those sustaining the injury) and the co-injury-adjusted MR (MRMAIS) for each injury within 6 age groups: 0-4, 5-9, 10-14, 15-18, 0-18, and 19+ years. MR differences were evaluated between age groups aggregately, between age groups based upon anatomic injury patterns and between age groups on an individual injury level using nonparametric Wilcoxon tests and chi-square or Fisher's exact tests as appropriate. Correlation between AIS and MR within each age group was also evaluated.

RESULTS

MR and MRMAIS distributions of the most common AIS 2+ injuries were right skewed. Aggregate MR of these most common injuries varied between the age groups, with 5- to 9-year-old and 10- to 14-year-old children having the lowest MRs and 0- to 4-year-old and 15- to 18-year-old children and adults having the highest MRs (all P <.05). Head and thoracic injuries imparted the greatest mortality risk in all age groups with median MRMAIS ranging from 0 to 6% and 0 to 4.5%, respectively. Injuries to particular body regions also varied with respect to MR based upon age. For example, thoracic injuries in adults had significantly higher MRMAIS than such injuries among 5- to 9-year-olds and 10- to 14-year-olds (P =.04; P <.01). Furthermore, though AIS was positively correlated with MR within each age group, less correlation was seen for children than for adults. Large MR variations were seen within each AIS grade, with some lower AIS severity injuries demonstrating greater MRs than higher AIS severity injuries. As an example, MRMAIS in 0- to 18-year-olds was 0.4% for an AIS 3 radius fracture versus 1.4% for an AIS 2 vault fracture.

CONCLUSIONS

Trauma severity metrics are important for outcome prediction models and can be used in pediatric triage algorithms and other injury research. Trauma severity may vary for similar injuries based upon developmental stage, and this difference should be reflected in severity metrics. The MR-based data-driven determination of injury severity in pediatric occupants of different age cohorts provides a supplement or an alternative to AIS severity classification for pediatric occupants in MVCs.

Circulating proteasome activity following mild head injury in children

PURPOSE

The aim of the study is to characterize changes in circulating proteasome (c-proteasome) activity following mild traumatic brain injury in children.

METHODS

Fifty children managed at the Department of Pediatric Surgery because of concussion-mild head injury was randomly included into the study. The children were aged 11 months to 17 years (median = 10.07 + -1.91 years). Plasma proteasome activity was assessed using Suc-Leu-Leu-Val-Tyr-AMC peptide substrate, 2-6 h, 12-16 h, and 2 days after injury. Twenty healthy children admitted for planned inguinal hernia repair served as controls.

RESULTS

Statistically significant elevation of plasma c-proteasome activity was noted in children with mild head injury 2-6 h, 12-16 h, and 2 days after the injury.

CONCLUSIONS

Authors observed a statistically significant upward trend in the c-proteasome activity between 2-6 and 12-16 h after the mild head injury, consistent with the onset of the symptoms of cerebral concussion and a downward trend in the c-proteasome activity in the plasma of children with mild head injury between 12-16 h and on the second day after the injury, consistent with the resolving of the symptoms of cerebral concussion. Further studies are needed to demonstrate that the proteasome activity could be a prognostic factor, which can help in further diagnostic and therapeutic decisions in patients with head injury.

Evaluation of the impact of implementing the emergency medical services traumatic brain injury guidelines in Arizona: the Excellence in Prehospital Injury Care (EPIC) study methodology

Traumatic brain injury (TBI) exacts a great toll on society. Fortunately, there is growing evidence that the management of TBI in the early minutes after injury may significantly reduce morbidity and mortality. In response, evidence-based prehospital and in-hospital TBI treatment guidelines have been established by authoritative bodies. However, no large studies have yet evaluated the effectiveness of implementing these guidelines in the prehospital setting. This article describes the background, design, implementation, emergency medical services (EMS) treatment protocols, and statistical analysis of a prospective, controlled (before/after), statewide study designed to evaluate the effect of implementing the EMS TBI guidelines-the Excellence in Prehospital Injury Care (EPIC) study (NIH/NINDS R01NS071049, "EPIC"; and 3R01NS071049-S1, "EPIC4Kids"). The specific aim of the study is to test the hypothesis that statewide implementation of the international adult and pediatric EMS TBI guidelines will significantly reduce mortality and improve nonmortality outcomes in patients with moderate or severe TBI. Furthermore, it will specifically evaluate the effect of guideline implementation on outcomes in the subgroup of patients who are intubated in the field. Over the course of the entire study (~9 years), it is estimated that approximately 25,000 patients will be enrolled.

