Novel Trauma Composite Score is a more reliable predictor of mortality than Injury Severity Score in pediatric trauma.
Adolescent
Age Factors
Child
Child, Preschool
Female
Humans
Infant
Injury Severity Score
Length of Stay
/ statistics & numerical data
Male
ROC Curve
Registries
/ statistics & numerical data
Reproducibility of Results
Retrospective Studies
Risk Assessment
/ methods
Shock
/ diagnosis
Trauma Centers
/ statistics & numerical data
Wounds, Nonpenetrating
/ complications
Wounds, Penetrating
/ complications
Journal
The journal of trauma and acute care surgery
ISSN: 2163-0763
Titre abrégé: J Trauma Acute Care Surg
Pays: United States
ID NLM: 101570622
Informations de publication
Date de publication:
01 10 2021
01 10 2021
Historique:
pubmed:
20
4
2021
medline:
11
11
2021
entrez:
19
4
2021
Statut:
ppublish
Résumé
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. 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. 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. 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. Retrospective review, level IV.
Sections du résumé
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.
Identifiants
pubmed: 33871405
doi: 10.1097/TA.0000000000003235
pii: 01586154-202110000-00005
doi:
Types de publication
Comparative Study
Evaluation Study
Journal Article
Langues
eng
Sous-ensembles de citation
IM
Pagination
599-604Informations de copyright
Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.
Références
Baker SP, O’Neill B, Haddon W, Long WB. The injury severity score: a method for describing patients with multiple injuries and evaluating emergency care. J Trauma . 1974;14(3):187–196.
Kilgo PD, Meredith JW, Hensberry R, Osler TM. A note on the disjointed nature of the injury severity score. J Trauma . 2004;57(3):479–485; discussion 486-487.
Aharonson-Daniel L, Giveon A, Stein M, Peleg K. Different AIS triplets: different mortality predictions in identical ISS and NISS. J Trauma Inj Infect Crit Care . 2006;61(3):711–717.
Borgman MA, Maegele M, Wade CE, Blackbourne LH, Spinella PC. Pediatric trauma BIG score: predicting mortality in children after military and civilian trauma. Pediatrics . 2011;127(4):e892–e897.
Tepas JJ, Veldenz HC, Discala C, Pieper P. Pediatric risk Indicator: an objective measurement of childhood injury severity. J Trauma Inj Infect Crit Care . 1997;43(2):258–262.
Schall LC, Potoka DA, Ford HR. A new method for estimating probability of survival in Pediatric patients using revised TRISS methodology based on age-adjusted weights. J Trauma Acute Care Surg . 2002;52(2):235–241.
Walther AE, Falcone RA, Pritts TA, Hanseman DJ, Robinson BRH. Pediatric and adult trauma centers differ in evaluation, treatment, and outcomes for severely injured adolescents. J Pediatr Surg . 2016;51(8):1346–1350.
Palmer C. Major trauma and the injury severity score—where should we set the bar? Annu Proc Assoc Adv Automot Med . 2007;51:13–29.
Brown JB, Gestring ML, Leeper CM, Sperry JL, Peitzman AB, Billiar TR, Gaines BA. The value of the injury severity score in pediatric trauma: time for a new definition of severe injury? J Trauma Acute Care Surg . 2017;82(6):995–1001.
Cassidy LD, Cook A, Ertl A, Gourlay D, Osler T. Is the Trauma Mortality Prediction Model (TMPM-ICD-9) a valid predictor of mortality in pediatric trauma patients? J Pediatr Surg . 2014;49(1):189–192.
Lopez-Raton M, Rodriguez-Alvarez M, Suarez C, Sampedro F. OptimalCutpoints: An R Package for Selecting Optimal Cutpoints in Diagnostic Tests. J Stat Softw . 61(8):1–36.
Venables WN, Ripley BD. Modern Applied Statistics with S . 4th ed. New York, NY: Springer.
Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg . 2015;50(2):331–334.
Wickham H. Ggplot2: Elegant Graphics for Data Analysis . New York, NY: Springer-Verlag; 2016. Available at: https://ggplot2.tidyverse.org . Accessed September 1, 2020.
Sullivan T, Haider A, DiRusso SM, Nealon P, Shaukat A, Slim M. Prediction of mortality in pediatric trauma patients: new injury severity score outperforms injury severity score in the severely injured. J Trauma . 2003;55(6):1083–1087; discussion 1087-8.
Tracy ET, Englum BR, Barbas AS, Foley C, Rice HE, Shapiro ML. Pediatric injury patterns by year of age. J Pediatr Surg . 2013;48(6):1384–1388. doi:10.1016/j.jpedsurg.2013.03.041.
doi: 10.1016/j.jpedsurg.2013.03.041
Smith BP, Goldberg AJ, Gaughan JP, Seamon MJ. A comparison of Injury Severity Score and New Injury Severity Score after penetrating trauma: a prospective analysis. J Trauma Acute Care Surg . 2015;79(2):269–274.
Kincaid EH, Chang MC, Letton RW, Chen JG, Meredith JW. Admission base deficit in pediatric trauma: a study using the National Trauma Data Bank. J Trauma . 2001;51(2):332–335.
Cuenca CM, Borgman MA, April MD, Fisher AD, Schauer SG. Validation of the age-adjusted shock index for pediatric casualties in Iraq and Afghanistan. Military Med Res . 2020;7(1):33.
Rotondo M, Cribari C, Stephen S. Resources for Optimal Care of the Injured Patient . Chicago, IL: American College of Surgeons; 2014.
Demetriades D, Martin M, Salim A, Rhee P, Brown C, Doucet J, Chan L. Relationship between American College of Surgeons trauma center designation and mortality in patients with severe trauma (Injury Severity Score > 15). J Am Coll Surg . 2006;202(2):212–215.