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Hanna S, Montmayeur J, Vergnaud E, Orliaguet G. Prognosis and assessment of the predictive value of severity scores in paediatric abdominal trauma: A French national cohort study. Eur J Anaesthesiol 2024; 41:632-640. [PMID: 38769943 DOI: 10.1097/eja.0000000000002019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2024]
Abstract
BACKGROUND Paediatric closed abdominal trauma is common, however, its severity and influence on survival are difficult to determine. No prognostic score integrating abdominal involvement exists to date in paediatrics. OBJECTIVES To evaluate the severity and short-term and medium-term prognosis of closed abdominal trauma in children, and the performance of severity scores in predicting mortality. DESIGN Retrospective, cohort, observational study. SETTING AND PARTICIPANTS Patients aged 0 to 18 years presenting at the trauma room of a French paediatric Level I Trauma Centre over the period 2015 to 2019 with an isolated closed abdominal trauma or as part of a polytrauma. MAIN OUTCOMES Primary outcome was the six months mortality. Secondary outcomes were related complications and therapeutic interventions, and performance for predicting mortality of the scores listed. Paediatric Trauma Score (PTS), Revised Trauma Score (RTS), Shock Index Paediatric Age-adjusted (SIPA) score, Reverse shock index multiplied by Glasgow Coma Scale score (rSIG), Base Deficit, International Normalised Ratio, and Glasgow Coma Scale (BIG), Injury Severity Score (ISS) and Trauma Score and the Injury Severity (TRISS) score. DATA COLLECTION Data collected include clinical, biological and CT scan data at admission, first 24 h management and prognosis. The PTS, RTS, SIPA, rSIG, BIG and ISS scores were calculated and mortality was predicted according to BIG score and TRISS methodology. RESULTS Of 1145 patients, 149 met the inclusion criteria and 12 (8.1%) died. Of the 12 deceased patients, 11 (91.7%) presented with severe head injury, 11 (91.7%) had blood products transfusion and 7 received tranexamic acid. ROC curves analysis concluded that PTS, RTS, rSIG and BIG scores accurately predict mortality in paediatric closed abdominal trauma with AUCs at least 0.92. The BIG score offered the best predictive performance for predicting mortality at a threshold of 24.8 [sensitivity 90%, specificity 92%, negative-predictive value (NPV) 99%, area under the curve (AUC) 0.93]. CONCLUSION PEVALPED is the first French study to evaluate the prognosis of paediatric closed abdominal trauma. The use of PTS, rSIG and BIG scores are relevant from the acute phase and the pathophysiological interest and accuracy of the BIG score make it a powerful tool for predicting mortality of closed abdominal trauma in children.
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Affiliation(s)
- Sidonie Hanna
- From the Department of Paediatric Anaesthesia and Intensive Care, Necker-Enfants Malades University Hospital, AP-HP Centre - University of Paris, France (SH, JM, EV, GO)
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Az A, Dogan Y, Sogut O, Akdemir T. Comparison of the BIG Score and Pediatric Trauma Score for Predicting Mortality. Pediatr Emerg Care 2024:00006565-990000000-00516. [PMID: 39190391 DOI: 10.1097/pec.0000000000003267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/28/2024]
Abstract
OBJECTIVES The BIG score (base deficit + [2.5 × international normalized ratio] + [15 - Glasgow Coma Score]) was compared with the Pediatric Trauma Score (PTS) for predicting mortality in pediatric patients with multiple trauma. METHODS This retrospective, single-center study included 318 consecutive pediatric patients (aged 1-18 years) with multiple trauma who were admitted to the emergency department between January 1, 2021, and December 31, 2023. The demographic characteristics, clinical characteristics, and trauma scores (BIG score and PTS) were compared between survivors and nonsurvivors to identify factors associated with mortality. RESULTS A PTS of 7 had 100% sensitivity and 81.03% specificity for predicting mortality, with an area under the curve of 0.97 (95% confidence interval 0.9-0.99). Although the positive predictive value (PPV) was low (33.7%), the negative predictive value (NPV) was 100%. A BIG score of 13.7 was identified as the cutoff for mortality, with 92.86% sensitivity and 95.52% specificity (area under the curve 0.98, 95% confidence interval 0.96-0.99). The PPV was 66.7% and the NPV was 99.3%. CONCLUSIONS Both the PTS and the BIG score were strong predictors of mortality in pediatric patients with multiple trauma. The BIG score had a higher specificity and PPV, whereas a PTS of 7 had 100% sensitivity and a higher NPV.
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Affiliation(s)
- Adem Az
- From the Department of Emergency Medicine, University of Health Sciences, Haseki Research and Training Hospital, Istanbul, Türkiye
| | - Yunus Dogan
- Department of Emergency MedicineMus State Hospital, Mus, Türkiye
| | - Ozgur Sogut
- From the Department of Emergency Medicine, University of Health Sciences, Haseki Research and Training Hospital, Istanbul, Türkiye
| | - Tarik Akdemir
- From the Department of Emergency Medicine, University of Health Sciences, Haseki Research and Training Hospital, Istanbul, Türkiye
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Miura S, Katsuta T, Nakamura Y. Predictive biomarker of mortality in children with infectious diseases: a nationwide data analysis. Front Pediatr 2024; 12:1381310. [PMID: 39015209 PMCID: PMC11250247 DOI: 10.3389/fped.2024.1381310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2024] [Accepted: 06/10/2024] [Indexed: 07/18/2024] Open
Abstract
Biomarkers play a crucial role in the early identification of high-risk children with infectious diseases. Despite their importance, few studies evaluated biomarkers' capabilities in predicting mortality. The aim of this study was to evaluate the biomarkers' predictive capabilities for mortality in children with infectious diseases. From an inpatient database covering ≥200 acute-care hospitals in Japan, we included children who underwent blood culture, and received antimicrobial treatment between 2012 and 2021. Biomarkers' results from the day of the initial blood culture were used. Biomarker discriminative capabilities were assessed using the area under receiver operating characteristic curves (AUCs). Of 11,365 eligible children with presumed infection, 1,378 (12.1%) required mechanical ventilation or vasoactive agents within 2 days of blood culture, and 100 (0.9%) died during admission. Of all children, 10,348 (91.1%) had community-onset infections and 1,017 (8.9%) had hospital-onset infections. C-reactive protein and white blood cell demonstrated limited discriminatory capabilities with AUCs of 0.44 [95% confidence interval (CI): 0.38-0.51] and 0.45 (95% CI: 0.39-0.52). In contrast, pH, prothrombin time-international normalized ratio, and procalcitonin exhibited strong discriminatory capabilities with AUCs of 0.77 (95% CI: 0.65-0.90), 0.77 (95% CI: 0.70-0.84) and 0.76 (95% CI: 0.29-1.00). In conclusions, our real-world data analysis suggested that C-reactive protein and white blood cell may not be reliable indicators for predicting mortality in children with presumed infection. These findings could warrant future studies exploring promising biomarkers, including those from blood gas analyses, coagulation studies and procalcitonin.
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Affiliation(s)
- Shinya Miura
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
- Graduate School of Public Health, Teikyo University, Tokyo, Japan
| | - Tomohiro Katsuta
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yukitsugu Nakamura
- Department of Pediatrics, St. Marianna University School of Medicine, Kawasaki, Japan
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Ulgen Tekerek N, Cebisli E, Erkan M, Koker A, Dursun O. How significant is the BIG score in childhood traumatic brain injury? Childs Nerv Syst 2024; 40:1827-1831. [PMID: 38358429 DOI: 10.1007/s00381-024-06315-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 02/06/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND This study aims to evaluate the reliability of the BIG score in predicting mortality in children with traumatic brain injury (TBI) and to compare it with the literature and other scoring systems. METHODS Patients who were followed up in the Pediatric Intensive Care Unit (PICU) for TBI between 2014 and 2019 in a tertiary reference hospital were evaluated retrospectively. RESULTS One hundred fifty-nine patients met the inclusion criteria. The most common injury mechanisms were falling from a height (39.6%). The mortality rate was 12.6% (n = 20). The mean BIG score, ISS, and PRISM III were statistically significantly higher in the mortality group (p < 0.001). The AUC values found in the ROC analysis in the whole study group, respectively, 0.962 (CI 0.920-0.986) for the BIG score, 0.952 (CI 0.906-0.979) for the ISS, 0.957 (CI 0.913-0.983) for the GCS, and 0.981 (CI 0.946-0.996) for the PRISM III. In the patients with isolated TBI, the AUC value for the BIG score was 0.988 (0.967-1.000) and higher than the ISS and PRISM 3 [0.983 (0.956-1.000), 0.969 (0.932-1.000) respectively]). The cut-off point for the BIG score in the whole group was 19 (sensitivity 95%, specificity 88%, positive predictive value 0.58, negative predictive value 0.99). In logistic regression model, we found that BIG score is an independent variable for mortality (AOR:1.4, 95%CI 1.22-1.63). CONCLUSION In children with traumatic brain injury, the BIG score is simple, quickly calculated, and a good predictor of mortality and disease severity. Prospective studies with more extensive series are needed on this subject.
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Affiliation(s)
- Nazan Ulgen Tekerek
- Pediatric Intensive Care Unit, Faculty of Medicine, Department of Child Health and Diseases Secretariat, Akdeniz University, Akdeniz University Hospital, Dumlupınar Boulevard, Campus, H Block 2 Floor, 07070, Antalya, Turkey.
| | - Erdem Cebisli
- Pediatric Intensive Care Unit, Antalya Training, and Research Hospital, Antalya, Turkey
| | - Mine Erkan
- Department of Pediatrics, Faculty of Medicine, Akdeniz University, Antalya, Turkey
| | - Alper Koker
- Pediatric Intensive Care Unit, Akdeniz University School of Medicine, Antalya, Turkey
| | - Oguz Dursun
- Pediatric Intensive Care Unit, Akdeniz University School of Medicine, Antalya, Turkey
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Ciorba MC, Maegele M. Polytrauma in Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:291-297. [PMID: 38471125 DOI: 10.3238/arztebl.m2024.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room. METHODS This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered. RESULTS Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial. CONCLUSION 4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.