Paediatric injuries at Bugando Medical Centre in Northwestern Tanzania: a prospective review of 150 cases

BACKGROUND

Injuries continue to be the leading cause of death and disability for children. The is a paucity of published data on paediatric injuries in our local environment. This study describes the etiological spectrum, injury characteristics and treatment outcome of paediatric injuries in our local setting and provides baseline data for establishment of prevention strategies as well as treatment guidelines.

METHODS

This was a descriptive cross-sectional study involving paediatric injury patients admitted to Bugando Medical Centre from August 2011 to April 2012. Statistical data analysis was done using SPSS version 17.0 and STATA version 12.0.

RESULTS

A total of 150 patients were studied. The age of patients ranged from 1 month to 10 years with a median age of 5 years. The male to female ratio was 2.3:1. Road traffic accident was the most common cause of injury (39.3%) and motorcycle (71.2%) was responsible for the majority of road traffic accidents. Only 11 (7.3%) patients received pre-hospital care. The head /neck (32.7%) and musculoskeletal (28.0%) were the most frequent body region injured. Open wounds (51.4%), foreign bodies (31.3%) and fractures (17.3%) were the most common type of injuries sustained. The majority of patients 84 (56.0%) were treated surgically. Complication rate was 3.9%. The mean duration of hospitalization was 9.7 ± 13.1 days. Mortality rate was 12.7%. Age of the patient (< 5 years), late presentation and presence of complications were the main predictors of length of hospital stay (P < 0.001), whereas burn injuries, severe head injuries and severity of injury (Paediatric trauma score = 0-5) significantly predicted mortality (P < 0.0001).

CONCLUSION

Paediatric injuries resulting from road traffic accidents (RTAs) remain a major public health problem in this part of Tanzania. Urgent preventive measures targeting at reducing the occurrence of RTAs is necessary to reduce the incidence of paediatric injuries in this region.

Computerized decision support in adult and pediatric critical care

Computerized decision support (CDS) is the most advanced form of clinical decision support available and has evolved with innovative technologies to provide meaningful assistance to medical professionals. Critical care clinicians are in unique environments where vast amounts of data are collected on individual patients, and where expedient and accurate decisions are paramount to the delivery of quality healthcare. Many CDS tools are in use today among adult and pediatric intensive care units as diagnostic aides, safety alerts, computerized protocols, and automated recommendations for management. Some CDS use have significantly decreased adverse events and improved costs when carefully implemented and properly operated. CDS tools integrated into electronic health records are also valuable to researchers providing rapid identification of eligible patients, streamlining data-gathering and analysis, and providing cohorts for study of rare and chronic diseases through data-warehousing. Although the need for human judgment in the daily care of critically ill patients has limited the study and realization of meaningful improvements in overall patient outcomes, CDS tools continue to evolve and integrate into the daily workflow of clinicians, and will likely provide advancements over time. Through novel technologies, CDS tools have vast potential for progression and will significantly impact the field of critical care and clinical research in the future.

Current approaches to the treatment of head injury in children

Head trauma is one of the most challenging fields of traumatology and demands immediate attention and intervention by first-line clinicians. Symptoms can vary from victim to victim and according to the victim's age, leading to difficulties in making timely and accurate decisions at the point of care. In children, falls, accidents while playing, sports injuries, and abuse are the major causes of head trauma. Traffic accidents are the main cause of disability and death in adolescents and adults. Injury sites include facial bones, muscles, ligaments, vessels, joints, nerves, and focal or whole-brain injuries. Of particular importance are cranial and intracranial injuries. A closed injury occurs when the head suddenly and violently hits an object but the object does not break through the skull. A penetrating injury occurs when an object pierces the skull and affects the brain tissue. Early diagnosis and proper management are crucial to treat patients with potentially life-threatening head and neck trauma. In this review, we discuss the different cases of traumatic brain injury and summarize the current therapies and neuroprotective strategies as well as the related outcomes for children with traumatic brain injury.

Injury severity scoring systems: a review of application to practice

AIM

This study reviews the historical development of injury severity scoring systems and their application to clinical practice.

BACKGROUND

A variety of injury severity scoring systems have been developed and applied since more than four decades. It is increasingly important for nurses to be familiar with these scoring systems, their strengths and weaknesses, and their applications to nursing practice.

DESIGN

Systematic literature review.

METHODS

The injury severity scoring systems developed from the 1970s to 2011 were identified via electronic database searches, footnote chasing and contact with clinical experts. The most frequently used scoring systems in the literature were classified according to the criteria used in each scoring system.

