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AAST 2020 PODIUM PAPERS

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

Lammers, Daniel T. MD; Marenco, Christopher W. MD; Do, Woo S. MD; Conner, Jeff R. MD; Horton, John D. MD; Martin, Matthew J. MD; Escobar, Mauricio A. Jr MD; Bingham, Jason R. MD; Eckert, Matthew J. MD

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Journal of Trauma and Acute Care Surgery: January 2021 - Volume 90 - Issue 1 - p 21-26
doi: 10.1097/TA.0000000000002946
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Abstract

Trauma represents the leading cause of mortality in pediatric and adolescent patients worldwide.1 Although adult trauma displays a robust research network, the decreased overall frequency and nonuniformed regionalization of care within the pediatric trauma community result in a body of pediatric trauma–specific literature that consequently pales in comparison.2 From prehospital care and patient transport to performance of definitive surgical intervention at major pediatric centers, a multitude of pediatric specific questions remain to be addressed. As such, further elucidation of optimal practices with regards to both individual care and the performance of pediatric trauma systems is needed.

The initial evaluation of trauma patients remains an area under constant assessment because early recognition of physiologic derangements and pathologies helps to drive rapid intervention and provide quality care. A recent emergence of studies assessing the use of early vital signs and presenting injury patterns has resulted in an influx of various scoring systems and models for predicting trauma related outcomes.3–7 Proponents who support the utilization of these models argue that they provide actionable information that can help guide clinical decision making and allow for strategic allocation of resources in an already taxed health care system. While well-resourced tertiary care facilities may benefit from these models, health care providers practicing in prehospital, austere, military, and low-resource settings likely receive the largest potential benefit because of the limited nature of their capabilities. Military environments, where multiple injuries secondary to blast and high-energy penetrating mechanisms prevail, particularly highlight the need for accurate prospective outcome predictors because the strategic allocation of the limited supply of blood products, medications, and medical devices remains mission critical for success.

Of the various prospective models that have recently emerged, shock index (SI), defined as heart rate divided by systolic blood pressure, has become popularized because of its ease of calculation and ability to be rapidly applied at the bedside.7 Pediatric age-adjusted shock index (SIPA) values have subsequently been defined to account for variations in physiologically normal ranges displayed by pediatric populations.5 These findings have been validated in both civilian and military pediatric trauma patients by demonstrating utility in predicting injury severity, need for emergent surgical procedures, transfusion requirements, and mortality.5,8,9 Although promising, failure to recognize mental status may limit its use because neurologic status on arrival has demonstrated prognostic utility in trauma patients.3,4 To combat this, the reverse shock index multiplied by arrival Glasgow Coma Scale (GCS) score (rSIG) recently has demonstrated promise for both civilian and military adult trauma patients.10–13 This study sought to expand upon these findings by comparing the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries.

PATIENTS AND METHODS

Institutional review board approval was obtained at Madigan Army Medical Center before data abstraction and analysis. A retrospective review of the Department of Defense Trauma Registry (DoDTR) between 2008 and 2016 was performed for all pediatric patients. Pediatric patients were defined as all patients younger than 18 years. The DoDTR is a database that was specifically created by the US Department of Defense to collect combat casualty data from recent conflicts within a single location to help advance combat casualty care through research efforts. The DoDTR represents the most comprehensive collection of patient-specific data points ranging from point of injury care through intertheater medical transport. Encompassed within the DoDTR are demographic data such as age, sex, nationality, injury patterns, and trauma-related outcomes data such as Injury Severity Score (ISS), Abbreviated Injury Score, mortality, and cause of death, as well as physiologic data to include basic laboratory values, vital signs, and medical treatments. Each unique patient identification number was evaluated to assure no redundancies within the data set.

The patient population included all patients initially treated at North American Treaty Organization (NATO) Role II and III facilities younger than 18 years with documented vital signs. Because there are no active duty personnel younger than 18 years, the population studied consisted solely of civilian patients affected by the local conflict who were initially brought to these NATO Role II and III military facilities for treatment. The NATO Role II medical treatment facility designation represents facilities capable of providing advanced trauma and emergency medical management. Resources at these facilities are limited to damage-control surgical and resuscitative principles. NATO Role III facilities encompass those facilities that can further provide specialized care to include definitive surgical procedures, critical care capabilities, and prolonged patient holding.

