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Sullivan TM, Sippel GJ, Gestrich-Thompson WV, Jensen AR, Burd RS. Survival bias in pediatric hemorrhagic shock: Are we misrepresenting the data? J Trauma Acute Care Surg 2024; 96:785-792. [PMID: 37752639 DOI: 10.1097/ta.0000000000004119] [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: 09/28/2023]
Abstract
BACKGROUND Studies of hemorrhage following pediatric injury often use the occurrence of transfusion as a surrogate definition for the clinical need for a transfusion. Using this approach, patients who are bleeding but die before receiving a transfusion are misclassified as not needing a transfusion. In this study, we aimed to evaluate the potential for this survival bias and to estimate its presence among a retrospective observational cohort of children and adolescents who died from injury. METHODS We obtained patient, injury, and resuscitation characteristics from the 2017 to 2020 Trauma Quality Improvement Program database of children and adolescents (younger than 18 years) who arrived with or without signs of life and died. We performed univariate analysis and a multivariable logistic regression to analyze the association between the time to death and the occurrence of transfusion within 4 hours after hospital arrival controlling for initial vital signs, injury type, body regions injured, and scene versus transfer status. RESULTS We included 6,063 children who died from either a blunt or penetrating injury. We observed that children who died within 15 minutes had lower odds of receiving a transfusion (odds ratio, 0.1; 95% confidence interval, 0.1-0.2) compared with those who survived longer. We estimated that survival bias that occurs when using transfusion administration alone to define hemorrhagic shock may occur in up to 11% of all children who died following a blunt or penetrating injury but less than 1% of all children managed as trauma activations. CONCLUSION Using the occurrence of transfusion alone may underestimate the number of children who die from uncontrolled hemorrhage early after injury. Additional variables than just transfusion administration are needed to more accurately identify the presence of hemorrhagic shock among injured children and adolescents. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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MESH Headings
- Humans
- Shock, Hemorrhagic/therapy
- Shock, Hemorrhagic/mortality
- Shock, Hemorrhagic/etiology
- Shock, Hemorrhagic/diagnosis
- Child
- Female
- Male
- Retrospective Studies
- Adolescent
- Blood Transfusion/statistics & numerical data
- Child, Preschool
- Infant
- Bias
- Wounds, Penetrating/mortality
- Wounds, Penetrating/therapy
- Wounds, Penetrating/complications
- Wounds, Penetrating/diagnosis
- Wounds, Nonpenetrating/mortality
- Wounds, Nonpenetrating/therapy
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/complications
- Resuscitation/methods
- Resuscitation/statistics & numerical data
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Affiliation(s)
- Travis M Sullivan
- From the Division of Trauma and Burn Surgery (T.M.S., G.J.S., W.V.G.-T., R.S.B.), Children's National Hospital, Washington, DC; Department of Surgery (A.R.J.), University of California San Francisco; and Division of Pediatric Surgery (A.R.J.), UCSF Benioff Children's Hospitals, San Francisco, CA
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MacArthur TA, Polites SF. How much is too much crystalloid? Building a foundation for the study of optimal resuscitation practices in pediatric trauma patients with severe traumatic brain injury: Authors' response to Ghasemian et al. J Trauma Acute Care Surg 2024; 96:e25-e26. [PMID: 38079249 DOI: 10.1097/ta.0000000000004236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
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Choi D, Park JW, Kwak YH, Kim DK, Jung JY, Lee JH, Jung JH, Suh D, Lee HN, Lee EJ, Kim JH. Comparison of age-adjusted shock indices as predictors of injury severity in paediatric trauma patients immediately after emergency department triage: A report from the Korean multicentre registry. Injury 2024; 55:111108. [PMID: 37858444 DOI: 10.1016/j.injury.2023.111108] [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: 08/16/2023] [Revised: 09/26/2023] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