CONCLUSIONS

All injury severity scoring systems are valuable but have certain problems. A universal scoring system applicable for various purposes appears difficult to achieve. However, the understanding and proper use of scoring systems will allow us to perform critical evaluations and continual refinement of trauma management.

RELEVANCE TO CLINICAL PRACTICE

As nurses and researchers, it is critical that we should know the application of these injury severity scoring systems to ensure their quality and appropriate utilization.

Common data elements for pediatric traumatic brain injury: recommendations from the working group on demographics and clinical assessment

The Common Data Elements (CDEs) initiative is a National Institutes of Health (NIH) interagency effort to standardize naming, definitions, and data structure for clinical research variables. Comparisons of the results of clinical studies of neurological disorders have been hampered by variability in data coding, definitions, and procedures for sample collection. The CDE project objective is to enable comparison of future clinical trials results in major neurological disorders, including traumatic brain injury (TBI), stroke, multiple sclerosis, and epilepsy. As part of this effort, recommendations for CDEs for research on TBI were developed through a 2009 multi-agency initiative. Following the initial recommendations of the Working Group on Demographics and Clinical Assessment, a separate workgroup developed recommendations on the coding of clinical and demographic variables specific to pediatric TBI studies for subjects younger than 18 years. This article summarizes the selection of measures by the Pediatric TBI Demographics and Clinical Assessment Working Group. The variables are grouped into modules which are grouped into categories. For consistency with other CDE working groups, each variable was classified by priority (core, supplemental, and emerging). Templates were produced to summarize coding formats, guide selection of data points, and provide procedural recommendations. This proposed standardization, together with the products of the other pediatric TBI working groups in imaging, biomarkers, and outcome assessment, will facilitate multi-center studies, comparison of results across studies, and high-quality meta-analyses of individual patient data.

Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma

OBJECTIVE

To develop a validated mortality prediction score for children with traumatic injuries.

PATIENTS AND METHODS

We identified all children (<18 years of age) in the US military established Joint Theater Trauma Registry from 2002 to 2009 who were admitted to combat-support hospitals with traumatic injuries in Iraq and Afghanistan. We identified factors associated with mortality using univariate and then multivariate regression modeling. The developed mortality prediction score was then validated on a data set of pediatric patients (≤ 18 years of age) from the German Trauma Registry, 2002-2007.

RESULTS

Admission base deficit, international normalized ratio, and Glasgow Coma Scale were independently associated with mortality in 707 patients from the derivation set and 1101 patients in the validation set. These variables were combined into the pediatric "BIG" score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Scale), which were each calculated to have an area under the curve of 0.89 (95% confidence interval: 0.83-0.95) and 0.89 (95% confidence interval: 0.87-0.92) on the derivation and validation sets, respectively.

CONCLUSIONS

The pediatric trauma BIG score is a simple method that can be performed rapidly on admission to evaluate severity of illness and predict mortality in children with traumatic injuries. The score has been shown to be accurate in both penetrating-injury and blunt-injury populations and may have significant utility in comparing severity of injury in future pediatric trauma research and quality-assurance studies. In addition, this score may be used to determine inclusion criteria on admission for prospective studies when accurately estimating the mortality for sample size calculation is required.

Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs

INTRODUCTION

Pediatric surgeon-directed trauma teams (STTs) provide lifesaving treatment but at a high cost. We used physiologically based criteria to improve STT utilization.

METHODS

We reviewed 152 consecutive STT activations at one center, comparing standard and physiologically focused criteria and 24-hour hospital costs/charges for overtriaged patients vs level 2 (emergency department managed) blunt trauma patients matched for age, Injury Severity Score (ISS), and necessity for operation.

RESULTS

Our cohort (73.0% male; 86.8% blunt; median age, 8.0 [interquartile range, 4.0-14.0] years) had 10 deaths (6.6%) and 18 (11.8%) emergent operations. Twenty-nine patients met neither standard nor physiologic criteria (group 1), 25 met standard but not physiologic criteria (overtriaged, group 2), and 98 met physiologic criteria (group 3). Group 3 had higher median ISS (19.0 [10.0-33.0] vs 10.0 [4.0-17.0] and 5.5 [5.0-16.75] for groups 1 and 2, P = .001), more intensive care unit admissions (67.2% vs 31.0% and 52.0%, P = .001), longer hospitalization (5.0 [3.0-9.25] days vs 3.0 [1.0-5.0] and 4.0 [2.0-5.0] days, P = .002), and all patients who died or required emergent operation (P < .001). Physiologic criteria maintained 100% sensitivity but improved specificity (49.2% vs 23.0%). Overtriaged patients (n = 18) had 78.2% higher charges ($4700; 95% confidence interval, 13.3%-180.1%; P = .013) and 53.4% higher costs ($800; 95% confidence interval, 1.8%-131.2%; P = .041) than level 2 patients (n = 259) after adjusting for age, ISS, and need for operation, largely because of computed tomography and emergency department charges (66% of overtriaged charges).