The objective of this study was to assess the value of rSIG compared with SIPA for mortality prediction in pediatric patients who sustained injuries secondary to military conflict. Shock index was defined by heart rate divided by systolic blood pressure on arrival to the trauma bay. For the purpose of this study, SI was considered elevated as defined by previously reported SIPA cutoff values of >1.22 for ages 0 to 6 years, 1.0 for ages 7 to 12 years, and 0.9 for ages 13 to 18 years.5,14 The rSIG was calculated by multiplying the inverse SI, systolic blood pressure divided by heart rate, with the presenting GCS score. Inverse SI was used to assure consistency for corresponding incremental increases and decreases between the vital signs and GCS. Optimal cutoff values for rSIG were calculated for age groups of 0 to 6 years, 7 to 12 years, and 13 to 18 years through receiver operating characteristic analysis of each respective age group assessing mortality by calculating the Youden index (YI). Youden index, defined as YI = sensitivity + specificity – 1, is a validated method used to determine optimal cutoff values from receiver operating characteristic analysis.15,16

Standard descriptive statistical analysis was performed for all study subjects and reported as frequencies or mean values with SDs as appropriate. Univariate analysis was performed based on mortality for categorical and continuous data between groups using the χ2 test and Student t test or Mann-Whitney U test as appropriate. Significance was determined using p < 0.05 for all data. Multivariate logistical regression was then used to identify prehospital and emergency room variables, including elevated SIPA and rSIG scores, independently associated with mortality in our patient cohorts. Adjusted odds ratio (OR) have been reported for the regression results. All data were analyzed using IBM SPSS version 24 (IBM Corp., Armonk, NY) and Microsoft Excel (Microsoft Corporation, Redmond, WA) software.

RESULTS

A total of 2,007 patients were identified for this study based on our selection criteria. The population was predominately male (79%), with median age range of 7 to 12 years, and sustained a penetrating mechanism of injury 63% of the time. The overall average ISS was 11.9 with 32% of patients sustaining injury patterns consistent with an overall severe injury defined by ISS of >15. Patients who sustained severe injury to the head and neck, face, torso, abdomen and pelvis, extremities, and external as defined by Abbreviated Injury Score of 3 or greater are further shown in Table 1. Isolated severe head injury was noted in 2.8% of patients. A total of 45% of the patients’ injuries were secondary to blast mechanisms, and 19% (386 patients) were due to gunshot wounds. The overall mortality of our studied cohort was 7.1% (143 patients). The study demographics are outlined in Table 1.

TABLE 1 - Overall Study Population Characteristics
Variable Overall
Male, n (%) 1590 (79)
Age, n (%)
 0–6 y 581 (29)
 7–12 y 966 (48.1)
 13–17 y 460 (22.9)
Penetrating injury, n (%) 1,254 (62.5)
Blast injury, n (%) 864 (44.5)
Average ISS, mean (SD) 11.9 (9.7)
Severe injury, n (%) 645 (32.1)
Severe head/neck injury, n (%) 235 (11.7)
Severe face injury, n (%) 6 (0.3)
Severe chest injury, n (%) 226 (11.3)
Severe abdominal injury, n (%) 185 (9.2)
Severe extremity injury, n (%) 379 (18.9)
Severe external injury, n (%) 138 (6.9)
Severe GCS, n (%) 548 (27.3)
Elevated SIPA, n (%) 874 (43.5)
Positive pediatric rSIG, n (%) 685 (34.1)
Mortality, n (%) 143 (7.1)
Overall study demographics.

Patients who died were more likely to be female, display an ISS of >15, sustain severe head or abdominal injury, and have a major burn injury. Based on arrival data, those who died were more likely to be coagulopathic or acidotic, display greater base deficit, and have a lower core body temperature. Demographic and arrival data for those who died versus those who survived can be found in Table 2. When broken down by age groups, mortality rates were highest in patients aged 0 to 6 years, while the 13- to 17-year-old cohort was associated with lower mortality rates. Despite this, mortality was most frequent in the overall population within the 7- to 12-year-old cohort representing 47.6% of reported deaths.