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Affiliation(s)
- Monica Christine Ciorba
- Department of Orthopedics, Trauma Surgery and Sports Traumatology, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Campus, Cologne, Germany
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Arsenault V, Lieberman L, Akbari P, Murto K. Canadian tertiary care pediatric massive hemorrhage protocols: a survey and comprehensive national review. Can J Anaesth 2024; 71:453-464. [PMID: 38057534 DOI: 10.1007/s12630-023-02641-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 06/27/2023] [Accepted: 07/09/2023] [Indexed: 12/08/2023] Open
Abstract
PURPOSE Hemorrhage is the leading cause of pediatric death in trauma and cardiac arrest during surgery. Adult studies report improved patient outcomes using massive hemorrhage protocols (MHPs). Little is known about pediatric MHP adoption in Canada. METHODS After waived research ethics approval, we conducted a survey of Canadian pediatric tertiary care hospitals to study MHP activations. Transfusion medicine directors provided hospital/patient demographic and MHP activation data. The authors extracted pediatric-specific MHP data from requested policy/procedure documents according to seven predefined MHP domains based on the literature. We also surveyed educational and audit tools. The analysis only included MHPs with pediatric-specific content. RESULTS The survey included 18 sites (100% response rate). Only 13/18 hospitals had pediatric-specific MHP content: eight were dedicated pediatric hospitals, two were combined pediatric/obstetrical hospitals, and three were combined pediatric/adult hospitals. Trauma was the most common indication for MHP activation (54%), typically based on a specific blood volume anticipated/transfused over time (10/13 sites). Transport container content was variable. Plasma and platelets were usually not in the first container. There was little emphasis on balanced plasma/platelet to red-blood-cell ratios, and most sites (12/13) rapidly incorporated laboratory-guided goal-directed transfusion. Transfusion thresholds were consistent with recent guidelines. All protocols used tranexamic acid and eight sites used an audit tool. DISCUSSION/CONCLUSION Pediatric MHP content was highly variable. Activation demographics suggest underuse in nontrauma settings. Our findings highlight the need for a consensus definition for pediatric massive hemorrhage, a validated pediatric MHP activation tool, and prospective assessment of blood component ratios. A national pediatric MHP activation repository would allow for quality improvement metrics.
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Affiliation(s)
- Valérie Arsenault
- Division of Transfusion Medicine, Department of Laboratory Medicine, University of Montreal, Montreal, QC, Canada
- Centre Hospitalier Universitaire (CHU) Sainte-Justine, Mother and Child Hospital of Montreal, Montreal, QC, Canada
| | - Lani Lieberman
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto General Hospital, Toronto, ON, Canada
| | - Pegah Akbari
- Department of Physical Therapy, University of Toronto, Toronto, ON, Canada
| | - Kimmo Murto
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, ON, Canada.
- Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Rd., Ottawa, ON, K1H 8L1, Canada.
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Lammers D, Williams J, Conner J, Francis A, Prey B, Marenco C, Morte K, Horton J, Barlow M, Escobar M, Bingham J, Eckert M. Utilization of Machine Learning Approaches to Predict Mortality in Pediatric Warzone Casualties. Mil Med 2024; 189:345-351. [PMID: 35730578 DOI: 10.1093/milmed/usac171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 05/19/2022] [Accepted: 05/27/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Identification of pediatric trauma patients at the highest risk for death may promote optimization of care. This becomes increasingly important in austere settings with constrained medical capabilities. This study aimed to develop and validate predictive models using supervised machine learning (ML) techniques to identify pediatric warzone trauma patients at the highest risk for mortality. METHODS Supervised learning approaches using logistic regression (LR), support vector machine (SVM), neural network (NN), and random forest (RF) models were generated from the Department of Defense Trauma Registry, 2008-2016. Models were tested and compared to determine the optimal algorithm for mortality. RESULTS A total of 2,007 patients (79% male, median age range 7-12 years old, 62.5% sustaining penetrating injury) met the inclusion criteria. Severe injury (Injury Severity Score > 15) was noted in 32.4% of patients, while overall mortality was 7.13%. The RF and SVM models displayed recall values of .9507 and .9150, while LR and NN displayed values of .8912 and .8895, respectively. Random forest (RF) outperformed LR, SVM, and NN on receiver operating curve (ROC) analysis demonstrating an area under the ROC of .9752 versus .9252, .9383, and .8748, respectively. CONCLUSION Machine learning (ML) techniques may prove useful in identifying those at the highest risk for mortality within pediatric trauma patients from combat zones. Incorporation of advanced computational algorithms should be further explored to optimize and supplement the diagnostic and therapeutic decision-making process.
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Affiliation(s)
- Daniel Lammers
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - James Williams
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Jeff Conner
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Andrew Francis
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Beau Prey
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Christopher Marenco
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Kaitlin Morte
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - John Horton
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Meade Barlow
- Department of Pediatric Surgery, Mary Bridge Children's Hospital, Tacoma, WA 98405, USA
| | - Mauricio Escobar
- Department of Pediatric Surgery, Mary Bridge Children's Hospital, Tacoma, WA 98405, USA
| | - Jason Bingham
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
| | - Matthew Eckert
- Department of General Surgery, Madigan Army Medical Center, Tacoma, WA 98431, USA
- Department of Surgery, University of North Carolina Medical Center, Chapel Hill, NC 27514, USA
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Evans M, Rajasekaran K, Murala A, Moreira A. Development and validation of a pediatric model predicting trauma-related mortality. BMC Pediatr 2023; 23:637. [PMID: 38110884 PMCID: PMC10726606 DOI: 10.1186/s12887-023-04437-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 11/20/2023] [Indexed: 12/20/2023] Open
Abstract
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.
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Affiliation(s)
- Mary Evans
- McGovern Medical School, 6431 Fannin St, Houston, TX, 77030, USA
| | - Karthik Rajasekaran
- Department of Otorhinolaryngology, Penn Medicine, Hospital of the University of Pennsylvania, 800 Walnut St, 18Th Floor, Philadelphia, PA, 19107, USA
| | - Anish Murala
- Texas A&M University, Administration Building, 400 Bizzell St, College Station, TX, 77843, USA
| | - Alvaro Moreira
- Neonatology Regenerative and Precision Medicine Laboratory, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA.
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Bai X, Wang R, Zhang C, Wen D, Ma L, He M. The prognostic value of an age-adjusted BIG score in adult patients with traumatic brain injury. Front Neurol 2023; 14:1272994. [PMID: 38020644 PMCID: PMC10656741 DOI: 10.3389/fneur.2023.1272994] [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: 08/05/2023] [Accepted: 10/09/2023] [Indexed: 12/01/2023] Open
Abstract
Background The base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score was previously developed to predict the outcomes of pediatric trauma patients. We designed this study to explore and improve the prognostic value of the BIG score in adult patients with traumatic brain injury (TBI). Methods Adult patients diagnosed with TBI in a public critical care database were included in this observational study. The BIG score was calculated based on the Glasgow Coma Scale (GCS), the international normalized ratio (INR), and the base deficit. Logistic regression analysis was performed to confirm the association between the BIG score and the outcome of included patients. Receiver operating characteristic (ROC) curves were drawn to evaluate the prognostic value of the BIG score and novel constructed models. Results In total, 1,034 TBI patients were included in this study with a mortality of 22.8%. Non-survivors had higher BIG scores than survivors (p < 0.001). The results of multivariable logistic regression analysis showed that age (p < 0.001), pulse oxygen saturation (SpO2) (p = 0.032), glucose (p = 0.015), hemoglobin (p = 0.047), BIG score (p < 0.001), subarachnoid hemorrhage (p = 0.013), and intracerebral hematoma (p = 0.001) were associated with in-hospital mortality of included patients. The AUC (area under the ROC curves) of the BIG score was 0.669, which was not as high as in previous pediatric trauma cohorts. However, combining the BIG score with age increased the AUC to 0.764. The prognostic model composed of significant factors including BIG had the highest AUC of 0.786. Conclusion The age-adjusted BIG score is superior to the original BIG score in predicting mortality of adult TBI patients. The prognostic model incorporating the BIG score is beneficial for clinicians, aiding them in making early triage and treatment decisions in adult TBI patients.
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Affiliation(s)
- Xue Bai
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Cuomaoji Zhang
- Department of Anesthesiology, Affiliated Sport Hospital of Chengdu Sport University, Chengdu, Sichuan, China
| | - Dingke Wen
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Min He
- Department of Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Park S, Wang IJ, Yeom SR, Park SW, Cho SJ, Yang WT, Tae W, Huh U, Song C, Kim Y, Park JH, Cho Y. Usefulness of the BIG Score in Predicting Massive Transfusion and In-Hospital Death in Adult Trauma Patients. Emerg Med Int 2023; 2023:5162050. [PMID: 37881258 PMCID: PMC10597729 DOI: 10.1155/2023/5162050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/14/2023] [Accepted: 09/19/2023] [Indexed: 10/27/2023] Open
Abstract
The base deficit (B), international normalized ratio (I), and Glasgow coma scale (GCS) (BIG) score is useful in predicting mortality in pediatric trauma patients; however, studies on the use of BIG score in adult patients with trauma are sparse. In addition, studies on the correlation between the BIG score and massive transfusion (MT) have not yet been conducted. This study aimed to evaluate the predictive value of BIG score for mortality and the need for MT in adult trauma patients. This retrospective study used data collected between 2016 and 2020 at our hospital's trauma center and registry. The predictive value of BIG score was compared with that of the Injury Severity Score (ISS) and Revised Trauma Score (RTS). Logistic regression analysis was carried out to assess whether BIG score was an independent risk factor. Receiver operating characteristic (ROC) curve analysis was performed, and predictive values were evaluated by measuring the area under the ROC curve (AUROC). In total, 5,605 patients were included in this study. In logistic regression analysis, BIG score was independently associated with in-hospital mortality (odds ratio (OR): 1.1859; 95% confidence interval (CI): 1.1636-1.2086) and MT (OR: 1.0802; 95% CI: 1.0609-1.0999). The AUROCs of BIG score for in-hospital mortality and MT were 0.852 (0.842-0.861) and 0.848 (0.838-0.857), respectively. Contrastingly, the AUROCs of ISS and RTS for in-hospital mortality were 0.795 (0.784-0.805) and 0.859 (0.850-0.868), respectively. Moreover, AUROCs of ISS and RTS for MT were 0.812 (0.802-0.822) and 0.838 (0.828-0.848), respectively. The predictive value of BIG score for mortality and MT was significantly higher than that of the ISS. The BIG score also showed a better AUROC for predicting in-hospital mortality compared with RTS. In conclusion, the BIG score is a useful indicator for predicting mortality and the need for MT in adult trauma patients.