INTRODUCTION Shock index paediatric-adjusted (SIPA) was presented for early prediction of mortality and trauma team activation in paediatric trauma patients. However, the derived cut-offs of normal vital signs were based on old references. We established alternative SIPAs based on the other commonly used references and compared their predictive values. METHODS We performed a retrospective review of all paediatric trauma patients aged 1-15 years in the Emergency Department (ED)-based Injury In-depth Surveillance (EDIIS) database from January 1, 2011 to December 31, 2019. A total of 4 types of SIPA values were obtained based on the references as follows: uSIPA based on the Nelson textbook of paediatrics 21st ed., SIATLS based on the ATLS 10th guideline, SIPALS based on the PALS 2020 guideline, and SIPA. In each SIPA group, the cut-off was established by dividing the group into 4 subgroups: toddler (age 1-3), preschooler (age 4-6), schooler (age 7-12), and teenager (age 13-15). We performed an ROC analysis and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) to compare the predicted values of each SIPA in mortality, ICU admission, and emergent surgery or intervention. RESULTS A total of 332,271 patients were included. The proportion of patients with an elevated shock index was 14.9 % (n = 49,347) in SIPA, 22.8 % (n = 75,850) in uSIPA, 0.3 % (n = 1058) in SIATLS, and 4.3 % (n = 14,168) in SIPALS. For mortality, uSIPA achieved the highest sensitivity (57.0 %; 95 % confidence interval 56.9 %-57.2 %) compared to SIPA (49.4 %, 95 % CI 49.2 %-49.5 %), SIATLS (25.5 %, 95 % CI 25.4 %-25.7 %), and SIPALS (43.8 %, 95 % CI 43.7 %-44.0 %), but there were no significant differences in the negative predictive value (NPV) or area under the curve (AUC). The positive predictive value (PPV) was highest in SIATLS (5.7 %, 95 % CI 5.6 %-5.8 %) compared to SIPA (0.2 %, 95 % CI 0.2 %-0.3 %), uSIPA (0.2 %, 95 % CI 0.2 %-0.2 %), and SIPALS (0.7 %, 95 % CI 0.7 %-0.8 %). The same findings were presented in ICU admission and emergent operation or intervention. CONCLUSION The ATLS-based shock index achieved the highest PPV and specificity compared to SIPA, uSIPA, and SIPALS for adverse outcomes in paediatric trauma.
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Affiliation(s)
- Dongmuk Choi
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea.
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin Hee Lee
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, Seong-Nam, 13620, Republic of Korea
| | - Jin Hee Jung
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul, 07061, Republic of Korea
| | - Dongbum Suh
- Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro, Bundang-gu, Seong-Nam, 13620, Republic of Korea
| | - Ha Ni Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Disaster Medicine Research Center, Seoul National University Medical Research Center, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea; Department of Emergency Medicine, Seoul National University College of Medicine, 103 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Eui Jun Lee
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
| | - Jin Hee Kim
- Department of Emergency Medicine, Seoul National University Hospital, 101 Daehak-ro, Jongno-gu, Seoul, 03080, Republic of Korea
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Wingren CJ. An evidence-based approach to forensic life-threat assessments using spleen injuries as an example. Forensic Sci Int 2023; 345:111614. [PMID: 36867983 DOI: 10.1016/j.forsciint.2023.111614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 02/17/2023] [Accepted: 02/24/2023] [Indexed: 02/27/2023]
Abstract
INTRODUCTION During the judicial process of addressing violent crime, a forensic practitioner may need to assess whether an inflicted injury should be considered life-threatening. This could be important for the classification of the crime. To some extent, these assessments are arbitrary since the natural course of an injury might not be completely known. To guide the assessment, a quantitative and transparent method based on rates of mortality and acute interventions is suggested, using spleen injuries as an example. METHOD The electronic database PubMed was searched using the term "spleen injuries" for articles reporting on rates of mortality and interventions such as surgery and angioembolization in spleen injuries. By combining these different rates, a method for a transparent and quantitative assessment of the risk to life across the natural course of spleen injuries is presented. RESULTS A total of 301 articles were identified, and 33 of these were included in the study. The mortality rate of spleen injuries, as reported in studies, varied between 0% and 2.9% in children, and between 0% and 15.4% in adults. However, when combining the rates of acute interventions and the mortality rates, the risk of death across the natural course of spleen injuries was estimated as 9.7% in children, and 46.4% in adults. CONCLUSION The calculated risk of death across the natural course of spleen injuries in adults was considerable higher than the observed mortality. A similar but smaller effect was observed in children. The forensic assessment of life-threat in cases involving spleen injury needs further research; however, the applied method is a step towards an evidence-based practice for forensic life-threat assessments.
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Affiliation(s)
- Carl Johan Wingren
- Forensic Medicine Unit, Department of Clinical Sciences, Malmö, Faculty of Medicine, Lund University, Lund, Sweden.
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Reppucci ML, Stevens J, Moulton SL, Acker SN. The Recognition of Shock in Pediatric Trauma Patients. CURRENT TRAUMA REPORTS 2022. [DOI: 10.1007/s40719-022-00239-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Stevens J, Phillips R, Meier M, Reppucci ML, Acker S, Shahi N, Shirek G, Bensard D, Moulton S. Novel tool (BIS) heralds the need for blood transfusion and/or failure of non-operative management in pediatric blunt liver and spleen injuries. J Pediatr Surg 2022; 57:202-207. [PMID: 34756419 DOI: 10.1016/j.jpedsurg.2021.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/10/2021] [Accepted: 09/21/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Non-operative management (NOM) is the standard of care for the majority of children with blunt liver and spleen injuries (BLSI). The shock index pediatric age-adjusted (SIPA) was previously shown to predict the need for blood transfusions in pediatric trauma patients with BLSI. We combined SIPA with base deficit (BD) and International Normalized Ratio (INR) to create the BIS score. We hypothesized that the BIS score would predict the need for blood transfusions and/or failure of NOM in pediatric trauma patients with BLSI. METHODS Patients (≤ 18 years) who presented to our Level I pediatric trauma center with BLSI from 2009 to 2019 were identified. BIS scores were calculated by giving 1 point for each of the following: base deficit ≤ -8.8, INR ≥ 1.5, or elevated SIPA. Receiver operating characteristic curves (ROC) were generated for BIS scores ≥ 1, ≥ 2, and ≥ 3. Area under the curve (AUC), sensitivity, and specificity of each score were calculated for ability to predict need for blood transfusions and/or failure of NOM. RESULTS Of 477 children included, 19.9% required a blood transfusion and 6.7% failed NOM. A BIS score ≥ 1 was the best predictor of the need for blood transfusions with an AUC of 0.81 and a sensitivity of 96.0%. A BIS score ≥ 1 was also the best predictor of failure of NOM with an AUC of 0.72 and a sensitivity of 97.0%. CONCLUSION The BIS score is a highly sensitive tool that identifies pediatric patients with BLSI at risk for blood transfusions and/or failure of NOM. LEVEL OF EVIDENCE Level III. TYPE OF STUDY Retrospective comparative study.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States.
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, United States
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, United States
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Reppucci ML, Stevens J, Cooper E, Meier M, Phillips R, Shahi N, Nolan M, Acker SN, Moulton SL, Bensard DD. Discreet Values of Shock Index Pediatric Age-Adjusted (SIPA) to Predict Intervention in Children With Blunt Organ Injuries. J Surg Res 2022; 279:17-24. [PMID: 35716446 DOI: 10.1016/j.jss.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 04/30/2022] [Accepted: 05/23/2022] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Elevated shock index pediatric age-adjusted (SIPA) has been shown to be associated with the need for both blood transfusion and intervention in pediatric patients with blunt liver and spleen injuries (BLSI). SIPA has traditionally been used as a binary value, which can be classified as elevated or normal, and this study aimed to assess if discreet values above SIPA cutoffs are associated with an increased probability of blood transfusion and failure of nonoperative management (NOM) in bluntly injured children. MATERIALS AND METHODS Children aged 1-18 y with any BLSI admitted to a Level-1 pediatric trauma center between 2009 and 2020 were analyzed. Blood transfusion was defined as any transfusion within 24 h of arrival, and failure of NOM was defined as any abdominal operation or angioembolization procedure for hemorrhage control. The probabilities of receiving a blood transfusion or failure of NOM were calculated at different increments of 0.1. RESULTS There were 493 patients included in the analysis. The odds of requiring blood transfusion increased by 1.67 (95% CI 1.49, 1.90) for each 0.1 unit increase of SIPA (P < 0.001). A similar trend was seen initially for the probability of failure of nonoperative management, but beyond a threshold, increasing values were not associated with failure of NOM. On subanalysis excluding patients with a head injury, increased 0.1 increments were associated with increased odds for both interventions. CONCLUSIONS Discreet values above age-related SIPA cutoffs are correlated with higher probabilities of blood transfusion in pediatric patients with BLSI and failure of NOM in those without head injury. The use of discreet values may provide clinicians with more granular information about which patients require increased resources upon presentation.