TABLE 2 - Demographic and Presenting Data in Survivors Versus Nonsurvivors
Variable Survived Died Significance
Total 1,864 143
Male, n (%) 1,487 (79.8) 103 (72.0) 0.028
Age, n (%)
 0–6 y 527 (28.3) 54 (37.8) 0.016
 7–12 y 898 (48.2) 68 (47.6) 0.886
 13–17 y 439 (23.6) 21 (14.7) 0.015
Penetrating injury, n (%) 1,167 (62.6) 87 (60.8) 0.674
Blast injury, n (%) 821 (44) 73 (51) 0.104
Average ISS, mean (SD) 10.96 (8.7) 24.05 (12.8) <0.001
Severe injury, ISS >15, n (%) 531 (28.5) 114 (79.7) <0.001
Severe head/neck injury, n (%) 180 (9.7) 55 (38.5) <0.001
Severe face injury, n (%) 6 (0.3) 0 (0.0) 0.497
Severe chest injury, n (%) 211 (11.3) 15 (10.5) 0.762
Severe abdominal injury, n (%) 163 (8.7) 22 (15.4) 0.008
Severe extremity injury, n (%) 356 (19.1) 23 (16.1) 0.375
Severe external injury, n (%) 111 (6.0) 27 (18.9) <0.001
Severe GCS, n (%) 441 (23.7) 107 (74.8) <0.001
Required ICU admission, n (%) 728 (39.1) 109 (76.2) <0.001
Need for mechanical ventilation, n (%) 170 (9.1) 24 (16.8) 0.003
Received blood products, n (%) 637 (34.2) 74 (51.7) <0.001
Received TXA, n (%) 60 (3.2) 9 (6.3) 0.052
Coagulopathic, INR ≥1.6, n (%) 201 (16.9) 44 (58.7) <0.001
Average INR on arrival, mean (SD) 1.27 (0.47) 2.22 (1.59) <0.001
Acidotic, pH ≤7.2, n (%) 203 (13.4) 63 (55.3) <0.001
Average pH on arrival, mean (SD) 7.31 (0.11) 7.15 (0.20) <0.001
Shock, base deficit >−2, n (%) 790 (52.1) 99 (88.4) <0.001
Average base deficit on arrival, mean (SD) −3.96 (4.58) −9.62 (7.00) <0.001
Hypothermia, temperature <96.8 F, n (%) 166 (9.6) 37 (33.3) <0.001
Average temperature on arrival, mean (SD), F 98.5 (3.19) 96.39 (9.15) 0.017
Elevated SIPA, n (%) 782 (42.0) 92 (64.3) <0.001
Positive pediatric rSIG, n (%) 563 (30.2) 122 (85.3) <0.001
Comparison between survival and death.
ICU, intensive care unit; INR, internationalized normalized ratio; TXA, tranexamic acid.

Based on previously reported adult SI cutoff values of >0.9, 62.4% of all pediatric patients included in the study demonstrated an elevated SI.17 To contrast this, only 44% of the patient population demonstrated an elevated SIPA value. Following analysis of receiver operator characteristic curves for each respective age group assessing rSIG on mortality, optimal cutoff values were determined using the YI. The rSIG values of <8.3, 10.5, and 10.8 for age groups 0 to 6 years, 7 to 12 years, and 13 to 17 years, respectively, were found to provide the optimal cutoff value for each cohort studied. Using these values, positive rSIG scores were found to be present in 34.1% of patients with an associated sensitivity of 85.3% compared with a 64.5% sensitivity associated with elevated SIPA scores. The rSIG demonstrated a superior negative predictive value compared with SIPA at 98.4% versus 95.5%, respectively. Furthermore, positive rSIG values using the aforementioned cutoff values were found to demonstrate a 24% increase in specificity compared with elevated SIPA scores (69.8% vs. 45.8%) within this patient population. Finally, a 12.4% increase in overall accuracy was seen based on the newly proposed rSIG values when compared with SIPA scores (70.9% vs. 58.5%).

