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The Base Deficit, International Normalized Ratio, and Glasgow Coma Scale (BIG) Score, and Functional Outcome at Hospital Discharge in Children With Traumatic Brain Injury*

Davis, Adrienne L. MD, MSc, FRCPC1,2; Hochstadter, Elana MD1; Daya, Tahira MD3; Kulkarni, Abhaya V. MD, PhD2,4; Wales, Paul MD, MSc2,5; Stephens, Derek MSc2; Schuh, Suzanne MD, FRCPC1,2

Pediatric Critical Care Medicine: October 2019 - Volume 20 - Issue 10 - p 970-979
doi: 10.1097/PCC.0000000000002050
Neurocritical Care
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Objectives: To examine the association of the base deficit, international normalized ratio, and Glasgow Coma Scale (BIG) score on emergency department arrival with functional dependence at hospital discharge (Pediatric Cerebral Performance Category ≥ 4) in pediatric multiple trauma patients with traumatic brain injury.

Design: A retrospective cohort study of a pediatric trauma database from 2001 to 2018.

Setting: Level 1 trauma program at a university-affiliated pediatric institution.

Patients: Two to 17 years old children sustaining major blunt trauma including a traumatic brain injury and meeting trauma team activation criteria.

Interventions: None.

Measurements and Main Results: Two investigators, blinded to the BIG score, determined discharge Pediatric Cerebral Performance Category scores. The BIG score was measured on emergency department arrival. The 609 study patients were 9.7 ± 4.4 years old with a median Injury Severity Score 22 (interquartile range, 12). One-hundred seventy-one of 609 (28%) had Pediatric Cerebral Performance Category greater than or equal to 4 (primary outcome). The BIG constituted a multivariable predictor of Pediatric Cerebral Performance Category greater than or equal to 4 (odds ratio, 2.39; 95% CI, 1.81–3.15) after adjustment for neurosurgery requirement (odds ratio, 2.83; 95% CI, 1.69–4.74), pupils fixed and dilated (odds ratio, 3.1; 95% CI, 1.49–6.38), and intubation at the scene or referral hospital (odds ratio, 2.82; 95% CI, 1.35–5.87) and other postulated predictors of poor outcome. The area under the BIG receiver operating characteristic curve was 0.87 (0.84–0.90). Using an optimal BIG cutoff less than or equal to 8, sensitivity and negative predictive value for functional dependence at discharge were 93% and 96%, respectively, compared with a sensitivity of 79% and negative predictive value of 91% with Glasgow Coma Scale less than or equal to 8. In children with Glasgow Coma Scale 3, the BIG score was associated with brain death (odds ratio, 2.13; 95% CI, 1.58–2.36). The BIG also predicted disposition to inpatient rehabilitation (odds ratio, 2.26; 95% CI, 2.17–2.35).

Conclusions: The BIG score is a simple, rapidly obtainable severity of illness score that constitutes an independent predictor of functional dependence at hospital discharge in pediatric trauma patients with traumatic brain injury. The BIG score may benefit Trauma and Neurocritical care programs in identifying ideal candidates for traumatic brain injury trials within the therapeutic window of treatment.

1Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.

2Research Institute, Hospital for Sick Children, Toronto, ON, Canada.

3Division of Pediatric Medicine, Department of Pediatrics, Hospital for Sick Children, Toronto, ON, Canada.

4Neurosurgery, Department of Surgery, Hospital for Sick Children, Toronto, ON, Canada.

5Division of General and Thoracic Surgery, Department of Surgery, Hospital for Sick Children, Toronto, ON, Canada.

*See also p. 996.

Presented, in part, as oral presentations at the: 1) Trauma Association of Canada meeting, Toronto, ON, Canada, February 23, 2018; and 2) Pediatric Academic Societies meeting, Toronto, ON, Canada, May 6, 2018.

Drs. Davis, Hochstadter, and Schuh conceived the study and wrote the protocol. Dr. Davis supervised data collection by Drs. Hochstadter and Daya. Mr. Stephens performed the data analysis. Drs. Davis, Hochstadter, and Schuh drafted the article and Drs. Davis, Hochstadter, Daya, Kulkarni, Wales, and Schuh contributed substantially to its revision. All authors take responsibility for the article as a whole.

The authors have disclosed that they do not have any potential conflicts of interest.

Address requests for reprints to: Adrienne Davis, MD, MSc, FRCPC, Division of Pediatric Emergency Medicine, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada. E-mail: adrienne.davis@sickkids.ca

Copyright © 2019 by the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies