Background
The pediatric resuscitation and trauma outcome (PRESTO) model was developed to aid comparisons of risk‐adjusted mortality after injury in low‐ and middle‐income countries (LMICs). We sought to validate PRESTO using data from a middle‐income country (MIC) trauma registry and compare its performance to the Pediatric Trauma Score (PTS), Revised Trauma Score, and pediatric age‐adjusted shock index (SIPA).
Methods
We included children (age < 15 years) admitted to a single trauma center in South Africa from December 2012 to January 2019. We excluded patients missing variables necessary for the PRESTO model—age, systolic blood pressure, pulse, oxygen saturation, neurologic status, and airway support. Trauma scores were assigned retrospectively. PRESTO's previously high‐income country (HIC)‐validated optimal threshold was compared to MIC‐validated threshold using area under the receiver operating characteristic curves (AUROC). Prediction of in‐hospital death using trauma scoring systems was compared using ROC analysis.
Results
Of 1160 injured children, 988 (85%) had complete data for calculation of PRESTO. Median age was 7 (IQR: 4, 11), and 67% were male. Mortality was 2% (n = 23). Mean predicted mortality was 0.5% (range 0–25.7%, AUROC 0.93). Using the HIC‐validated threshold, PRESTO had a sensitivity of 26.1% and a specificity of 99.7%. The MIC threshold showed a sensitivity of 82.6% and specificity of 89.4%. The MIC threshold yielded superior discrimination (AUROC 0.86 [CI 0.78, 0.94]) compared to the previously established HIC threshold (0.63 [CI 0.54, 0.72], p < 0.0001). PRESTO showed superior prediction of in‐hospital death compared to PTS and SIPA (all p < 0.01).
Conclusion
PRESTO can be applied in MIC settings and discriminates between children at risk for in‐hospital death following trauma. Further research should clarify optimal decision thresholds for quality improvement and benchmarking in LMIC settings.
Background: Bacterial translocation (BT) from the gut can develop and persist after short periods of hemorrhagic shock secondary to traumatic injuries. Erythroopoietin (EPO) exerts hemodynamic and anti-inflammatory effects in addition to its erythropoietic effect. We tested the hypothesis that EPO given at the time of acute resuscitation with normal saline (NS), Ringer's lactate (RL) or 7.5% hypertonic saline (7.5%HTS) will limit shock-induced mucosal injury and BT. Methods: Rats were hemorrhaged 30 mL/kg over 10 minutes via arterial catheter for 50 minutes, then randomized to 1 of 6 resuscitation groups (n = 5/group): NS, NS+EPO, RL, RL+EPO, 7.5%HTS and 7.5%HTS+EPO. Intravenous EPO (1000 U/kg) was given at the start of NS or RL (3 times the volume of shed blood) and 4 mL/kg of 7.5%HTS+1 volume of RL resuscitation. Postresuscitation gut function was evaluated using agar cultures of mesenteric lymph nodes and portal vein plasma lipopolysaccharide, IL-6 and TNF-α levels. Three of 5 rats per group underwent light microscopic examination using semi-thin plastic sections of the distal ileum and fluorescein isothiocyanate dextran 4000 used to assess the distal ileum mucosal permeability to macromolecules. Results: Two hours postshock and resuscitation, BT to mesenteric lymph nodes decreased in the NS+EPO versus the NS group (299 ± 104 v. 1050 ± 105 CFU/gm, p < 0.05); the addition of EPO to the RL or 7.5%HTS had no effect. Comparing different solutions, there was a significant increase in BT in the NS group versus the RL+EPO, 7.5%HTS+EPO and 7.5%HTS groups (1050 ± 105 v. 357 ± 134, 462 ± 129, 428 ± 106 CFU/gm, respectively; p < 0.05). There were no significant differences in terminal ileum permeability between groups, but there was a noticeable trend in decreasing terminal ileum permeability in the EPO-treated groups: NS versus NS+EPO (18.0 ± 9.5 v. 12.9 ± 6.3 µg/mL, p = 0.84), RL versus RL+EPO (17.7 ± 5.9 v. 8.4 ± 2.7 µg/mL, p = 0.22) and 7.5%HTS versus 7.5%HTS+EPO (11.4 ± 6.4 v. 6.5 ± 2.9 µg/mL, p = 0.69). There was no significant morphological evidence of mucosal injuries and no cytokine differences between groups and within groups. Conclusion: Preliminary data from an uncontrolled mean arterial pressure hemorrhagic shock rat model revealed that BT is an early event occurring within 2 hours of injury and resuscitation before any evidence of histological injury. Erythroopoietin with NS significantly decreased BT to the portal vein as compared with NS alone, but not with RL and 7.5%HTS.Analgesia in the management of pediatric trauma in the resuscitative phase: the role of the trauma centre.
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