The value of the injury severity score in pediatric trauma

Abstract

Background The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS>15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and AIS to predict mortality and define optimal thresholds of severe injury in pediatric trauma. Methods Patients from the Pennsylvania trauma registry 2000–2013 were included. Children were defined as age<16years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cut-off for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated association between mortality and maximum AIS in each body-region, controlling for age, mechanism, and non-accidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed. Results There were 352,127 adults and 50,579 children included. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cut-off in children was ISS>25 and had a positive predictive value (PPV) of 19% and negative predictive value (NPV) of 99% compared to PPV of 7% and NPV of 99% for ISS>15 to predict mortality. In single-system injured children, mortality was associated with head (OR 4.80; 95%CI 2.61–8.84, p<0.01) and chest AIS (OR 3.55; 95%CI 1.81–6.97, p<0.01), but not abdomen, face, neck, spine, or extremity AIS (p>0.05). For multisystem injury, all body region AIS were associated with mortality except extremities. Sensitivity analysis demonstrated ISS>23 to predict need for full trauma activation, and ISS>26 to predict impaired functional independence were optimal. Conclusions ISS>25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system injured children. These findings should be considered in benchmarking and performance improvement efforts. Level of Evidence III, epidemiologic

Assessment of polytraumatized patients according to the Berlin Definition: Does the addition of physiological data really improve interobserver reliability?

“…One advantage of the Berlin Definition is that it uses the MAIS definitions, which in our study showed better agreement between experts than the ISS, which is consistent with Brown et al [ 24 ]. Consequently, ISS-based definitions might give better results by automatic estimation of the ISS, and perhaps to some extent the MAIS for the Berlin Definition, as is done in some registries.…”

“…Another reason might be that the calculation of the ISS can be difficult. As an example of the discussion concerning the ideal cutoff if using the ISS to identify a patient with polytrauma, a recent registry study of nearly 400,000 patients showed that for children compared with adults, the optimal cutoff was ISS ≥25 points [ 24 ]. We cannot address this issue here, because there were few children included in our study, but it emphasizes the point that there is an ongoing need for discussion of the ISS ≥16 points cutoff value for defining polytrauma and of all ISS-based classification the interobserver reliability was best in ISS ≥25 points.…”

Clinical role of low hemoglobin ratio in poor neurologic outcomes in infants with traumatic intracranial hemorrhage

“…In addition, a lower HB level during admission was more common in the infants with TBI with poor neurologic outcomes compared to those with favorable neurologic outcomes. We also found that a lower HB was associated with poor neurologic outcomes and in-hospital mortality independent of other risk factors including initial GCS, ISS, RBCT, neurosurgery, imaging findings, and retinal hemorrhage, all of which have been reported to be strong predictors for outcomes in infants with TBI in previous studies 15,20,21 . Previous studies have reported that initial GCS and ISS are both risk factors for a poor prognosis in pediatric TBI cases 22,23 .…”

“…In addition, the nadir HB developed within the first 2 days, and was thus a feasible and www.nature.com/scientificreports www.nature.com/scientificreports/ practical parameter. In previous studies on pediatric TBI, initial GCS and ISS were the most commonly used risk factors for a poor prognosis [20][21][22][23] . In the final model of our study, we identified initial GCS and ratio of ΔHB as the predictors for a poor prognosis, both of which were more powerful than ISS.…”

Characterization of organ dysfunction and mortality in pediatric patients with trauma with acute traumatic coagulopathy

“…Injury severity was assessed by the Injury Severity Score (ISS) which was considered as a continuous scale and categorized into mild (0-14), moderate (15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29), and severe (30-75) trauma. [28][29][30] Arterial hypotension was defined as a systolic blood pressure of <60 mm Hg in neonates 0 to 30 days old, <70 mm Hg in infants 30 days to 1 year old, <70 mm Hg + (age in years x 2) mm Hg in children 1 year to 10 years old, and <90 mm Hg in children and adolescents > 10 years old based on reference points established in the Pediatric Advanced Life Support guidelines. 31 copyright.…”