Elevated SIPA and positive rSIG were each assessed in a multivariate logistic regression analysis for mortality. Following adjustment for demographics, injury type and severity, and presenting laboratory parameters, elevated SIPA (OR, 2.74; p < 0.01) and rSIG (OR, 4.05; p = 0.01) were both found to be independently associated with mortality. In the model tested, severe head trauma, elevated base deficit on arrival, platelet count of <50 on arrival, and hypothermia on arrival further proved to be independently associated with increased mortality, while ages 7 to 12 years were independently associated with a decreased risk of mortality (Table 2). On further stratification, elevated SIPA (OR, 2.5; p = 0.02) and positive rSIG (OR, 8.9; p < 0.01) were both independently associated with mortality in patient cohorts displaying an ISS of >15. Conversely, in less severely injured patients, both scoring systems failed to demonstrate a significant independent association with mortality.

DISCUSSION

Prospectively identifying trauma patients at the highest risk for mortality provides actionable data for both the clinical and logistical decision-making processes. Developing improved triage and scoring systems may help mitigate unnecessary expenditures in an already taxed health care system, while still allowing appropriate patient management to take place. Although the multitude of scoring systems previously studied all show some benefit for their intended purpose, a criterion standard for traumatic injuries has yet to emerge as each system displays its own limitations. Because of the relatively decreased amount of pediatric trauma specialty centers compared with adult trauma facilities, pediatric trauma further highlights the importance for appropriate early triage during patient transport to assure optimal care is reached. Although this concept remains important in well-resourced settings, it is crucially important for military, austere, and humanitarian missions, as they remain particularly vulnerable because of environmental complexity, constrained resources, and inadequate staffing. Ultimately, these environments may benefit most from improved triage and early prognostic scoring systems demonstrating that these concepts should remain an utmost focus for austere providers to optimize trauma-related outcomes. This study sought to examine the additive effects of including neurologic status to SI in pediatric patients using military data as a prospective predictor of mortality.

To our knowledge, this article represents the first assessment of rSIG within pediatric trauma populations. Previously reported data assessing rSIG in adult trauma patients suggest a cutoff value of 14.8, which supported a sensitivity of 65.9% and specificity of 92.9% for mortality prediction.13 Follow-up assessment addressing the use of rSIG in adult military trauma populations demonstrated comparable findings, albeit a much-improved sensitivity at 89% with an optimal cutoff value of 14.1, validating its use for military triage.10 Furthermore, rSIG outperformed multiple other prospective mortality prediction tools within the military populations to include SI and the Revised Trauma Score.10 Although there are no previously reported data for optimized rSIG cutoff values within pediatric trauma patients, our findings suggest the optimal values in pediatric patients to be much lower than their adult counterparts. The retrospective nature of this study limits the interpretation of these findings; however, we believe that the inherent differences in vital signs for pediatric patients, as well as the relative lack of comorbidities displayed within pediatric populations, which may suggest a better overall tolerance to physiologic duress, likely account for the differing values between the adult and pediatric populations. Moreover, the sensitivities displayed from this study were roughly 20% higher than the adult civilian literature and displayed relatively similar values to previously reported adult military data.10,13 These findings may suggest that rSIG is best suited for screening purposes in military trauma populations where complex multiple injuries and high-energy mechanisms often prevail. To date, evaluation within civilian pediatric patients is not available for comparison purposes. Despite this, it is important to note that the population demographics and injury patterns within these studies varied drastically; therefore, further assessment is needed before establishing comparisons between the various trauma populations.