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Affiliation(s)
- Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado.
| | - Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Emily Cooper
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Ryan Phillips
- Department of Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Niti Shahi
- Department of Surgery, University of Massachusetts, Worcester, Massachusetts
| | - Margo Nolan
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado
| | - Shannon N Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Steven L Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Denis D Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, Aurora, Colorado; Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado; Department of Surgery, Denver Health Medical Center, Denver, Colorado
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Huang HC, Teng TC, Ming YC, Lin JJ, Liao CH, Hsieh CH, Li PH, Fu CY. Older Children with Torso Trauma Could Be Managed by Adult Trauma Surgeons in Collaboration with Pediatric Surgeons. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9030444. [PMID: 35327816 PMCID: PMC8947374 DOI: 10.3390/children9030444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 11/16/2022]
Abstract
Background: The purpose of this study is to assess the roles of pediatric surgeons and adult trauma surgeons in the management of pediatric torso trauma patients in a Level I adult trauma center. Methods: From 2015 to 2019, pediatric torso trauma patients (age < 18 years) were studied. A comparison between patients who did and did not undergo surgery was performed. Older children (age: 10−18 years) were compared with young adults (age: 18−35 years) selected with the same criteria using propensity score matching (PSM) and inverse probability of treatment weighting (IPTW). Results: A total of 226 patients were included in the study. Patients who underwent surgery for torso trauma (N = 61) were significantly older than patients who did not undergo surgery (N = 165) (13.1 vs. 10.4 years, p = 0.019). Both PSM and IPTW showed that the older children and young adult groups had similar proportions of patients requiring surgery (32.6% vs. 32.6%, standard difference (SD) = 0.000), proportions of patients who required torso angioembolization (8.7% vs. 9.8%, SD = 0.072), length of hospital stay (LOS) (8.1 vs. 8.0 days, SD = 0.026), and intensive care unit admission LOS (2.6 vs. 2.7 days, SD = 0.033). However, 7.1% of older children received critical care from pediatric surgeons. Additionally, 31.9% of younger children were cared for by pediatric surgeons/pediatricians. Conclusions: Adult trauma surgeons can feasibly perform surgeries for older children with torso trauma in collaboration with pediatric surgeons who provide critical care.
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Affiliation(s)
- Hsiang-Chieh Huang
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (H.-C.H.); (Y.-C.M.)
| | - Tzu-Chi Teng
- Department of Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Yung-Ching Ming
- Department of Pediatric Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (H.-C.H.); (Y.-C.M.)
| | - Jainn-Jim Lin
- Department of Pediatrics, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan;
| | - Chien-Hung Liao
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
| | - Chi-Hsun Hsieh
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
| | - Pei-Hua Li
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
- Correspondence: (P.-H.L.); (C.-Y.F.); Tel.: +886-3-3281200 (ext. 3651) (C.-Y.F.); Fax: +886-3-3289582 (C.-Y.F.)
| | - Chih-Yuan Fu
- Department of Trauma and Emergency Surgery, Chang Gung Memorial Hospital, Linkou Medical Center, Chang Gung University, Taoyuan City 333, Taiwan; (C.-H.L.); (C.-H.H.)
- Correspondence: (P.-H.L.); (C.-Y.F.); Tel.: +886-3-3281200 (ext. 3651) (C.-Y.F.); Fax: +886-3-3289582 (C.-Y.F.)