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Affiliation(s)
- Sejun Park
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Il Jae Wang
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Seok-Ran Yeom
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Sung-Wook Park
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Suck Ju Cho
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Wook Tae Yang
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Wonwoong Tae
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Up Huh
- Department of Thoracic and Cardiovascular Surgery, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Chanhee Song
- Medical Research Institute, Pusan National University, Busan 49241, Republic of Korea
| | - Yeaeun Kim
- Department of Health Care Management, Catholic University of Pusan, Busan 46252, Republic of Korea
| | - Jong-Hwan Park
- Health Convergence Medicine Laboratory, Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
| | - Youngmo Cho
- Department of Emergency Medicine, School of Medicine, Pusan National University and Biomedical Research Institute, Pusan National University Hospital, Busan 49241, Republic of Korea
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Toida C, Muguruma T, Gakumazawa M, Shinohara M, Abe T, Takeuchi I. Validation of the Conventional Trauma and Injury Severity Score and a Newly Developed Survival Predictive Model in Pediatric Patients with Blunt Trauma: A Nationwide Observation Study. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1542. [PMID: 37761503 PMCID: PMC10529461 DOI: 10.3390/children10091542] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023]
Abstract
To date, there is no clinically useful prediction model that is suitable for Japanese pediatric trauma patients. Herein, this study aimed to developed a model for predicting the survival of Japanese pediatric patients with blunt trauma and compare its validity with that of the conventional TRISS model. Patients registered in the Japan Trauma Data Bank were grouped into a derivation cohort (2009-2013) and validation cohort (2014-2018). Logistic regression analysis was performed using the derivation dataset to establish prediction models using age, injury severity, and physiology. The validity of the modified model was evaluated by the area under the receiver operating characteristic curve (AUC). Among 11 predictor models, Model 1 and Model 11 had the best performance (AUC = 0.980). The AUC of all models was lower in patients with survival probability Ps < 0.5 than in patients with Ps ≥ 0.5. The AUC of all models was lower in neonates/infants than in other age categories. Model 11 also had the best performance (AUC = 0.762 and 0.909, respectively) in patients with Ps < 0.5 and neonates/infants. The predictive ability of the newly modified models was not superior to that of the current TRISS model. Our results may be useful to develop a highly accurate prediction model based on the new predictive variables and cutoff values associated with the survival mortality of injured Japanese pediatric patients who are younger and more severely injured by using a nationwide dataset with fewer missing data and added valuables, which can be used to evaluate the age-related physiological and anatomical severity of injured patients.
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Affiliation(s)
- Chiaki Toida
- Department of Emergency Medicine, Teikyo University School of Medicine, Tokyo 173-8606, Japan
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
| | - Takashi Muguruma
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
| | - Masayasu Gakumazawa
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
| | - Mafumi Shinohara
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
| | - Takeru Abe
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
| | - Ichiro Takeuchi
- Department of Emergency Medicine, Yokohama City University Graduate School of Medicine, Yokohama 232-0024, Japan; (T.M.); (M.G.); (M.S.); (T.A.); (I.T.)
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The Use of Blood in Pediatric Trauma Resuscitation. CURRENT SURGERY REPORTS 2023. [DOI: 10.1007/s40137-023-00356-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
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Wright AM, Ramage L, Barratt J, Grier G, Hughes A. A narrative review of damage control resuscitation for paediatric trauma patients in Iraq and Afghanistan from 2001 to 2016. TRAUMA-ENGLAND 2023. [DOI: 10.1177/14604086231152661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Introduction Requirement for blood transfusion in the injured paediatric civilian population is rare. Therefore, a substantial evidence base underpinning damage control resuscitation (DCR) in paediatric patients is lacking. Published outcome data originating from Iraq and Afghanistan offer a unique opportunity to study large cohorts of children who received DCR. It is hoped that by collating the data, this review will inform pre-deployment medical training and support the development of paediatric specific DCR guidelines, which can be used in all trauma environments. Methodology A comprehensive search of the literature was conducted using online databases, grey literature searching and screening of reference lists. Papers discussing blood product, crystalloid or tranexamic acid (TXA) administration in paediatric patients injured in Iraq and Afghanistan from 2001to present were included. Results Eighteen papers were included – all were retrospective studies of data from military trauma databases. Most children that received massive transfusion were male (73.4%), injured in Afghanistan (69.9%) by explosives (60.4%) with a median age of 9 years. A definition of paediatric massive transfusion of 40 ml/kg of all blood products within 24 h was developed. Massive transfusion rates were high (15.7% of children). Whole blood administration occurred in 4% of patients requiring blood transfusions. Low crystalloid volumes in combination with balanced blood product ratios were associated with improved survival, along with the use of whole blood and TXA. Conclusion The review offers insight into the paediatric population likely to require DCR and the optimal DCR strategies to be used in their management.
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Affiliation(s)
- Annie Mae Wright
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, The Institute of Prehospital Care, London, UK
| | - Lisa Ramage
- Emergency Department, Addenbrookes Hospital, Magpas Air Ambulance, Queen Mary University of London, London, UK
| | - Jon Barratt
- Academic Department of Military Emergency Medicine, University Hospitals of the North Midlands NHS Trust, East Anglian Air Ambulance, Queen Mary University of London, London, UK
| | - Gareth Grier
- Royal London Hospital, Queen Mary University London, Centre for Excellence Project Lead, Essex and Herts Air Ambulance, London, UK
| | - Amy Hughes
- Bart's Health NHS Trust, Essex and Herts Air Ambulance, Queen Mary University of London, Essex, UK
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Cohen N, Davis AL, Test G, Singer–Harel D, Pasternak Y, Beno S, Scolnik D. Evaluation of activation criteria in paediatric multi-trauma. Paediatr Child Health 2023; 28:17-23. [PMID: 36865755 PMCID: PMC9971577 DOI: 10.1093/pch/pxac085] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 07/21/2022] [Indexed: 11/14/2022] Open
Abstract
Objective To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. Methods A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. Results We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Conclusions Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients.
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Affiliation(s)
- Neta Cohen
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Adrienne L Davis
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Gidon Test
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Dana Singer–Harel
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Yehonatan Pasternak
- Division of Clinical Immunology and Allergy, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Suzanne Beno
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Scolnik
- Division of Paediatric Emergency Medicine, Department of Paediatrics, SickKids, University of Toronto, Toronto, Ontario, Canada
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15
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Modifications of Glasgow Coma Scale—a Systematic Review. Indian J Surg 2023. [DOI: 10.1007/s12262-023-03678-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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16
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Abbas Q, Zeeshan A, Jawwad M, Moazzam M, Yousafzai M. BIG score and its comparison with different scoring systems for mortality prediction in children with severe traumatic brain injury admitted in pediatric intensive care unit. J Pediatr Neurosci 2023. [DOI: 10.4103/jpn.jpn_16_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
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17
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Phillips R, Shahi N, Acker SN, Meier M, Shirek G, Stevens J, Recicar J, Moulton S, Bensard D. Not as simple as ABC: Tools to trigger massive transfusion in pediatric trauma. J Trauma Acute Care Surg 2022; 92:422-427. [PMID: 34538826 DOI: 10.1097/ta.0000000000003412] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early and accurate identification of pediatric trauma patients who will receive massive transfusion (MT) is not well established. We developed the ABCD (defined as penetrating mechanism, positive focused assessment with sonography for trauma, shock index, pediatric age-adjusted [SIPA], lactate, and base deficit [BD]) and BIS scores (defined as a combination of BD, international normalized ratio [INR], and SIPA) and hypothesized that the BIS score would perform best in the ability to predict the need for MT in children. METHODS Pediatric trauma patients (≤18 years old) admitted to our trauma center between 2008 and 2019 were identified. Using a receiver operator curve, we defined cutoff points for lactate (≥3.2), BD (≤-6.9), and INR (≥1.4). ABCD scores were calculated by combining penetrating mechanism; positive focused assessment with sonography for trauma examination; SIPA; lactate; and BD. BIS scores were calculated by combining BD, INR, and SIPA. The sensitivity, specificity, and accuracy of each score were calculated based on receiving MT. RESULTS Seven hundred seventy-two patients were included, of which 59 (7.6%) underwent MT. The best predictor of receiving MT was achieved by a BIS score of ≥2 that was 98% sensitive and 23% specific with an area under the curve of 0.81. The ABCD score of ≥2 was 97% sensitive and 20% specific with an area under the curve of 0.77. CONCLUSION The BIS score, which takes into account derangements in acidosis, coagulopathy, and SIPA, is accurate and easy to perform and can be incorporated into a simple bedside screening tool for triggering MT in pediatric trauma patients. LEVEL OF EVIDENCE Diagnostic Tests or Criteria, Level IV.
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Affiliation(s)
- Ryan Phillips
- From the Division of Pediatric Surgery (R.P., N.S., S.N.A., G.S., J.S., J.R., S.M., D.B.), Children's Hospital Colorado; Department of Surgery (R.P., N.S., S.N.A., G.S., J.S., S.M., D.B.) and Center for Research in Outcomes for Children's Surgery (M.M.), Center for Children's Surgery, University of Colorado School of Medicine; Division of Nursing (J.R.), Children's Hospital Colorado, Aurora; and Department of Surgery (D.B.), Denver Health Medical Center, Denver, Colorado
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Yoon TJ, Ko Y, Lee J, Huh Y, Kim JH. Performance of the BIG Score in Predicting Mortality in Normotensive Children With Trauma. Pediatr Emerg Care 2021; 37:e1582-e1588. [PMID: 32555014 DOI: 10.1097/pec.0000000000002122] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Tae Jin Yoon
- From the Department of Emergency, Department of Trauma Surgery, Ajou University School of Medicine, Suwon, Korea
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19
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Cirks BT, Rajnik M, Madden KB, Otollini M. Pediatric Infectious Diseases Encountered During Wartime Part II: Infectious Diseases Complications in the Individual Pediatric Patient. Curr Infect Dis Rep 2021. [DOI: 10.1007/s11908-021-00771-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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20
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Keskey RC, Hampton DA, Biermann H, Cirone J, Zakrison TL, Cone JT, Wilson KL, Slidell MB. Novel Trauma Composite Score is a more reliable predictor of mortality than Injury Severity Score in pediatric trauma. J Trauma Acute Care Surg 2021; 91:599-604. [PMID: 33871405 DOI: 10.1097/ta.0000000000003235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The equivalent Injury Severity Score (ISS) cutoffs for severe trauma vary between adult (ISS, >16) and pediatric (ISS, >25) trauma. We hypothesized that a novel injury severity prediction model incorporating age and mechanism of injury would outperform standard ISS cutoffs. METHODS The 2010 to 2016 National Trauma Data Bank was queried for pediatric trauma patients. Cut point analysis was used to determine the optimal ISS for predicting mortality for age and mechanism of injury. Linear discriminant analysis was implemented to determine prediction accuracy, based on area under the curve (AUC), of ISS cutoff of 25 (ISS, 25), shock index pediatric adjusted (SIPA), an age-adjusted ISS/abbreviated Trauma Composite Score (aTCS), and our novel Trauma Composite Score (TCS) in blunt trauma. The TCS consisted of significant variables (Abbreviated Injury Scale, Glasgow Coma Scale, sex, and SIPA) selected a priori for each age. RESULTS There were 109,459 blunt trauma and 9,292 penetrating trauma patients studied. There was a significant difference in ISS (blunt trauma, 9.3 ± 8.0 vs. penetrating trauma, 8.0 ± 8.6; p < 0.01) and mortality (blunt trauma, 0.7% vs. penetrating trauma, 2.7%; p < 0.01). Analysis of the entire cohort revealed an optimal ISS cut point of 25 (AUC, 0.95; sensitivity, 0.86; specificity, 0.95); however, the optimal ISS ranged from 18 to 25 when evaluated by age and mechanism. Linear discriminant analysis model AUCs varied significantly for each injury metric when assessed for blunt trauma and penetrating trauma (penetrating trauma-adjusted ISS, 0.94 ± 0.02 vs. ISS 25, 0.88 ± 0.02 vs. SIPA, 0.62 ± 0.03; p < 0.001; blunt trauma-adjusted ISS, 0.96 ± 0.01 vs. ISS 25, 0.89 ± 0.02 vs. SIPA, 0.70 ± 0.02; p < 0.001). When injury metrics were assessed across age groups in blunt trauma, TCS and aTCS performed the best. CONCLUSION Current use of ISS in pediatric trauma may not accurately reflect injury severity. The TCS and aTCS incorporate both age and mechanism and outperform standard metrics in mortality prediction in blunt trauma. LEVEL OF EVIDENCE Retrospective review, level IV.
