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Khavandegar A, Salamati P, Zafarghandi M, Rahimi-Movaghar V, Sharif-Alhoseini M, Fakharian E, Saeed-Banadaky SH, Hoseinpour V, Sadeghian F, Nasr Isfahani M, Rahmanian V, Ghadiphasha A, Pourmasjedi S, Piri SM, Mirzamohamadi S, Hassan Zadeh Tabatabaei MS, Naghdi K, Baigi V. Comparison of nine trauma scoring systems in prediction of inhospital outcomes of pediatric trauma patients: a multicenter study. Sci Rep 2024; 14:7646. [PMID: 38561381 PMCID: PMC10985103 DOI: 10.1038/s41598-024-58373-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/28/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- Armin Khavandegar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Payman Salamati
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Vafa Rahimi-Movaghar
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahdi Sharif-Alhoseini
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Esmaeil Fakharian
- Trauma Research Center, Kashan University of Medical Sciences, Kashan, Iran
| | - Seyed Houssein Saeed-Banadaky
- Trauma Research Center, Rahnemoon Hospital, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
| | - Vahid Hoseinpour
- Department of Emergency Medicine, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Farideh Sadeghian
- Center for Health-Related Social and Behavioral Sciences Research, Shahroud University of Medical Sciences, Shahroud, Iran
| | - Mehdi Nasr Isfahani
- Department of Emergency Medicine, Faculty of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
- Trauma Data Registration Center, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Vahid Rahmanian
- Research Center for Social Determinants of Health, Jahrom University of Medical Sciences, Jahrom, Iran
| | - Amir Ghadiphasha
- Shahid Modarres Hospital, Saveh University of Medical Sciences, Saveh, Iran
| | - Sobhan Pourmasjedi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Seyed Mohammad Piri
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Sara Mirzamohamadi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | | | - Khatereh Naghdi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Vali Baigi
- Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran.
- Department of Epidemiology and Biostatistics, School of Public Health, Tehran University of Medical Science, Tehran, Iran.
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Lerner EB, Drendel AL, Badawy M, Cushman JT, Fumo N, Jones CMC, Shah MN, Gourlay DM. Accuracy of the American College of Surgeons Minimum Criteria for Full Trauma Team Activation for Children. Pediatr Emerg Care 2024; 40:187-190. [PMID: 37308172 DOI: 10.1097/pec.0000000000002995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
OBJECTIVE Pediatric trauma centers use reports from emergency medical service providers to determine if a trauma team should be sent to the emergency department to prepare to care for the patient. Little scientific evidence supports the current American College of Surgeons (ACS) indicators for trauma team activation. The objective of this study was to determine the accuracy of the ACS Minimum Criteria for Full Trauma Team Activation for children as well as the accuracy of the modified criteria used at the local sites for trauma activation. METHODS Emergency medical service providers who transported an injured child aged 15 years or younger to a pediatric trauma center in 1 of 3 cities were interviewed after emergency department arrival. Emergency medical service providers were asked if each of the activation indicators were present based on their evaluation. The need for full trauma team activation was determined through a medical record review using a published criterion standard definition. Undertriage and overtriage rates and positive likelihood ratios (+LRs) were calculated. RESULTS Emergency medical service provider interviews were conducted and outcome data were obtained for 9483 children. There were 202 (2.1%) cases that met the criterion standard for need for trauma team activation. Based on the ACS Minimum Criteria, 299 (3.0%) cases should have received a trauma activation. The ACS Minimum Criteria undertriaged 44.1% and overtriaged 20% (+LR, 27.9; 95% confidence interval, 23.1-33.7). Based on the actual activation status using the local criteria, 238 cases received a full trauma activation, 45% were undertriaged, and 1.4% were overtriaged (+LR, 40.1; 95% confidence interval, 32.4-49.7). There was 97% agreement between the ACS Minimum Criteria and the actual local activation status at the receiving institution. CONCLUSIONS The ACS Minimum Criteria for Full Trauma Team Activation for children have a high rate of undertriage. Changes that individual institutions have made to improve the accuracy of activations at their institutions seem to have had a limited effect on decreasing undertriage.
