Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in pediatric trauma

Abstract

INTRODUCTION Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries. METHODS Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality. RESULTS A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality. CONCLUSION Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population. LEVEL OF EVIDENCE Prognostic study, level IV.

Addition of neurological status to pediatric adjusted shock index to predict early mortality in trauma: A pediatric Trauma Quality Improvement Program analysis

“…To contrast this, penetrating injury has recently been demonstrated in more than 40% of pediatric injuries within combat environments, suggesting that the injury patterns between these studies are not comparable. 16,17 Furthermore, the rSIG cutoff values that we previously demonstrated from combat-related data were relatively higher than the values seen within this study. For instance, this study demonstrated optimal cutoff values of 5.2, 5.9, 9.0, and 9.6 for children aged 0 to 3, 4 to 6, 7 to 12, and 13 to 18 years, respectively.…”

“…To contrast this, our previous work using military data found the optimal cutoff values of 8.3, 10.5, and 10.8 for children aged 0 to 6 years, 7 to 12 years, and 13 to 18 years, respectively. 17 We believe that this may be due to several reasons. While the differing patient populations and associated injury patterns likely accounts for some of the variation, the mortality rates displayed in our previous work were largely only representational of early death within the resuscitative phase because of the circumstances often surrounding the medical rules of engagement in combat zones.…”

“…These findings, once again, correlate with the previously published military data suggesting that rSIG outperforms SIPA for severely injured pediatric trauma patients. 17 Although this study represents the largest evaluation of rSIG in the pediatric trauma literature, the retrospective nature of this article must be taken into account before clinical implementation. Although promising, prospective study and further evaluation should be performed to validate its use and ascertain the specific patient populations that would receive the largest clinical benefit from its use.…”

Derivation and validation of an improved pediatric shock index for predicting need for early intervention and outcomes in pediatric trauma

“…Proposed uses include intensive care unit admission guidelines, 17,18 study inclusion criteria, 25 and risk prediction 21 . It has also been incorporated as one component of multifaceted mortality prediction tools 16,21,26 …”

Improved identification of severely injured pediatric trauma patients using reverse shock index multiplied by Glasgow Coma Scale

“…[8][9][10] Reverse shock index multiplied by Glasgow Coma Scale has recently been shown to be more predictive of mortality than SIPA in both military and civilian settings. 11,12 This suggests that rSIG may be more generalizable than SIPA to pediatric trauma patients regardless of injury mechanism; however, its full utility is unstudied in the pediatric population. Thus, the purpose of this study was to determine if rSIG is a useful tool for identifying severely injured pediatric trauma patients.…”