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Affiliation(s)
- Robert C Keskey
- From the Department of Surgery (R.C.K., D.A.H., T.L.Z., J.T.C., K.L.W., M.B.S.), Section of Trauma and Acute Care Surgery (D.A.H., T.L.Z., J.T.C., K.L.W.), University of Chicago Medicine, Chicago, Illinois; Emory School of Medicine (H.B.), Atlanta, Georgia; Department of Surgery (J.C.), Dartmouth-Hitchcock, Lebanon, New Hampshire; and Section of Pediatric Surgery (M.B.S.), Comer Children's Hospital, University of Chicago Medicine, Chicago, Illinois
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Ko Y, Kim JH, Hwang K, Lee J, Huh Y. Comparison of Base Deficit and Vital Signs as Criteria for Hemorrhagic Shock Classification in Children with Trauma. Yonsei Med J 2021; 62:352-358. [PMID: 33779089 PMCID: PMC8007427 DOI: 10.3349/ymj.2021.62.4.352] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 11/30/2022] Open
Abstract
PURPOSE Base deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma. MATERIALS AND METHODS We retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1-6.0 mmol/L; III, 6.1-10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13-17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels. RESULTS In total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods. CONCLUSION BD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.
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Affiliation(s)
- Yura Ko
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyungjin Hwang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea.
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Huh Y, Ko Y, Hwang K, Jung K, Cha YH, Choi YJ, Lee J, Kim JH. Admission Lactate and Base Deficit in Predicting Outcomes of Pediatric Trauma. Shock 2021; 55:495-500. [PMID: 32890310 DOI: 10.1097/shk.0000000000001652] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND To compare admission lactate and base deficit (BD), which physiologically reflect early hemorrhagic shock, as outcome predictors of pediatric trauma. METHODS We reviewed the data of children with trauma who visited a Korean academic hospital from 2010 through 2018. Admission lactate and BD were compared between children with and without primary outcomes. The outcomes included in-hospital mortality, early (≤24 h) transfusion, and early surgical interventions for the torso or major vessels. Subsequently, performances of lactate and BD in predicting the outcomes were compared using receiver operating characteristic curves. Logistic regressions were conducted to identify the independent associations of the two markers with each outcome. RESULTS Of the 545 enrolled children, the mortality, transfusion, and surgical interventions occurred in 7.0%, 43.5%, and 14.9%, respectively. Cutoffs of lactate and BD for each outcome were as follows: mortality, 5.1 and 6.7 mmol/L; transfusion, 3.2 and 4.9 mmol/L; and surgical interventions, 2.9 and 5.2 mmol/L, respectively. No significant differences were found in the areas under the curve for each outcome. Of the two markers, a lactate of >5.1 mmol/L was associated with mortality (adjusted odds ratio, 6.43; 95% confidence interval, 2.61-15.84). A lactate of >3.2 mmol/L (2.82; 1.65-4.83) and a BD of >4.9 mmol/L (2.32; 1.32-4.10) were associated with transfusion, while only a BD of >5.2 mmol/L (2.17; 1.26-3.75) was done with surgical interventions. CONCLUSIONS In pediatric trauma, lactate is more strongly associated with mortality. In contrast, BD may have a marginally stronger association with the need for hemorrhage-related procedures.
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Affiliation(s)
- Yo Huh
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Yura Ko
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Kyungjin Hwang
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Kyoungwon Jung
- Division of Trauma Surgery, Department of Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Yoon-Ho Cha
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Yoo Jin Choi
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jisook Lee
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Jung Heon Kim
- Department of Emergency Medicine, Ajou University School of Medicine, Suwon, Korea
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23
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Comparison of Trauma Severity Scores (ISS, NISS, RTS, BIG Score, and TRISS) in Multiple Trauma Patients. J Trauma Nurs 2021; 28:100-106. [PMID: 33667204 DOI: 10.1097/jtn.0000000000000567] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Trauma severity scoring systems are routinely used to monitor trauma patient outcomes. Yet, the most accurate scoring system remains an elusive target. OBJECTIVE We aim to compare trauma severity scales (ISS, NISS, RTS, TRISS, and BIG) in multitrauma patients and investigate BIG as one of the new trauma severity scoring systems. METHODS The demographic data of the patients, vital signs, injury mechanisms, body regions exposed to trauma, final diagnosis, the injury severity scales-Injury Severity Score (ISS), New Injury Severity Score (NISS), Revised Trauma Score (RTS), base deficit, international normalized ratio, and Glasgow Coma Scale (BIG), and Trauma and Injury Severity Score (TRISS)-the length of stay in hospital, and the progress of the patients were examined. RESULTS A total of 426 cases were included in the study. The best performing score in determining mortality was TRISS (area under the curve [AUC]: 0.93, sensitivity 97.1% and specificity 76.7%). This was followed by the NISS, BIG, ISS, and RTS, respectively. For the prediction of intensive care unit admission, the NISS was the most successful with an AUC value of 0.81. There was a significant relationship in terms of the length of stay in all trauma scores (p < .05). CONCLUSIONS The most successful score in predicting mortality in trauma patients was the TRISS, whereas the NISS was the most successful in predicting intensive care unit admission. The newly developed BIG score can be used as a strong scoring method for predicting prognosis in trauma patients.
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Keneally RJ, Meyers BA, Shields CH, Ricca R, Creamer KM. Pediatric Thoracic Trauma Mortality in Iraq and Afghanistan Compared to the United States National Trauma Data Bank. Mil Med 2021; 187:e338-e342. [PMID: 33506871 DOI: 10.1093/milmed/usab020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/08/2020] [Accepted: 01/18/2021] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION The authors compared pediatric thoracic patients in the Joint Theatre Trauma Registry (JTTR) to those in the National Trauma Data Bank (NTDB) to assess differences in patient mortality rates and mortality risk accounting for age, injury patterns, and injury severity. MATERIALS AND METHODS Patients less than 19 years of age with thoracic trauma were identified in both the JTTR and NTDB. Multiple logistic regression, χ2, Student's t-test, or Mann-Whitney U test were used as indicated to compare the two groups. RESULTS Pediatric thoracic trauma patients seen in Iraq and Afghanistan (n = 955) had a significantly higher mortality rate (15.1 vs. 6.0%, P <.01) than those in the NTDB (n = 9085). After controlling for covariates between the JTTR and the NTDB, there was no difference in mortality (odds ratio for mortality for U.S. patients was 0.74, 95% CI 0.52-1.06, P = .10). The patients seen in Iraq or Afghanistan were significantly younger (8 years old, interquartile ratio (IQR) 2-13 vs. 15, IQR 10-17, P <.01) had greater severity of injuries (injury severity score 17, IQR 12-26 vs. 12, IQR 8-22, P <.01), had significantly more head injuries (29 vs. 14%, P <.01), and over half were exposed to a blast. DISCUSSION Pediatric patients with thoracic trauma in Iraq and Afghanistan in the JTTR had similar mortality rates compared to the civilian population in the NTDB after accounting for confounding covariates. These findings indicate that deployed military medical professionals are providing comparable quality of care in extremely challenging circumstances. This information has important implications for military preparedness, medical training, and casualty care.
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Affiliation(s)
- Ryan J Keneally
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC 20052, USA.,Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Brittney A Meyers
- Department of Anesthesiology and Critical Care Medicine, The George Washington University, Washington, DC 20052, USA
| | - Cynthia H Shields
- Department of Anesthesiology, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Robert Ricca
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Kevin M Creamer
- Department of Pediatrics, The George Washington University, Washington, DC 20052, USA
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Neff LP, Beckwith MA, Russell RT, Cannon JW, Spinella PC. Massive Transfusion in Pediatric Patients. Clin Lab Med 2020; 41:35-49. [PMID: 33494884 DOI: 10.1016/j.cll.2020.10.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Massive transfusion in pediatric patients is infrequent but associated with much higher mortality than in adults. Blood transfusion and hematology has conceptualized ideas such as blood failure and the interplay of the blood-endothelium interface to understand coagulopathy in the context of hemorrhagic shock. Researchers are still searching for an appropriate definition of what constitutes a pediatric massive transfusion. There is no universally accepted protocol for massive transfusion and how to address the many complications that can arise. Pharmacologic adjuncts to resuscitation may prove beneficial in reducing coagulopathy during pediatric massive transfusion, but high-quality evidence has not yet emerged.
