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

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.

Development and validation of a Bayesian belief network predicting the probability of blood transfusion after pediatric injury

“…Few studies have described the relative contribution of each variable on the dependent variable being considered. With the addition of GCS, rSIG has better predictive performance than SIPA for several measures, including 4-hour blood transfusion, intubation, intracranial cerebral pressure monitor placement, and intensive care unit admission 12 . Our study supports the value of GCS as a predictor of the need for transfusion, in addition to systolic blood pressure and mechanism of injury.…”

“…To be applicable to children, adult triage scores have been modified to include age-based vital sign thresholds. These modified triage scores include SIPA (pediatric version of shock index), a pediatric version of rSIG, and pediatric versions of ABC 11–14 . These pediatric triage tools have several disadvantages, including the need to define age-based vital sign reference ranges, limited accuracy, and a requirement for values of all components of the score for use.…”

“…1) (Supplemental Digital Content, Supplementary Data 3, http://links.lww.com/TA/C617). We calculated SIPA and rSIG values using previously described thresholds 12,14 . Because TRAIN generates probabilities, we defined a probability threshold using prehospital and emergency department data for comparison with SIPA and rSIG.…”

“…These tools produce binary outputs based upon a "cutoff " value specific to an outcome or intervention, including blood transfusion within 4 to 24 hours following injury, massive transfusion protocol activation, intubation, intracranial cerebral pressure monitor placement, and intensive care unit admission. [11][12][13][14] The inclusion of the Glasgow Coma scale (GCS) score in rSIG and mechanism of injury, ultrasound, and laboratory results in the ABC score improves the predictive performance of the need for blood transfusion and massive transfusion protocol activation. 11,12 Improvement in predictions using these additional variables suggests that physiological changes and anatomic injury features in addition to hypotension and tachycardia are predictors of injury-associated hemorrhage.…”

Time is Tissue: Barriers to Timely Transfusion after Pediatric Injury

“…13,38,[41][42][43] Third, several scores, such as SIPA and rSIG, function as binary predictors (present/absent need for transfusion) and do not yield a probability or risk estimate like some adult tools. [41][42][43] Because interventions for hemorrhage may be chosen using a cost-effectiveness standard or differ based on risk of hemorrhage, binary classification may limit the applicability of these tools. Fourth, tools like the pediatric version of the ABC score require laboratory and imaging results that are often not available before patient arrival or early after arrival to the hospital.…”