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Stevens J, Reppucci ML, Meier M, Phillips R, Shahi N, Shirek G, Acker S, Bensard D, Moulton S. Pre-hospital and emergency department shock index pediatric age-adjusted (SIPA) "cut points" to identify pediatric trauma patients at risk for massive transfusion and/or mortality. J Pediatr Surg 2022; 57:302-307. [PMID: 34753559 DOI: 10.1016/j.jpedsurg.2021.09.053] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Shock index pediatric age-adjusted (SIPA) is a validated measure to identify severely injured children. Previous literature categorized SIPA as normal or elevated, but the relationship between specific SIPA values and outcomes has not been determined. We sought to determine specific SIPA cut points in the pre-hospital and Emergency Department (ED) settings to identify patients at risk for massive transfusion (MT) and/or mortality. METHODS Patients ≤ 18 years old admitted to our Level I pediatric trauma center following trauma activation were included. Youdin J index was used to define pre-hospital and ED SIPA cut points to identify those at risk of MT and/or mortality for the following age groups: < 1 year, 1-6 years, 7-12 years, and > 12 years old. Sensitivity, specificity, accuracy, and area under the curve (AUC) were calculated to determine SIPA threshold values associated with MT and/or mortality. RESULTS Of 1,072 patients, 6.3% (n = 68) required MT and 8.4% (n = 90) died. For predicting MT, pre-hospital SIPA cut points performed best in the > 12 year-old age group (AUC = 0.86) and ED SIPA cut points performed best in the 6-12 year-old age group (AUC = 0.87). For predicting mortality, pre-hospital (AUC = 0.78) and ED SIPA cut points (AUC = 0.84) performed best in the > 12 year-old age group. CONCLUSION Pre-hospital and ED SIPA cut points performed better at predicting MT and/or mortality in older pediatric patients compared to very young children. Age remains an important factor when determining the validity of SIPA to predict outcomes in pediatric trauma patients. STUDY TYPE/LEVEL OF EVIDENCE Level III, Retrospective Cohort Study.
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Affiliation(s)
- Jenny Stevens
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Marina L Reppucci
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Maxene Meier
- The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Ryan Phillips
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Niti Shahi
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gabrielle Shirek
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Shannon Acker
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Denis Bensard
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Steven Moulton
- Division of Pediatric Surgery, Children's Hospital Colorado, 13213 E 16th Ave, Box 323, Anschutz Medical Campus, Aurora, CO 80045, USA; Department of Surgery, University of Colorado School of Medicine, Aurora, CO, USA
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Reppucci ML, Acker SN, Cooper E, Meier M, Stevens J, Phillips R, Moulton SL, Bensard DD. Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale. J Trauma Acute Care Surg 2022; 92:69-73. [PMID: 34932042 DOI: 10.1097/ta.0000000000003432] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The shock index pediatric age-adjusted (SIPA) predicts the need for increased resources and mortality among pediatric trauma patients without incorporating neurological status. A new scoring tool, rSIG, which is the reverse shock index (rSI) multiplied by the Glasgow Coma Scale (GCS), has been proven superior at predicting outcomes in adult trauma patients and mortality in pediatric patients compared with traditional scoring systems. We sought to compare the accuracy of rSIG to Shock Index (SI) and SIPA in predicting the need for early interventions in civilian pediatric trauma patients. METHODS Patients (aged 1-18 years) in the 2014 to 2018 Pediatric Trauma Quality Improvement Program database with complete heart rate, systolic blood pressure, and total GCS were included. Optimal cut points of rSIG were calculated for predicting blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. From the optimal thresholds, sensitivity, specificity, and area under the curve were calculated from receiver operating characteristics analyses to predict each outcome and compared with SI and SIPA. RESULTS A total of 604,931 patients with a mean age of 11.1 years old were included. A minority of patients had a penetrating injury mechanism (5.6%) and the mean Injury Severity Score was 7.6. The mean SI and rSIG scores were 0.85 and 18.6, respectively. Reverse shock index multiplied by Glasgow Coma Scale performed better than SI and SIPA at predicting early trauma outcomes for the overall population, regardless of age. CONCLUSION Reverse shock index multiplied by Glasgow Coma Scale outperformed SI and SIPA in the early identification of traumatically injured children at risk for early interventions, such as blood transfusion within 4 hours, intubation, intracranial pressure monitoring, and intensive care unit admission. Reverse shock index multiplied by Glasgow Coma Scale adds neurological status in initial patient assessment and may be used as a bedside triage tool to rapidly identify pediatric patients who will likely require early intervention and higher levels of care. LEVEL OF EVIDENCE Prognostic, level III.
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Affiliation(s)
- Marina L Reppucci
- From the Pediatric Surgery (M.L.R., S.N.A., J.S., R.P., S.L.M., D.D.B.), Children's Hospital Colorado, Aurora, Colorado; Division of Pediatric Surgery, Department of Surgery (M.L.R., S.N.A., J.S., R.P., S.L.M., D.D.B.), University of Colorado School of Medicine, Aurora, CO; The Center for Research in Outcomes for Children's Surgery, Center for Children's Surgery (E.C., M.M.), University of Colorado School of Medicine, Aurora, CO; and Department of Surgery (D.D.B.), Denver Health Medical Center, Denver, CO
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