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Affiliation(s)
| | - Amy L Drendel
- Section of Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Mohamed Badawy
- Section of Emergency Medicine, Department of Pediatrics, University of Texas-Southwestern, Dallas, TX
| | - Jeremy T Cushman
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - Nicole Fumo
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Courtney M C Jones
- Department of Emergency Medicine, University of Rochester, Rochester, NY
| | - Manish N Shah
- BerbeeWalsh Department of Emergency Medicine, University of Wisconsin - Madison, Madison, WI
| | - David M Gourlay
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
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Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children. J Trauma Acute Care Surg 2023; 94:295-303. [PMID: 36694336 DOI: 10.1097/ta.0000000000003693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND The American College of Surgeons (ACS) requires trauma centers to use six minimum criteria (ACS-6) for full trauma team activation. Our goal was to evaluate the effect of adding age-adjusted shock index (SI) to the ACS-6 for the prediction of severe injury among pediatric trauma patients with the hypothesis that SI would significantly improve sensitivity with an acceptable decrease in specificity. METHODS We performed a secondary analysis of prospectively collected EMS and trauma registry data from two urban pediatric trauma centers. Age-adjusted SI thresholds were calculated as heart rate divided by systolic blood pressure using 2020 Pediatric Advanced Life Support SI vital sign ranges and previously published Shock Index, Pediatric Adjusted (SIPA) thresholds. The primary outcome was a composite of emergency operative (within 1 hour of arrival) or emergency procedural intervention (EOPI) or Injury Severity Score (ISS) greater than 15. Sensitivities, specificities, and 95% CIs were calculated for the ACS-6 alone and in combination with age-adjusted SI. RESULTS There were 8,078 patients included; 20% had an elevated age-adjusted SI and 17% met at least one ACS minimum criterion; 1% underwent EOPI; and 17% had ISS >15. Sensitivity and specificity of the ACS-6 for EOPI or ISS > 5 were 45% (95% confidence interval [CI], 41-50%) and 89% (95% CI, 81-96%). Inclusion of Pediatric Advanced Life Support-SI and SIPA resulted in sensitivities of 51% (95% CI, 47-56%) and 69% (95% CI, 65-72%), and specificities of 80% (95% CI, 71-89%) and 60% (95% CI, 53-68%), respectively. Similar trends were seen for each secondary outcome. CONCLUSION In this cohort of pediatric trauma registry patients, the addition of SIPA to the ACS-6 for trauma team activation resulted in significantly increased sensitivity for EOPI or ISS greater than 15 but poor specificity. Future investigation should explore using age-adjusted shock index in a two-tiered trauma activation system, or in combination with novel triage criteria, in a population-based cohort. LEVEL OF EVIDENCE Diagnostic Tests or Criteria; Level II.
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Sung J, Yao A, Antoniou G, Cooksey R, Winters J, Ee M, Williams N. Failure to initiate trauma team activation for patients who meet the criteria in a level 1 paediatric trauma centre: which patients are missing out? ANZ J Surg 2022; 92:2628-2634. [PMID: 35833510 PMCID: PMC9796087 DOI: 10.1111/ans.17906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 06/10/2022] [Accepted: 07/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Trauma team activation (TTA) is paramount in the early hospital management of trauma patients. This study aimed to evaluate factors which contribute to failure to activate the Trauma team for management of paediatric trauma. METHODS A retrospective cohort study of Emergency Department (ED) presentations at the paediatric major trauma hospital in Adelaide, South Australia was conducted over a 16-month period. Data from the hospital's trauma registry, individual case files and digital medical records were evaluated to determine factors that were associated with no TTA. RESULTS During the study period, 617 trauma patients who met Level 1 or Level 2 TTA criteria attended the trauma centre. For 29 (4.7%) of these patients, there was no TTA. Predictors of no TTA included sustaining abdomen and/or pelvis injuries compared to limb injuries (unadjusted odds ratio [OR] = 10.59, 95% confidence interval [CI] 1.98-56.69, P = 0.006), sustaining non-accidental injury (NAI) versus an injury with vehicle involvement (OR = 30.13, 95% CI 6.43-141.21, P < 0.001), and arriving via emergency medical retrieval service compared to private vehicle (OR = 14.23, 95% CI 3.94-51.36, P < 0.001). No patients transferred directly to Paediatric Intensive Care Unit (PICU), or High Dependency Unit (HDU) received an appropriate TTA. CONCLUSION Multiple factors were associated with no TTA in paediatric trauma patients. The results highlight that even in PICU and HDU admissions and transfer patients, vigilant clarification of mechanism of injury and potential for occult injuries should be undertaken to ensure appropriate TTA and improve patient outcome.
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Affiliation(s)
- Jonghoo Sung
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Angela Yao
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia
| | - Georgia Antoniou
- Department of Orthopaedic SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Rebecca Cooksey
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Jacqueline Winters
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric MedicineWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Michael Ee
- Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia,Department of Paediatric SurgeryWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
| | - Nicole Williams
- Faculty of Health and Medical SciencesThe University of AdelaideAdelaideSouth AustraliaAustralia,Paediatric Major Trauma Service, Division of Surgical ServicesWomen's and Children's HospitalAdelaideSouth AustraliaAustralia
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National Needs Assessment for a Pediatric Trauma Toolkit: General Requirements for Moderate- and High-Volume Hospitals. J Trauma Nurs 2021; 28:378-385. [PMID: 34766932 DOI: 10.1097/jtn.0000000000000617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Optimal outcomes have been reported for children treated at pediatric trauma centers; however, most children are treated at nonpediatric trauma centers or nonpediatric general hospitals. Hospitals that are not verified or designated pediatric trauma centers may lack the training and level of comfort and skill when treating severely injured children. OBJECTIVE This study focused on identifying common pediatric guidelines for standardization across all trauma centers to inform a pediatric trauma toolkit. METHODS A needs assessment survey was developed highlighting the guidelines from an expert committee review. The purpose of the survey was to prioritize needed items for the development of a pediatric trauma toolkit. Professional trauma organizations distributed the survey to their respective memberships to ensure good representation of people who care for traumatically injured children and work in trauma centers. Deidentified survey results were analyzed with frequencies and descriptive statistics provided. Data were compared by hospital trauma verification level using a chi-square test. The value of p < .05 was considered statistically significant. RESULTS A total of 303 people responded to the survey. The majority of respondents reported a high value in the creation of a pediatric trauma toolkit for the guidelines that were included. There was variability in the reported access to the guidelines, indicating a significant need for the toolkit development and dissemination. CONCLUSION As expected, Level III centers reported the largest gaps in access to standardized pediatric guidelines and demonstrated high levels of interest and need.