While this study represents the sole and, consequently, largest assessment of rSIG in pediatric trauma, its focus on injuries sustained within the combat zone preclude it from direct extrapolation to civilian counterparts. The high proportion of primary penetrating and blast-associated injuries demonstrates injury patterns unparalleled within the civilian pediatric literature.18,19 Our study displayed a primary penetrating mechanism within 62.5% of the studied patients. The associated blast injury rate of 44.5% further suggests that many of these injuries were components of complex multiple injuries as opposed to isolated injuries. As such, it remains clear that this study population represents a different population than commonly explored at major tertiary care and pediatric facilities. Pediatric age-adjusted shock index has, however, demonstrated promise in both military and civilian literature, which suggests that rSIG may have similar utility in both realms, although, as previously mentioned, its significance in civilian populations remains unknown. Should this association hold true, one could surmise that pediatric rSIG values may hold greater overall prognostic power than SIPA for civilian mortality prediction based on the regression models presented from these data. From these models, the data suggest that the odds of a fatal injury secondary to combat-related trauma in pediatric populations is nearly 1.5-fold higher when displaying a positive rSIG value compared with an elevated SIPA score. When stratified by severe injury, denoted by ISS of >15, the mortality odds displayed by this study were nearly fourfold higher for positive rSIG values compared with SIPA, suggesting that this triage tool may prove most beneficial within patients sustaining more complex and severe injuries.

The inherent nature of this assessment and the data set should, however, be taken into account when interpreting the data. As mentioned, this study focuses on injuries sustained largely within developing countries secondary to the combat zone and, therefore, cannot be directly applied to civilian pediatric trauma. Furthermore, to provide an accurate comparison, the age groups used in this study were based on previously reported SIPA values and may not accurately reflect the optimal cohorts for rSIG. Further study assessing optimal groupings based on neurologic status and function should be sought. This notion may be highlighted by patients within the 0- to 6-year-old grouping, where cognitive ability is widely varied between the represented ages, suggesting that a unified rSIG value may not be the most appropriate prognostic technique. With regards to the patients represented in this study, these children represent a population that is not readily applicable to the civilian pediatric trauma population. Significant bias should be accounted for because this study population represented patients who all initially were brought to military treatment facilities and failed to capture the cohort of patients presenting to the local civilian hospitals. Although the mortality rates displayed within the data come from the most accurate military data source currently available, visibility of patient outcomes following transfer from the military treatment facilities to the civilian sector is often nonexistent; therefore; there remains a high degree of possibility that overall mortality rates may be higher than reported. Despite these limitations, this study was the first to combine neurologic status and SI for pediatric trauma patients. This work represents an incremental step toward improving trauma triage scores and the utilization of this simple, bedside scoring system should continue to be studied to help optimize triage, guide care, and aide with resource allocation.

AUTHORSHIP

D.T.L., C.W.M., W.S.D., and J.R.C. conducted the literature search. D.T.L., C.W.M., J.R.B., J.D.H., and M.J.E. contributed to study design. D.T.L., C.W.M., J.R.C., and J.D.H. participated in data acquisition. D.T.L., J.R.B., M.J.M., M.A.E., and M.J.E. contributed to the data analysis and interpretation. D.T.L., C.W.M., W.S.D., and J.R.C. drafted the article. J.D.H., J.R.B., M.J.M., M.A.E., and M.J.E. critically revised the final article. D.T.L., C.W.M., W.S.D., J.R.C., J.D.H., J.R.B., M.J.M., M.A.E., and M.J.E. reviewed and approved the final article.

ACKNOWLEDGMENTS

We thank the Department of Clinical Investigations at Madigan Army Medical Center in Tacoma, Washington, for providing support throughout this project.

DISCLOSURE

The authors declare no conflicts of interest.

The view expressed are those of the authors and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government. In addition, they do not reflect the official policy of the position of any affiliated institution of the author group.

REFERENCES

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DISCUSSION

RANDALL S. BURD, M.D., Ph.D. (Washington, District of Columbia): Yes, thank you, Dr. Lammers for a nice study. I think that defining the population of injured children at high risk for adverse outcomes, including mortality, remains an important goal to achieve in both civilian and military settings.

The Shock Index and its pediatric counterpart, the SIPA score have been suggested as initial assessment that can identify patients at high risk for adverse outcomes. In fact, the validity of these measures increases when changing their values rather than static values are considered.

Severe traumatic brain injury is an important cause of adverse outcomes after pediatric injury that, when combined with shock, likely synergistically increases the likelihood of adverse outcomes. Given these observations, it is logical to develop a score that incorporates a measure of shock and severity of head injury.