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Affiliation(s)
- Lucas P Neff
- Department of General Surgery, Section of Pediatric Surgery, Wake Forest University School of Medicine, 5th Floor, Watlington Hall, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
| | - Michael Aaron Beckwith
- Division of Trauma and Acute Care Surgery, Department of Surgery, University of Alabama at Birmingham, 1922 7th Avenue South, KB 120, Birmingham, AL 35294, USA
| | - Robert T Russell
- Pediatric General Surgery, Division of Pediatric Surgery, Department of Surgery, University of Alabama at Birmingham, 1600 7th Avenue South, Lowder, Suite 300, Birmingham, AL 35233, USA
| | - Jeremy W Cannon
- Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Penn Presbyterian Medical Center, 51 North 39th Street, Suite 120 MOB, Philadelphia, PA 19104, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, The Washington University of Saint Louis, 4905 Children's Place, St Louis, MO 63110, USA
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Bianchi W, George T, McEvoy C, Piehl M, Manzano A, Boboc M, Zarow GJ, Natarajan R, Gaspary MJ, Auten J, Roszko PJD. Intravenous and Intraosseous Blood Transfusion With Three Different Pediatric Pressure Transfusion Strategies in an Immature Swine (Sus scrofa) Model of Hemorrhagic Shock: A Pilot Study. Mil Med 2020; 185:121-129. [PMID: 32074308 DOI: 10.1093/milmed/usz200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Exsanguination remains the leading cause of preventable death in military conflicts, and pediatric casualties are common. Transfusion is crucial to preserve life, but vascular access is challenging in children, so intraosseous (IO) access is often required. However, the optimal transfusion method is unclear. There was therefore the need for feasibility testing of a model for contrasting the efficacy of blood infusion devices via intravenous (IV) and IO access in immature swine with bone densities similar to children. MATERIALS AND METHODS Eighteen immature swine (21 ± 1 kg) were bled 31% of estimated blood volume and then received autologous blood delivered by pressure bag, push-pull (PP), or LifeFlow Rapid Infuser via IO (15-gauge IO needle placed in the humeral head) or IV (auricular 20-gauge), with monitoring for 60 minutes. RESULTS Flow rates for LifeFlow (172 ± 28 mL/kg) were 4-fold higher than pressure bag (44 ± 13 mL/kg, P < 0.001) and 80% higher than PP (95 ± 28 mL/kg, P < 0.02). However, higher hemolysis was evident in the IV LifeFlow condition, with 6-fold more plasma-free hemoglobin than other conditions (P < 0.0001). CONCLUSIONS IV LifeFlow conferred higher flows, but higher hemolysis in this pilot study demonstrates the feasibility of an immature swine model toward determining optimal methods for resuscitating children with hemorrhagic shock.
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Affiliation(s)
- William Bianchi
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Taylor George
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Christian McEvoy
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Mark Piehl
- 410 Medical, Inc., Durham, NC.,WakeMed Health and Hospitals. Pediatric Critical Care and Hospital Medicine, Raleigh, NC.,University of North Carolina School of Medicine, Department of Pediatrics, Chapel Hill, NC
| | - Ana Manzano
- Combat Trauma Research Group, Naval Medical Center Portsmouth, General Dynamics Information Technology (GDIT), Fairfax, Virginia
| | - Michael Boboc
- Combat Trauma Research Group, Naval Medical Center Portsmouth, General Dynamics Information Technology (GDIT), Fairfax, Virginia
| | - Gregory J Zarow
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Ramesh Natarajan
- Combat Trauma Research Group, Naval Medical Center Portsmouth, General Dynamics Information Technology (GDIT), Fairfax, Virginia
| | - Micah J Gaspary
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Jonathan Auten
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
| | - Paul J D Roszko
- Naval Medical Center Portsmouth, Department of Emergency Medicine, Combat Trauma Research Group
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Use of the BIG score to predict mortality in pediatric trauma. Am J Emerg Med 2020; 45:472-475. [PMID: 33077313 DOI: 10.1016/j.ajem.2020.09.060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 09/14/2020] [Accepted: 09/24/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE The BIG score, which is comprised of admission base deficit (B), International Normalized Ratio (I), and GCS (G), is a severity of illness score that can be used to rapidly predict in-hospital mortality in pediatric patients presenting following traumatic injury. We sought to compare the mortality prediction of the pediatric trauma BIG score with other well-established pediatric trauma severity of illness scores: the pediatric logistic organ dysfunction (PELOD); the pediatric index of mortality 2 (PIM2); and the pediatric risk of mortality (PRISM III). METHODS In this retrospective cohort study, data from 2009 to 2015 was collected using a multi-institutional database. All pediatric patients admitted following traumatic injury with a recorded initial GCS were included. BIG, PELOD, PIM2, and PRISM III scores were calculated, and Receiver Operator Characteristic curves were derived for all severity of illness scores. Mortality prediction performance for each score was compared by the area under the curve (AUC). RESULTS A total of 29,204 patients were included in this analysis. AUC for BIG, PELOD, PIM2, and PRISM III scores were 0.97 (0.97-0.98), 0.98 (0.98-0.98), 0.98 (0.97-0.98), and 0.99 (0.98-0.99), respectively. At the optimum cut-off point of 16, the BIG score had a sensitivity of 0.937, specificity of 0.938, positive predictive value of 0.514, and negative predictive value of 0.995. CONCLUSIONS In this massive cohort of pediatric trauma patients, the BIG score using imputation of missing variables performed similarly to the PELOD, PIM2, and PRISM III, further validating the score as a predictor of mortality.
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Evangelista ME, Gaffley M, Neff LP. Massive Transfusion Protocols for Pediatric Patients: Current Perspectives. J Blood Med 2020; 11:163-172. [PMID: 32547282 PMCID: PMC7247594 DOI: 10.2147/jbm.s205132] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 04/24/2020] [Indexed: 01/03/2023] Open
Abstract
In adults, the use of balanced resuscitation and study of massive transfusion protocols have led to improved outcomes for patients and continues to be refined. In children, massive transfusion protocols require further development and study to assess efficacy. Standardization is needed as transfusions and activation of protocols still rely on physician discretion in most pediatric settings. Further research is required to define the pediatric trauma population that will benefit, when to activate these protocols and how to use adjuncts such as tranexamic acid or factor VII in resuscitation. In addition, future implementation of technology such as hemoglobin-based oxygen carriers to increase survival should be studied further in this subset of patients.
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Affiliation(s)
| | - Michaela Gaffley
- General Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
| | - Lucas P Neff
- Pediatric Surgery, Wake Forest School of Medicine, Winston-Salem, NC, USA
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Hanna K, Hamidi M, Anderson KT, Ditillo M, Zeeshan M, Tang A, Henry M, Kulvatunyou N, Joseph B. Pediatric resuscitation: Weight-based packed red blood cell volume is a reliable predictor of mortality. J Trauma Acute Care Surg 2020; 87:356-363. [PMID: 31349349 DOI: 10.1097/ta.0000000000002305] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The definition of massive transfusion (MT) in civilian pediatric trauma patients is not established. In combat-injured pediatric patients, the definition of MT is based on the volume of total blood products transfused. The aim of this study is to define MT in civilian pediatric trauma patients based on a packed red blood cell (PRBC) volume threshold and compare its predictive power to a total blood products volume threshold. METHODS An analysis of the pediatric American College of Surgeons Trauma Quality Improvement Program database was performed (2014-2016) including pediatric trauma patients (4-18 years) who received blood products within 24 hours. Receiver operator characteristic curves for predicting mortality determined the optimal PRBC MT threshold. Area under receiver operating characteristic curve (AUROC) curve analysis was performed to compare the predictive power of a PRBC threshold to a total blood product threshold. RESULTS A total of 1,495 patients were included. Sensitivity and specificity for 24-hour and in-hospital mortality were optimal at a PRBC threshold of 20 mL/kg. As compared with total blood products threshold, 20 mL/kg PRBCs volume achieved higher discriminatory power for predicting 24-hour (AUROC, 0.803 vs. 0.672; p < 0.001) and in-hospital mortality (AUROC, 0.815 vs. 0.686, p < 0.001). Patients who received an MT had higher Injury Severity Score (p < 0.001) and were more likely to receive mechanical ventilation (p < 0.001) and intensive care unit admission (p < 0.001). Overall 24-hour mortality (23.1% vs. 7.6%, p < 0.001) and in-hospital mortality (44.9% vs. 15.8%, p < 0.001) were higher in the MT group. On regression analysis, MT significantly predicted in-hospital mortality (odds ratio, 3.8 [2.9-4.9, 95% CI]) and 24-hour mortality (odds ratio, 3.3 [2.4-4.7, 95% CI]). CONCLUSION The use of a PRBCs MT definition in civilian pediatric patients is a better predictor of mortality compared with total blood products threshold. These results provide a framework for MT protocol development. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Kamil Hanna
- From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery (K.N., M.H., K.T.A., M.Z., A.T., M.H., N.K., B.J.), College of Medicine, University of Arizona, Tucson, Arizona; and Department of Trauma Surgery (M.D.), Allegheny General Hospital, Pittsburgh, Pennsylvania
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The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury. Pediatr Crit Care Med 2019; 20:970-979. [PMID: 31246737 DOI: 10.1097/pcc.0000000000002050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury. DESIGN A retrospective cohort study of a pediatric trauma database from 2001 to 2018. SETTING Level 1 trauma program at a university-affiliated pediatric institution. PATIENTS Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81-3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69-4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49-6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35-5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84-0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58-2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17-2.35). CONCLUSIONS The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The BIG score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment.
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Getting the Right Score for Pediatric Traumatic Brain Injury-Is BIG a Help? Pediatr Crit Care Med 2019; 20:996-997. [PMID: 31580278 DOI: 10.1097/pcc.0000000000002063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Muisyo T, Bernardo EO, Camazine M, Colvin R, Thomas KA, Borgman MA, Spinella PC. Mortality prediction in pediatric trauma. J Pediatr Surg 2019; 54:1613-1616. [PMID: 30270118 DOI: 10.1016/j.jpedsurg.2018.08.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 08/13/2018] [Accepted: 08/16/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND In trauma research, accurate estimates of mortality that can be rapidly calculated prior to enrollment are essential to ensure appropriate patient selection and adequate sample size. This study compares the accuracy of the BIG (Base Deficit, International normalized ratio and Glasgow Coma scale) score in predicting mortality in pediatric trauma patients to Pediatric Risk of Mortality III (PRISM III) score, Pediatric Index of Mortality 2 (PIM2) score and Pediatric Logistic Organ Dysfunction (PELOD) score. METHODS Data were collected from Virtual Pediatric Systems (VPS, LLC) database for children between 2004 and 2015 from 149 PICUs. Logistic regression models were developed to evaluate mortality prediction. The Area under the Curve (AUC) of Receiver Operator Characteristic (ROC) curves were derived from these models and compared between scores. RESULTS A total of 45,377 trauma patients were analyzed. The BIG score could only be calculated for 152 patients (0.33%). PRISM III, PIM2, and PELOD scores were calculated for 44,360, 45,377 and 14,768 patients respectively. The AUC of the BIG score was 0.94 compared to 0.96, 0.97 and 0.93 for the PRISM III, PIM2, and PELOD respectively. CONCLUSIONS The BIG score is accurate in predicting mortality in pediatric trauma patients. LEVEL OF EVIDENCE Level I prognosis.