CONCLUSIONS

Physiologic STT activation criteria would have saved 25 activations, $20,000 in costs, and $120,000 in charges annually without compromising patient safety.

Disparities in trauma center access despite increasing utilization: data from California, 1999 to 2006

BACKGROUND

Although efforts have been made to address disparities in access to trauma care in the past decade, there is little evidence to show if utilization has changed. We use patient-level data to describe the changes in utilization of trauma centers (TCs) in an 8-year period in California.

METHODS

We analyzed all statewide trauma admissions (n = 752,706) using the California Office of Statewide Health Planning and Discharge Patient Discharge Database from the period of 1999 to 2006, and determined the trends in admissions and place of care.

RESULTS

The proportion of severe injuries admitted increased by 3.6% (p < 0.05), with a concomitant rise in the proportion of patients with trauma to TCs, from 39.3% (95% CI: 39.0%-39.7%) to 49.7% (49.4%-50.0%). Within the severely injured with injury severity scores (ISS) >15, 82.4% were treated in a TC if they resided in a county with a TC, compared with 30.8% of patients who did not live in a county with a TC. After adjustment, patients living greater than 50 miles away from a TC still had a likelihood ratio of 0.11 (p < 0.0001) of receiving care in a TC compared with those less than 10 miles away. Similarly, even severely injured patients not living in a county with a TC had a likelihood ratio of 0.35 (p < 0.0001) of being admitted to a TC compared with those residing in counties with TCs.

CONCLUSION

Admissions to TCs for all categories of injury severity are increasing. There remains, however, a large disparity in TC care depending on geographical distance and availability of a TC within county.

Severity of head computed tomography scan findings fail to explain racial differences in mortality following child abuse

INTRODUCTION

Differences in head injury severity may not be fully appreciated in child abuse victims. The purpose of this study was to determine if differential findings on initial head computed tomography (CT) scan could explain observed differential outcome by race.

METHODS

We identified 164 abuse patients from our trauma registry with an Injury Severity Score (ISS) > or = 15. Their initial head CT scan was graded from 1 to 4 (normal to severe). Statistical analysis was performed to asses the correlation between race, head CT grade, Glasgow Coma Scale (GCS) score, and mortality.

RESULTS

Overall mortality was 17%: 11% for white children, 32% for African-American children (P < .05). In review of the head CT scans there was no difference by race in types of injuries or head CT grade. Using a multivariate regression model, African-American race remained an independent risk factor for mortality with an odd ratio of 4.3 (95% confidence interval [CI] 1.6-11.5).

CONCLUSION

African-American children had a significantly higher mortality rate despite similar findings on initial head CT scans. Factors other than injury severity may explain these disparate outcomes.

Trauma Triage: Concepts in Prehospital Trauma Care

This report examines the efficacy of current trauma triage rules to determine the exigency of field care and transport of severely injured patients from a variety of medical populations.

Functional Status Scale: new pediatric outcome measure

OBJECTIVE

The goal was to create a functional status outcome measure for large outcome studies that is well defined, quantitative, rapid, reliable, minimally dependent on subjective assessments, and applicable to hospitalized pediatric patients across a wide range of ages and inpatient environments.

METHODS

Functional Status Scale (FSS) domains of functioning included mental status, sensory functioning, communication, motor functioning, feeding, and respiratory status, categorized from normal (score = 1) to very severe dysfunction (score = 5). The Adaptive Behavior Assessment System II (ABAS II) established construct validity and calibration within domains. Seven institutions provided PICU patients within 24 hours before or after PICU discharge, high-risk non-PICU patients within 24 hours after admission, and technology-dependent children. Primary care nurses completed the ABAS II. Statistical analyses were performed.

RESULTS

A total of 836 children, with a mean FSS score of 10.3 (SD: 4.4), were studied. Eighteen percent had the minimal possible FSS score of 6, 44% had FSS scores of >or=10, 14% had FSS scores of >or=15, and 6% had FSS scores of >or=20. Each FSS domain was associated with mean ABAS II scores (P < .0001). Cells in each domain were collapsed and reweighted, which improved correlations with ABAS II scores (P < .001 for improvements). Discrimination was very good for moderate and severe dysfunction (ABAS II categories) and improved with FSS weighting. Intraclass correlations of original and weighted total FSS scores were 0.95 and 0.94, respectively.