In the current study the authors have shown that the rSIG performs better than SIPA as a predictor of mortality in a military setting population of injured children.

I have several questions for the authors mainly related to the use of GCS total which I know was done in the adult counterpart of the results that you showed today but whether GCS motor should be considered.

So GCS has a non-linear relationship with mortality yet the rSIG models this relationship in a linear way. In contrast the GCS motor score has a much more linear relationship with mortality that can be further made linear by transformation. Should the GCS motor score, instead, be used for this composite sore?

And a related question is the total GCS score is influenced by sedation and intubation. Did you consider the need for mechanical ventilation as a factor in your multivariate analysis of SIPA and rSIG as predictors of mortality to account for this factor?

DANIEL LAMMERS, M.D. (Joint Base Lewis-McChord, Washington): Thank you, Dr. Berg, for those questions. I will address your second question first with the need for mechanical ventilation.

From what we were able to assess with the DoDTR and the nature of the patients that were brought in the majority of the patients were from civilian counterparts and local nationals, therefore, a lot of them were not – or the majority and in fact all of them, from what I can recall, none of them were sedated or intubated prior to arrival.

That being said, you mentioned the change in, you know, SIPA scores as well as Shock Index previously, that would be something we would consider for the future, the need for mechanical ventilation and how that would affect their GCS scores.

In regards to the question regarding their GCS motor score, that is a very good observation, a very good idea and something that we did not look at in this.

But definitely one of the major limitations as to this initial work showing that we balanced essentially the GCS as well as the Shock Index on equal playing fields when, in reality, in order to create the most optimal scoring system they may not be equal in terms of the degree of traumatic brain injury versus the degree of shock that a patient is experiencing.

So future work to look at the exact weight that each of those predictors holds should definitely be sought, and it’s definitely something that we plan on looking into. However, for this first initial work that we did we wanted to just validate the initial scoring system as is.

MARY E. FALLAT, M.D. (Louisville, Kentucky): Dr. Lammers let me ask you a couple of practical questions. I think the first is what percent of the trauma victims that someone might see in the field in a setting like this are kids?

And practically, how does your study help translate so that adults can take better care of kids, adult surgeons can take better care of kids?

DANIEL LAMMERS, M.D. (Joint Base Lewis-McChord, Washington): Sure. Great questions and thank you very much. With regards to from a practical standpoint, what I was able to assess from the DoDTR is there is over roughly 30,000 patients and less than about a tenth of those are, were pediatric patients. So it’s a relatively small percentage.

And, obviously, that is going to be combined with the regions in the combat zone where you are deployed as opposed to a lot of the other local factors and the agreements with the civilian sector as to what type of patients you can bring in.

But from what I was able to see it was a small percentage, under 10 percent of the patients within the DoDTR in total, were pediatric patients.

And then with regards to your second question, I think one of the major utilities would be scoring systems.

As an adult trauma surgeon looking at them for pediatric patients would be assessing the need to, one, determine how likely this child is to be, you know, severely sick by factors that may show up in their vital signs prior to actual clinical exam; and how we can get them rapidly triaged to the appropriate level of care.

So potentially in the prehospital arena when maybe EMS is calling to decide what type of hospital this child needs to go to – do they need to go to a Level I trauma center; do they need to go to a pediatric trauma center; or would they be fine going to, say, a local Level II trauma center – I think a lot of these early scoring systems would help with the appropriate prehospital triage to make sure that the child is getting to the appropriate level of care early.

MARY E. FALLAT, M.D. (Louisville, Kentucky): Do you know in the military setting if the medics who bring the patients in have specific training for children, children’s injuries?

DANIEL LAMMERS, M.D. (Joint Base Lewis-McChord, Washington): I am not aware of anything specifically; however, that being said, I have not physically been deployed or in those positions so I haven’t witnessed that firsthand.

I do know the medics do get a lot of training on various triage scores and scoring systems; however, off the top of my head I do not know about pediatric ones specifically.

Keywords:

Pediatric trauma; combat; shock; triage; resuscitation

Copyright © 2020 American Association for the Surgery of Trauma.