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Affiliation(s)
- Teddy Muisyo
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Erika O Bernardo
- Department of Pediatrics, Section of Critical Care Medicine, Baylor College of Medicine, Houston, TX, 6621 Fannin Street, Houston, TX, 77030, USA.
| | - Maraya Camazine
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Ryan Colvin
- Department of Pediatrics, Pediatric Computing Facility, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA.
| | - Kimberly A Thomas
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
| | - Matthew A Borgman
- Department of Pediatrics, San Antonio Military Medical Center, 3551 Roger Brooke Dr, Fort Sam, Houston, TX, 78234, USA.
| | - Philip C Spinella
- Department of Pediatrics, Division of Critical Care Medicine, Washington University School of Medicine, 660 S. Euclid Avenue, St. Louis, MO, 63110, USA
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The evolution of pediatric transfusion practice during combat operations 2001-2013. J Trauma Acute Care Surg 2019; 84:S69-S76. [PMID: 29554046 DOI: 10.1097/ta.0000000000001869] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Hemostatic resuscitation principles have significantly changed adult trauma resuscitation over the past decade. Practice patterns in pediatric resuscitation likely have changed as well; however, this evolution has not been quantified. We evaluated pediatric resuscitation practices over time within a combat trauma system. METHODS The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric patients (<18 years). Patients with burns, drowning, and missing injury severity score were excluded. Volumes of crystalloid, packed red blood cells (PRBC), whole blood, plasma, and platelets (PLT) given in the first 24 hours were calculated per kilogram body weight. Tranexamic acid use was also determined. Patients were divided into Early (2001-2005) and Late (2006-2013) cohorts, and subgroups of transfused (TX+) and massively transfused (MT+) patients were created. Intensive care unit and hospital length of stay and 24-hour and in-hospital mortality rates were compared. RESULTS A total of 4,358 patients met inclusion criteria. Comparing Early versus Late, injuries from explosions, isolated or predominant head injuries, and injury severity score all increased. The proportion of TX+ patients also increased significantly (13.6% vs 37.4%, p < 0.001) as did the number of MT+ patients (2.1% vs 15.5%, p < 0.001). Transfusion of high plasma:RBC and PLT:RBC ratios increased in both the TX+ and MT+ subgroups, although overall, PLT and whole blood use was low. After adjusting for differences between groups, the odds of death was no different Early versus Late but decreased significantly in the MT+ patients with time as a continuous variable. CONCLUSION Transfusion practice in pediatric combat casualty care shifted toward a more hemostatic approach over time. All-cause mortality was low and remained stable overall and even decreased in MT+ patients despite more injuries due to explosions, more head injuries, and greater injury severity. However, further study is required to determine the optimal resuscitation practices in critically injured children. LEVEL OF EVIDENCE Epidemiologic study, level IV.
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Saini A, Spinella PC, Ignell SP, Lin JC. Thromboelastography Variables, Immune Markers, and Endothelial Factors Associated With Shock and NPMODS in Children With Severe Sepsis. Front Pediatr 2019; 7:422. [PMID: 31681719 PMCID: PMC6814084 DOI: 10.3389/fped.2019.00422] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Accepted: 10/03/2019] [Indexed: 01/17/2023] Open
Abstract
Objective: Evaluate hemostatic dysfunction in pediatric severe sepsis by thromboelastography (TEG) and determine if TEG parameters are associated with new or progressive multiple organ dysfunction syndrome (NPMODS) or shock, defined as a lactate ≥2mmol/L. We explored the relationship between TEG variables, selective cytokines, and endothelial factors. Design: Prospective observational. Setting: Single-center, quaternary care pediatric intensive care unit. Patients: Children aged 6- months to 14- years with severe sepsis with expected PICU stay for >72 h. Interventions: None. Measurements and Main Results: Twenty-eight children were enrolled with median (IQR) age of 7.3 years (4.4-11.4), PELOD score (study day-1) of 11(1.25-13), and PICU length of stay of 10 days (5-28). TEG-defined hypercoagulable state occurred most commonly in 73% (94/129) of samples, followed by hypocoagulable state in 7.8% (10/129) and mixed coagulation state in 1.5% (2/129) of samples in the study cohort. In contrast, hypocoagulable state occurred most commonly in 66% (98/148) of samples based on standard coagulation parameters. In the seven children who developed shock with NPMODS compared to eight patients with shock without NPMODS and 12 patients with severe sepsis only, we found more profound coagulopathy [thrombocytopenia (p = 0.04), elevated INR (p = 0.038), low fibrinogen level (p = 0.049), and low TEG-G value (p = 0.01)] and higher peak of interleukin-6 (p = 0.0014) and IL-10 (p = 0.007). Peak lactate in the first 5 study days had moderate correlation with standard coagulation assays, TEG parameters, and selective cytokines. Peak lactate did not correlate with markers of endothelial activation. Lowest TEG -G value had moderate correlation with peak IL-10 (ρ -0.442, p =0.019), peak VCAM (ρ - 0.495, p = 0.007), and peak lactate (ρ -0.542, p = 0.004) in the first 5 study days. A combination of TEG-G value and IL-6 concentration best discriminated children with shock and NPMODS [AUC 0.979 (95%CI 0.929-1.00), p < 0.001]. Conclusion: This exploratory analysis of hemostasis dysfunction on TEG in pediatric severe sepsis suggests that while hypercoagulability is more common, a hypocoagulable state is associated with shock and NPMODS. In addition, TEG abnormalities are also associated with immune and endothelial factors. A larger cohort study is needed to validate these findings.
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Affiliation(s)
- Arun Saini
- Division of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, United States
| | - Philip C Spinella
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - Steven P Ignell
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
| | - John C Lin
- Division of Critical Care Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, United States
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Hwu RS, Keller MS, Spinella PC, Baker D, Shi J, Leonard JC. Identifying potential predictive indicators of massive transfusion in pediatric trauma. TRAUMA-ENGLAND 2018. [DOI: 10.1177/1460408617721729] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ruth S Hwu
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Emory University Atlanta, GA, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Washington University School of Medicine, St. Louis, MO, USA
| | - David Baker
- St. Louis Children’s Hospital, St. Louis, MO, USA
| | - Junxin Shi
- Nationwide Children’s Hospital, Columbus, OH, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Pediatric Emergency Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
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Analysis of Pediatric Trauma in Combat Zone to Inform High-Fidelity Simulation Predeployment Training. Pediatr Crit Care Med 2018; 19:e199-e206. [PMID: 29369076 DOI: 10.1097/pcc.0000000000001461] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The military uses "just-in-time" training to refresh deploying medical personnel on skills necessary for medical and surgical care in the theater of operations. The burden of pediatric care at Role 2 facilities has yet to be characterized; pediatric predeployment training has been extremely limited and primarily informed by anecdotal experience. The goal of this analysis was to describe pediatric care at Role 2 facilities to enable data-driven development of high-fidelity simulation training and core knowledge concepts specific to the combat zone. SETTING AND PATIENTS A retrospective review of the Role 2 Database was conducted on all pediatric patients (< 18 yr) admitted to Role 2 in Afghanistan from 2008-2014. INTERVENTIONS Three cohorts were determined based on commercially available simulation models: Group 1: less than 1 year, Group 2: 1-8 years, Group 3: more than 8 years. The groups were sub-stratified by point of injury care, pre-hospital management, and Role 2 facility medical/surgical management. MEASUREMENTS AND MAIN RESULTS Appropriate descriptive statistics (chi square and Student t test) were utilized to define demographic and epidemiologic characteristics of this population. Of 15,404 patients in the Role 2 Database, 1,318 pediatric subjects (8.5%) were identified. The majority of patients were male (80.0%) with a mean age of 9.5 years (± SD, 4.5). Injury types included: penetrating (56%), blunt (33%), and burns (7%). Mean transport time from point of injury to Role 2 was 198 minutes (±24.5 min). Mean Glasgow Coma Scale and Revised Trauma Score were 14 (± 0.1) and 7.0 (± 1.4), respectively. Role 2 surgical procedures occurred for 424 patients (32%). Overall mortality was 4% (n = 58). CONCLUSIONS We have described the epidemiology of pediatric trauma admitted to Role 2 facilities, characterizing the spectrum of pediatric injuries that deploying providers should be equipped to manage. This analysis will function as a needs assessment to facilitate high-fidelity simulation training and the development of "pediatric trauma core knowledge concepts" for deploying providers.
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Aladegbami B, Choi PM, Keller MS, Vogel AM. A Pilot Study of Viscoelastic Monitoring in Pediatric Trauma: Outcomes and Lessons Learned. J Emerg Trauma Shock 2018; 11:98-103. [PMID: 29937638 PMCID: PMC5994857 DOI: 10.4103/jets.jets_150_16] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Examine the characteristics and outcomes of pediatric trauma patients at risk for coagulopathy following implementation of viscoelastic monitoring. Materials and Methods: Injured children, aged <18 years, from September 7, 2014, to December 21, 2015, at risk for trauma-induced coagulopathy were identified from a single, level-1 American College of Surgeons verified pediatric trauma center. Patients were grouped by coagulation assessment: no assessment (NA), conventional coagulation testing alone (CCT), and conventional coagulation testing with rapid thromboelastography (rTEG). Coagulation assessment was provider preference with all monitoring options continuously available. Groups were compared and outcomes were evaluated including blood product utilization, Intensive Care Unit (ICU) utilization, duration of mechanical ventilation, and mortality. Results: A total of 155 patients were identified (NA = 78, CCT = 54, and rTEG = 23). There was no difference in age, gender, race, or mechanism. In practice, rTEG patients were more severely injured, more anemic, and received more blood products and crystalloid (P < 0.001). rTEG patients also had increased mortality with fewer ventilator and ICU-free days. Multivariate logistic regression and covariance analysis indicated that while rTEG use was not associated with mortality, it was associated with increased use of blood products, duration of mechanical ventilation, and ICU length of stay. Conclusions: Viscoelastic monitoring was infrequently performed, but utilized in more severely injured patients. Well-designed prospective studies in patients at high risk of coagulopathy are needed to evaluate goal-directed hemostatic resuscitation strategies in children.
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Affiliation(s)
- Bola Aladegbami
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Pamela M Choi
- Department of Surgery, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Martin S Keller
- Department of Surgery, Division of Pediatric Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, MO 63110, USA
| | - Adam M Vogel
- Department of Surgery, Division of Pediatric Surgery, Baylor College of Medicine, Texas Childresn's Hospital, Houston, Texas 77030, USA
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High ratio plasma resuscitation does not improve survival in pediatric trauma patients. J Trauma Acute Care Surg 2017; 83:211-217. [PMID: 28481839 DOI: 10.1097/ta.0000000000001549] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Damage control resuscitation including balanced resuscitation with high ratios of plasma (PLAS) and platelets (PLT) to packed red blood cells (PRBC) improves survival in adult patients. We sought to evaluate the effect of a high ratio PLAS to PRBC resuscitation strategy in massively transfused pediatric patients with combat injuries. METHODS The Department of Defense Trauma Registry was queried from 2001 to 2013 for pediatric trauma patients (<18 years). Burns, drowning, isolated head trauma, and older teens were excluded. Those who received massive transfusion (≥40 mL/kg total blood products in 24 hours) and early deaths who received any blood products were then evaluated. Primary outcomes were mortality at 24 hours and in-hospital. Secondary outcomes included blood product utilization over 24 hours, ventilator-free days, intensive care unit-free days, and hospital length of stay. RESULTS The Department of Defense Trauma Registry yielded 4,980 combat-injured pediatric trauma patients, of whom 364 met inclusion criteria. Analysis of PLAS/PRBC ratios across the entire spectrum of possible ratios in these patients demonstrated no clear inflection point for mortality. Using a division between low (LO) and high (HI) ratios of PLAS/PRBC 1:2, there was no difference in all-cause mortality at 24 hours (LO, 9.2% vs. HI, 8.0%; p = 0.75) and hospital discharge (LO, 21.5% vs. HI, 17.1%; p = 0.39). HI ratio patients received less PRBC but more PLAS and PLT and more total blood products. Those in the HI ratio group also had longer hospital length of stay. Regression analysis demonstrated no associated mortality benefit with a HI ratio (hazards ratio, 2.04; 95% confidence interval, 0.48-8.73; p = 0.34). CONCLUSION In combat-injured children undergoing a massive transfusion, a high ratio of PLAS/PRBC was not associated with improved survival. Further prospective studies should be performed to determine the optimal resuscitation strategy in critically injured pediatric patients. LEVEL OF EVIDENCE Therapeutic study, level III.