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Pediatric trauma triage: A Pediatric Trauma Society Research Committee systematic review. J Trauma Acute Care Surg 2020; 89:623-630. [PMID: 32301877 DOI: 10.1097/ta.0000000000002713] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Significant variability exists in the triage of injured children with most systems using mechanism of injury and/or physiologic criteria. It is not well established if existing triage criteria predict the need for intervention or impact morbidity and mortality. This study evaluated existing evidence for pediatric trauma triage. Questions defined a priori were as follows: (1) Do prehospital trauma triage criteria reduce mortality? (2) Do prehospital trauma scoring systems predict outcomes? (3) Do trauma center activation criteria predict outcomes? (4) Do trauma center activation criteria predict need for procedural or operative interventions? (5) Do trauma bay pediatric trauma scoring systems predict outcomes? (6) What secondary triage criteria for transfer of children exist? METHODS A structured, systematic review was conducted, and multiple databases were queried using search terms related to pediatric trauma triage. The literature search was limited to January 1990 to August 2019. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was applied with the methodological index for nonrandomized studies tool used to assess the quality of included studies. Qualitative analysis was performed. RESULTS A total of 1,752 articles were screened, and 38 were included in the qualitative analysis. Twelve articles addressed questions 1 and 2, 21 articles addressed question 3 to 5, and five articles addressed question 6. Existing literature suggest that prehospital triage criteria or scoring systems do not predict or reduce mortality, although selected physiologic parameters may. In contrast, hospital trauma activation criteria can predict the need for procedures or surgical intervention and identify patients with higher mortality; again, physiologic signs are more predictive than mechanism of injury. Currently, no standardized secondary triage/transfer protocols exist. CONCLUSION Evidence supporting the utility of prehospital triage criteria for injured children is insufficient, while physiology-based trauma system activation criteria do appropriately stratify injured children. The absence of strong evidence supports the need for further prehospital and secondary transfer triage-related research. LEVEL OF EVIDENCE Systematic review study, level II.
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Need for surgeon presence: Continuing to Re-Think pediatric trauma triage strategies. Am J Surg 2020; 221:19-20. [PMID: 33187629 DOI: 10.1016/j.amjsurg.2020.10.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/24/2022]
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Pek JH, Ong YKG, Quek ECS, Feng XYJ, Allen JC, Chong SL. Evaluation of the criteria for trauma activation in the paediatric emergency department. Emerg Med J 2019; 36:529-534. [PMID: 31326954 DOI: 10.1136/emermed-2018-207857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 06/26/2019] [Accepted: 07/03/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Trauma team activation criteria have a variable performance in the paediatric population. We aimed to identify predictors for high-level resource utilisation during trauma resuscitation in the ED. METHODS A retrospective study was conducted in the ED of a tertiary paediatric hospital. Patient data were collected from trauma surveillance registry and analysis was performed to identify significant predictors. We then assessed the sensitivity and specificity of proposed models with respect to observed patient outcomes. RESULTS Among 11 282 cases, the mean age was 6.1±4.9 (SD) years old. Fall was the most common mechanism of injury in 7364 (65.3%) patients. Eighty-eight (0.8%) patients required at least one high-level resource. Significant predictors for high-resource utilisation were overall GCS of <14 (relative risk (RR) 38.841, 95% CI 21.328 to 70.739, p<0.001), high-risk mechanisms of fall from height and motor vehicle collision (RR 7.863, 95% CI 4.687 to 13.192, p<0.001), as well as age-specific tachycardia (RR 1.796, 95% CI 1.145 to 2.817, p=0.0108). A model consisting of GCS and high-risk mechanism would under-triage 21 (0.2%) patients and over-triage 681 (6.0%) patients. When age-specific tachycardia was added, 8 (0.1%) less patients would be under-triaged but an additional 3251 (28.9%) patients would be over-triaged. CONCLUSION As utilisation of high-level resources in paediatric trauma was rare, it was difficult to find an appropriate balance between under-triage and over-triage. Between the two, minimising the proportion of under-triage is more important as patient safety is paramount in paediatric trauma care.
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Affiliation(s)
- Jen Heng Pek
- Department of Emergency Medicine, Sengkang General Hospital, Singapore, Singapore
| | - Yong-Kwang Gene Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | - En Ci Samuel Quek
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
| | | | - John Carson Allen
- Centre for Quantitative Medicine, Duke-NUS Medical School, Singapore, Singapore
| | - Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore
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