CONCLUSIONS

The FSS met our objectives and is well suited for large outcome studies.

A comparison of two mechanisms of severe paediatric injury in northern Israel

BACKGROUND

An increased incidence of severe injury due to falls from buildings (FFB) is reported in the rural area of northern Israel. This makes FFB, and motor vehicle collision (MVC) the two leading causes of severe paediatric trauma.

METHODS

A single-centre, age-sex matched comparison analysis of the two mechanisms of injury was conducted. Children involved in MVC (study subjects) or FFB (controls), who were brought by the Emergency Medical System Mobile-Intensive-Care-Unit from the field to the trauma bay of the Emergency Department (ED) were enrolled on the basis of a convenience sample. Immediately following ED admission, heart rate (HR), systolic blood pressure (SBP), and base deficit (BD) were recorded. Types of injuries, Glasgow Coma Score (GCS) on scene, and Injury Severity Score (ISS) were also obtained.

RESULTS

Eleven study subjects and 22 controls were enrolled during a 1-year period. The mean ISS for the study subjects group and for the controls was 23.4 and 19.5, respectively. No difference was found in comparing the ISS, BD, SBP and HR of the two groups (p=0.261, p=0.421, p=0.314, and p=0.824, respectively). Controls had a lower GCS (p<0.031) and were more likely to have a skull fracture (p<0.0082). Study subjects were more likely to have limb injuries (p<0.0001) and thoracoabdominal injuries (p<0.0059).

CONCLUSIONS

This study suggests that the Injury Severity Score of the two mechanisms of paediatric injury is high. The haemodynamic characteristics on ED admission were comparable between the two groups of patients but the likelihood of specific type of injury was different.

Paediatric trauma and trauma care in Flanders (Belgium). Methodology and first descriptive results of the PENTA registry

Paediatric injury surveillance and prevention are definite priorities for the European, Belgian, and Flemish authorities. Current available data for Flanders (Belgium) are fragmentary and out-of-date. The PENTA registry (PaEdiatric Network around TraumA) was therefore set up to obtain recent population-based data on trauma and trauma care in children and youngsters in Flanders. Data were collected prospectively in a representative sample (n = 18) of Flemish emergency departments (ED). All children (age 0-17 years) who presented at the ED in 2005 or died prehospital due to trauma were included. The registry was split into two levels. The basic A registry ('all' trauma) consisted of 30 variables, and the more exhaustive B registry ('severe trauma', defined as length of hospitalisation >48 hours, including all nonsurvivors) collected data on 291 variables. The incidence for paediatric trauma presenting at Flemish ED was approximately 119/1000/year. Further data were collected in a random sample of 7,879 cases (21.9% of 35,900 eligible patients). Of all cases, 0.8% were considered 'severe' and included in the B registry. In conclusion, the 'burden' of injury in Flanders is still enormous. PENTA provides the first population-based data about the circumstances and the extent of injury in children and youngsters for the Flemish region. In this article we present in detail the surplus value of the methods used, the difficulties encountered, and the most relevant epidemiological findings from the registry.

Despite overall low pediatric head injury mortality, disparities exist between races

BACKGROUND

To continually improve quality of care, it is important for centers caring for children with head injury to evaluate their overall outcome and that among diverse patient groups.

METHODS

Data on children with head injuries were extracted from the National Trauma Data Bank of the American College of Surgeons and our local trauma registry. Unadjusted mortality, as well as stratified analysis and logistic regression modeling, was used to evaluate overall and race-specific mortality.

RESULTS

There were 13,363 children in the National Trauma Data Base and 3111 in our database included. Our overall mortality rate compared favorably with the national data (3.2% vs 6.8%, P < .05). Our local data, however, showed a significant difference in mortality between white and African American (AA) children (2.2% vs 5.3%, P < .05), which was not identified in the national data. After stratification, the disparities by race persisted. Finally, multivariate regression modeling revealed that AA race was an independent predictor of mortality among our patient population, with an odds ratio of 3.1 (95% confidence interval, 1.2-7.8).

CONCLUSION

Despite excellent outcomes for children with head injuries, we have uncovered unsettling inequities between AA and white children. These findings support the need to evaluate outcomes among specific groups to identify disparities that require further careful investigation.