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A comparison of base deficit and vital signs in the early assessment of patients with penetrating trauma in a high burden setting. Injury 2017; 48:1972-1977. [PMID: 28684079 DOI: 10.1016/j.injury.2017.06.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Revised: 06/15/2017] [Accepted: 06/16/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION An assessment of physiological status is a key step in the early assessment of trauma patients with implications for triage, investigation and management. This has traditionally been done using vital signs. Previous work from large European trauma datasets has suggested that base deficit (BD) predicts clinically important outcomes better than vital signs (VS). A BD derived classification of haemorrhagic shock appeared superior to one based on VS derived from ATLS criteria in a population of predominantly blunt trauma patients. The initial aim of this study was to see if this observation would be reproduced in penetrating trauma patients. The power of each individual variable (BD, heart rate (HR), systolic blood pressure (SBP), shock index(SI) (HR/SBP) and Glasgow Coma Score (GCS)) to predict mortality was then also compared. METHODS A retrospective analysis of adult trauma patients presenting to the Pietermaritzburg Metropolitan Trauma Service was performed. Patients were classified into four "shock" groups using VS or BD and the outcomes compared. Receiver Operator Characteristic (ROC) curves were then generated to compare the predictive power for mortality of each individual variable. RESULTS 1863 patients were identified. The overall mortality rate was 2.1%. When classified by BD, HR rose and SBP fell as the "shock class" increased but not to the degree suggested by the ATLS classification. The BD classification of haemorrhagic shock appeared to predict mortality better than that based on the ATLS criteria. Mortality increased from 0.2% (Class 1) to 19.7% (Class 4) based on the 4 level BD classification. Mortality increased from 0.3% (Class 1) to 12.6% (Class 4) when classified based by VS. Area under the receiver operator characteristic (AUROC) curve analysis of the individual variables demonstrated that BD predicted mortality significantly better than HR, GCS, SBP and SI. AUROC curve (95% Confidence Interval (CI)) for BD was 0.90 (0.85-0.95) compared to HR 0.67(0.56-0.77), GCS 0.70(0.62-0.79), SBP 0.75(0.65-0.85) and SI 0.77(0.68-0.86). CONCLUSION BD appears superior to vital signs in the immediate physiological assessment of penetrating trauma patients. The use of BD to assess physiological status may help refine their early triage, investigation and management.
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Retrospective evaluation of the BIG score to predict mortality in pediatric blunt trauma. CAN J EMERG MED 2017; 20:592-599. [PMID: 28803574 DOI: 10.1017/cem.2017.379] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Soni KD, Mahindrakar S, Gupta A, Kumar S, Sagar S, Jhakal A. Comparison of ISS, NISS, and RTS score as predictor of mortality in pediatric fall. BURNS & TRAUMA 2017; 5:25. [PMID: 28795055 PMCID: PMC5547492 DOI: 10.1186/s41038-017-0087-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 06/08/2017] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Kapil Dev Soni
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
| | - Santosh Mahindrakar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
| | - Amit Gupta
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
| | - Subodh Kumar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
| | - Sushma Sagar
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
| | - Ashish Jhakal
- Department of Trauma Surgery and Critical Care, Jai Prakash Narayan Trauma Centre, AIIMS, New Delhi, India
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Jeong JH, Park YJ, Kim DH, Kim TY, Kang C, Lee SH, Lee SB, Kim SC, Lim D. The new trauma score (NTS): a modification of the revised trauma score for better trauma mortality prediction. BMC Surg 2017; 17:77. [PMID: 28673278 PMCID: PMC5496419 DOI: 10.1186/s12893-017-0272-4] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 06/23/2017] [Indexed: 12/29/2022] Open
Abstract
Background Since its introduction, the Revised Trauma Score (RTS) has been widely used to determine the prognosis of trauma patients. Recent studies have revealed a need to change the parameters of the RTS. We have designed a new trauma score (NTS) based on revised parameters, including the adoption of the actual Glasgow Coma Scale (GCS) score instead of a GCS code, the revision of the systolic blood pressure interval used for the code value and the incorporation of peripheral oxygen saturation (SpO2) instead of respiratory rate. The purpose of this study was to evaluate the predictive performance of the NTS for in-hospital mortality compared with the RTS and other trauma scores. Methods This was a prospective observational study using data from the trauma registry of a tertiary hospital. The subjects were selected from patients who arrived at the ED between July 1, 2014, and June 30, 2016, and, for external validation purposes, those who arrived at the ED between July 1, 2011, and June 30, 2013. Demographic data and physiological data were analyzed. NTS models were calculated using logistic regression for GCS score, SBP code values, and SpO2. The mortality predictive performance of NTS was compared with that of other trauma scores. Results A total of 3263 patients for derivation and 3106 patients for validation were included in the analysis. The NTS showed better discrimination than the RTS (AUC = 0.935 vs. 0.917, respectively, AUC difference = 0.018, p = 0.001; 95% CI, 0.0071–0.0293) and similar discrimination to that of mechanism, Glasgow Coma scale, age, and arterial pressure (MGAP) and the Glasgow Coma Scale, age, and systolic arterial pressure (GAP). In the validation cohort, the global properties of the NTS for mortality prediction were significantly better than those of the RTS (AUC = 0.919 vs. 0.906, respectively; AUC difference = 0.013, p = 0.013; 95% CI, 0.0009–0.0249) and similar to those of the MGAP and GAP. Conclusions The NTS predicts in-hospital mortality substantially better than the RTS.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea. .,Institute of Health Sciences, Gyeongsang National University, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea.
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Institute of Health Sciences, Gyeongsang National University, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, 52727, Republic of Korea.,Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Kim SC, Kim DH, Kim TY, Kang C, Lee SH, Jeong JH, Park YJ, Lee SB, Lim D. The Revised Trauma Score plus serum albumin level improves the prediction of mortality in trauma patients. Am J Emerg Med 2017. [PMID: 28637583 DOI: 10.1016/j.ajem.2017.06.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION The Revised Trauma Score (RTS) is used worldwide in prehospital practice and in the emergency department (ED) settings to triage trauma patients. The main purpose of this study was to evaluate the value of the RTS plus serum albumin (RTS-A) and to compare it with other existing trauma scores as well as to compare the predictive performance of the Trauma and Injury Severity Score with the RTS-A (TRISS-A) with the original TRISS. METHODS This was a single center, trauma registry based observational cohort study. Data were collected from consecutive patients with blunt or penetrating injuries who presented to the emergency department of a tertiary referral hospital, between January 2012 and June 2016. 3145 and 2447 patients were assigned to the derivation group and validation group, respectively. Main outcome was in-hospital mortality. RESULTS Among patients in the derivation group, the median [interquartile range] age was 59 [43-73] years, and 66.7% were male. The area under the receiver operating characteristic curves (AUC) of the RTS-A (0.948; 95% CI: 0.939-0.955) was higher than that of the RTS (0.919; 95% CI: 0.909-0.929). In patients with blunt trauma, the AUC of the TRISS-A (0.960; 95% CI: 0.952-0.967) was significantly higher than that of the original TRISS (0.949; 95% CI: 0.941-0.957). CONCLUSION The value of the RTS-A predicts the in-hospital mortality of trauma patients better than the RTS, and the TRISS-A is a better mortality predictor compared to the original TRISS in patients with blunt trauma.
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Affiliation(s)
- Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea.
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea
| | - Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea; Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Yong Joo Park
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, 15, Jinju-daero 816beon-gil, Jinju-si, Republic of Korea
| | - Daesung Lim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Gyeongsang National University Changwon Hospital, Changwon, Republic of Korea
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Roth JA, Widmer AF, Tschudin-Sutter S, Dangel M, Frei R, Battegay M, Hug BL. The Model for End-stage Liver Disease (MELD) as a predictor of short-term mortality in Staphylococcus aureus bloodstream infection: A single-centre observational study. PLoS One 2017; 12:e0175669. [PMID: 28414786 PMCID: PMC5393572 DOI: 10.1371/journal.pone.0175669] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 03/29/2017] [Indexed: 02/06/2023] Open
Abstract
Background Automated laboratory-based prediction models may support clinical decisions in Staphylococcus aureus bloodstream infections (BSIs), which carry a particularly high mortality. Small studies indicated that the laboratory-based Model for End-stage Liver Disease (MELD) score is a risk factor for mortality in critically ill patients with infections. For S. aureus BSIs, we therefore aimed to assess a potential association of the MELD score with mortality. Methods In this single-centre observational study, all consecutive patients with a first episode of methicillin-susceptible S. aureus BSI occurring between 2001 and 2013 were eligible. Relevant patient data were retrieved from our prospective in-house BSI database. We assessed the association of the MELD score at day of BSI onset (range ± two days) with 30-day all-cause mortality using uni- and multivariable logistic regression analysis. Results 561 patients were included in the final analysis. The MELD score at BSI onset was associated with 30-day mortality in S. aureus BSIs (odds ratio per 1-point increase, 1.06; 95% confidence interval, 1.03‒1.09; P < 0.001). After adjustment for relevant patient and infection characteristics, an increased MELD score remained a predictor of 30-day mortality (adjusted odds ratio per 1-point increase, 1.05; 95% confidence interval, 1.01‒1.08; P = 0.005). Conclusions In our study population, the MELD score at BSI onset was an independent predictor of mortality in S. aureus BSIs. We therefore suggest to prospectively validate the MELD score as part of clinical decision support systems in inpatients with suspected or confirmed BSI.
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Affiliation(s)
- Jan A. Roth
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Andreas F. Widmer
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Sarah Tschudin-Sutter
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Marc Dangel
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Reno Frei
- University of Basel, Basel, Switzerland
- Division of Clinical Microbiology, University Hospital Basel, Basel, Switzerland
| | - Manuel Battegay
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland
- University of Basel, Basel, Switzerland
| | - Balthasar L. Hug
- University of Basel, Basel, Switzerland
- Department of Internal Medicine, Kantonsspital Luzern, Lucerne, Switzerland
- * E-mail:
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Systematic review and need assessment of pediatric trauma outcome benchmarking tools for low-resource settings. Pediatr Surg Int 2017; 33:299-309. [PMID: 27873009 DOI: 10.1007/s00383-016-4024-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2016] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Trauma is a leading cause of mortality and disability in children worldwide. The World Health Organization reports that 95% of all childhood injury deaths occur in Low-Middle-Income Countries (LMIC). Injury scores have been developed to facilitate risk stratification, clinical decision making, and research. Trauma registries in LMIC depend on adapted trauma scores that do not rely on investigations that require unavailable material or human resources. We sought to review and assess the existing trauma scores used in pediatric patients. Our objective is to determine their wideness of use, validity, setting of use, outcome measures, and criticisms. We believe that there is a need for an adapted trauma score developed specifically for pediatric patients in low-resource settings. MATERIALS AND METHODS A systematic review of the literature was conducted to identify and compare existing injury scores used in pediatric patients. We constructed a search strategy in collaboration with a senior hospital librarian. Multiple databases were searched, including Embase, Medline, and the Cochrane Central Register of Controlled Trials. Articles were selected based on predefined inclusion criteria by two reviewers and underwent qualitative analysis. RESULTS The scores identified are suboptimal for use in pediatric patients in low-resource settings due to various factors, including reliance on precise anatomic diagnosis, physiologic parameters maladapted to pediatric patients, or laboratory data with inconsistent accessibility in LMIC. CONCLUSION An important gap exists in our ability to simply and reliably estimate injury severity in pediatric patients and predict their associated probability of outcomes in settings, where resources are limited. An ideal score should be easy to calculate using point-of-care data that are readily available in LMIC, and can be easily adapted to the specific physiologic variations of different age groups.
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Potter DD, Berns KS, Elsbernd TA, Zietlow SP. Prehospital use of blood and plasma in pediatric trauma patients. Air Med J 2016; 34:40-3. [PMID: 25542727 DOI: 10.1016/j.amj.2014.07.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Accepted: 07/26/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Our rural trauma center uses packed red blood cells (PRBCs) and plasma onboard our helicopter to offset the delay of transport. We summarize our initial experience with prehospital blood use in pediatric trauma patients. METHODS Our air ambulance service began carrying PRBCs in 1987 and plasma in 2009. We performed a 9-year retrospective review including patients (< 18 years) who received blood during helicopter transports. Only patients transported to our level 1 trauma center were included to ensure complete follow-up. RESULTS Sixteen patients (6 females) were identified with a mean age of 13 years. The mean transport time was 30 minutes with 75% transferred in from a referring center. Injuries were blunt in 9 patients and penetrating in 2 patients. The mean Injury Severity Score was 30. Fifteen patients received an average of 1.5 units of PRBCs during flight. Indications for PRBCs were severe anemia (6), known blood loss (5), and nonresponder to intravenous fluids (4). Average hemoglobin improved from 9.4 to 11.4 mg/dL at our center. Base deficit improved from -7 to -5.7 at arrival. Five patients received a mean of 1.4 units of plasma. The arrival international normalized ratio was 1.4. The average length of stay was 9.3 days. Four patients died. Trauma Related Injury Severity Score showed 3 patients were unexpected survivors (0.24, 0.24, and 0.38). CONCLUSION Prehospital use of blood in injured children is rare. However, when indicated, this initial review of our protocol showed increased hemoglobin, decreased acidosis, and unexpected survivors with our program. Because of the rarity of prehospital blood use in children, administration triggers require continued review and refinement.
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Affiliation(s)
- D Dean Potter
- Division of Pediatric Surgery, University of Iowa, Iowa City, IA
| | - Kathleen S Berns
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN; Mayo Clinic Medical Transport, Mayo Clinic Rochester, Rochester, MN
| | | | - Scott P Zietlow
- Department of Surgery, Mayo Clinic Rochester, Rochester, MN; Mayo Clinic Medical Transport, Mayo Clinic Rochester, Rochester, MN.
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Roumeliotis N, Ducruet T, Bateman ST, Randolph AG, Lacroix J, Emeriaud G. Determinants of red blood cell transfusion in pediatric trauma patients admitted to the intensive care unit. Transfusion 2016; 57:187-194. [PMID: 27696446 DOI: 10.1111/trf.13857] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 08/13/2016] [Accepted: 08/18/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND There are no well-designed prospective studies evaluating transfusion practices in pediatric trauma. We sought to describe red blood cell (RBC) transfusion practices in trauma patients who were admitted to a pediatric intensive care unit (PICU). STUDY DESIGN AND METHODS This study is a post-hoc analysis of a prospective, 6-month observational study in 30 PICUs. We studied a total of 580 patients aged less than 18 years who had been admitted to a PICU for more than 48 hours, including 95 who were trauma patients. RESULTS Trauma patients more frequently received transfusion before PICU admission (p < 0.001), were older (p < 0.0001), and more frequently were mechanically ventilated (p = 0.05). In the PICU, trauma patients received more transfusions (55% vs. 37%; p < 0.001), although admission hemoglobin levels were similar in both groups (p = 0.86). The mean (± standard deviation) pretransfusion hemoglobin level in the PICU was 9.0 ± 2.4 g/dL for trauma patients compared with 8.3 ± 2.4 g/dL for nontrauma patients (p = 0.09). Among the trauma patients, transfusion was associated with younger age, higher Pediatric Logistic Organ Regression scores, mechanical ventilation, bleeding, and transfusion before PICU admission. Multivariate regression demonstrated that receiving an RBC transfusion before admission was strongly associated with receiving a blood transfusion in the PICU (p = 0.008). CONCLUSION Trauma patients are at high risk for receiving an RBC transfusion both before and during their PICU stay, despite a similar transfusion threshold compared with nontrauma patients. Transfusion before PICU admission is a strong determinant, suggesting ongoing bleeding that will require re-transfusion. Further studies are needed to evaluate whether a restrictive transfusion strategy can safely be considered in these patients.
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Affiliation(s)
- Nadia Roumeliotis
- Division of Pediatric Critical Care Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Thierry Ducruet
- Research Center of Centre Hospitalier Universitaire Sainte-Justine, Université de Montréal, Montréal, Québec, Canada
| | - Scot T Bateman
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Adrienne G Randolph
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Guillaume Emeriaud
- Division of Pediatric Critical Care Medicine, Université de Montréal, Montréal, Québec, Canada
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Hwu RS, Keller MS, Spinella PC, Baker D, Tao Y, Leonard JC. Potential effects of high plasma to red blood cell ratio transfusion in pediatric trauma. TRAUMA-ENGLAND 2016. [DOI: 10.1177/1460408616645613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective High ratio of plasma to red blood cells during massive transfusion is associated with improved survival of traumatic injuries in adults, but this has not been demonstrated in children. Our objective was to compare the outcome of children who received high (≥1:2) versus low (<1:2) plasma: red blood cells (P:R) ratios at 24 h from injury. Methods We conducted a retrospective chart review of children <18 years of age who presented to the emergency department over a 7-year period and received massive transfusion (≥40 ml/kg red blood cells or ≥80 ml/kg total blood products in 24 h). Our primary outcome of interest was in-hospital mortality. Results We identified 38 children who received massive transfusion. There was no significant difference in in-hospital mortality (45.8% vs. 64.3%) between the high (n = 24, median ratio 1:1.1) and low P:R ratio (n = 14, median 1:3.2) groups. In subset analyses, there was reduced mortality for high P:R patients with BIG score ≥24 (69.2% vs. 100%) and those taken to the operating room within 6 h of arrival (21.4% vs. 60.0%), respectively ( p < 0.05). There was a trend for improved survival in high P:R patients without severe traumatic brain injury (TBI) (0% vs. 40.0%). Conclusions This study suggests that high P:R transfusion may improve in-hospital survival of injured children at high risk of mortality and in children without severe TBI, supporting the need for large, multi-center studies.
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Affiliation(s)
- Ruth S Hwu
- Division of Pediatric Emergency Medicine, Emory University School of Medicine, USA
| | - Martin S Keller
- Division of Pediatric Surgery, St. Louis Children’s Hospital, USA
| | - Philip C Spinella
- Division of Critical Care Medicine, Washington University School of Medicine, USA
| | - David Baker
- Blood Bank Supervisor, St. Louis Children’s Hospital, USA
| | - Yu Tao
- Division of Biostatistics, Washington University School of Medicine in St. Louis, USA
| | - Julie C Leonard
- Division of Pediatric Emergency Medicine, Nationwide Children's Hospital, USA
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Smith SA, Livingston MH, Merritt NH. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg 2016; 51:848-52. [PMID: 26960738 DOI: 10.1016/j.jpedsurg.2016.02.034] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Accepted: 02/07/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND Severely injured pediatric trauma patients often present to hospital with early coagulopathy and metabolic acidosis. These derangements are associated with poor outcomes, but it is unclear to what degree they predict transfusion of packed red blood cells (pRBC). METHODS We retrospectively identified pediatric trauma patients from a level 1 trauma center from 2006 to 2013. Inclusion criteria were age less than 18years, Injury Severity Score greater than 12, and pRBC transfusion within 24h of admission. RESULTS We identified 96 pediatric trauma patients who underwent pRBC transfusion within 24h of presentation to hospital. On admission, 43% of these patients had one or more signs of coagulopathy, and 81% had metabolic acidosis. Size of pRBC transfusion in the first 24h ranged from 3 to 177mL/kg (mean 29mL/kg), and nineteen patients (20%) underwent massive transfusion (>40ml/kg in 24h). Univariate analysis indicated that size of pRBC transfusion was associated with initial base excess (r=0.46), international normalized ratio (r=0.35), partial thromboplastin time (r=0.41), fibrinogen (r=0.46), and BIG score (Base deficit, INR, Glasgow Coma Scale (GCS), r=0.36). Platelet count, age, GCS, and direct versus referred presentation were not predictive. Multivariable linear regression confirmed that coagulopathy and metabolic acidosis remained predictive after adjusting for direct versus referred presentation (R(2)=0.30). CONCLUSIONS Early coagulopathy and metabolic acidosis predict size of pRBC transfusion among pediatric trauma patients. Further research is needed to develop massive transfusion protocols and guidelines for activation.
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Affiliation(s)
- Shane A Smith
- Division of General Surgery, Western University, London, Ontario, Canada
| | | | - Neil H Merritt
- Division of General Surgery, Western University, London, Ontario, Canada; Division of Pediatric Surgery, Western University, London, Ontario, Canada.
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