Pediatric Revised Trauma Score

[Shane Rouse]

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Background: Patients' trauma burdens are a combination of anatomic damage, physiologic derangement, and the resultant depletion of reserve. Typically, Injury Severity Score (ISS) >15 defines major anatomic injury and Revised Trauma Score (RTS)

Methods: Thirty-eight adult and pediatric U.S. trauma centers submitted data for 88,488 encounters. Mixed models tested ISS greater than 15, RTS less than 7.84, and NFTI's associations with complications, survivors' discharge to continuing care, and survivors' length of stay (LOS).

Conclusion: In this multicenter study, NFTI had better model fit and stronger associations with the outcomes than ISS and RTS. By determining depletion of reserve via resource consumption, NFTI+ may be a better definition of major trauma than the standard definitions of ISS greater than 15 and RTS less than 7.84. Using NFTI may improve retrospective triage monitoring and statistical risk adjustments.

We analyzed the accuracy of TRISS and a revised TRISS to predict survival outcome in a group of 1,562 consecutive children less than 15 years old admitted with blunt trauma to a pediatric trauma center. TRISS is an index that computes a probability of survival for each patient based on Trauma Score, Injury Severity Score, and age. R-TRISS uses the Revised Trauma Score instead of the Trauma Score. We used a statistical method based on TRISS and R-TRISS to compare patient outcomes from the pediatric study group with those of an adult baseline control group from the Major Trauma Outcome Study. Both TRISS and R-TRISS have the capability to accurately quantify survival outcome for children with blunt trauma; there was no statistical difference between the two methods to do so.

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Trauma is the primary cause of mortality in children, and extensive research has been conducted to identify effective strategies for reducing the resulting morbidity and mortality rates1,2. Accurately measuring the severity of injuries is crucial for assessing the quality of care provided to children with trauma and for conducting research on their outcomes3. Despite the guidelines put forth by the American College of Surgeons (ACS) Committee on Trauma (COT), the triage of children still exhibits considerable inconsistency. At present, there is a lack of consensus on a universally accepted pediatric triage scoring system4. To address this issue and to facilitate the prompt assessment and effective allocation of resources for pediatric trauma patients, scoring systems have been employed to ensure efficient and accurate decision-making in trauma patients4.

Scoring systems have been classically classified as anatomical, physiological, or combined scoring systems5,6. The AIS, ISS, and NISS are anatomical scoring systems that employ anatomical variables, including the location and severity of injury7. The GCS, RTS, and PHI are among the physiological scoring systems used and can be calculated through values retrieved from physical examination data7,8. Finally, the TRISS, NTRISS, and aTRISS are combined scoring systems that utilize both anatomical and physiological features of trauma9. The GCS is primarily utilized to evaluate the level of consciousness impairment in patients, achieved through the assessment of ocular, motor, and verbal responses10. The abbreviated injury AIS has also been employed in pediatric trauma by appointing a value of one to six to the injury10. The two main derivates of the AIS, ISS and NISS, were also utilized to predict pediatric outcomes following trauma based on the three injuries with the highest scores10,11. Similarly, the TRISS showed acceptable predictive performance for pediatric trauma outcomes11. RTS and PHI play significant roles in improving pediatric trauma triage4,8,12.

The AIS was first developed in 196913. After that, in 1974, simultaneously, the GCS was announced by Teasdale and Jennett in Scotland14, and the ISS was established by Baker to address the cumulative effect of injury, which was missed in conventional AIS15. Seven years after that, in 1981, the first version of the TRISS was introduced, claiming that the combined use of physiological and anatomical indices in addition to the age range is a very powerful tool for survival prediction16. In 1986, the PHI was developed primarily based on four items as a triage-based trauma scoring system17. In 1989, a revision of the trauma score named the RTS, was introduced18. In 1997, Osler et al. provided a new version of the ISS called the NISS19. Eventually, in 2018, a novel modified version of the TRISS, called the NTRISS, was introduced by Domingues et al.9.

During the initial assessment of a trauma patient, it is crucial to predict various factors, including the need for intensive care and the potential for morbidity and mortality. The objective of this study was to ascertain the prognostic significance of commonly utilized trauma scores, specifically in pediatric patients. We used the National Trauma Registry of Iran (NTRI) to perform a comprehensive comparison among the AIS, ISS, NISS, RTS, PHI, TRISS, and two of its variants (aTRISS and NTRISS) scoring systems for pediatric trauma and evaluated their ability to predict in-hospital mortality and ICU admission.

All ethical and moral issues were considered in this study. Informed consent was obtained from the patients or their next of kin. This study was approved by the ethics committee of Sina Hospital, Tehran University of Medical Sciences (Approval ID:IR.TUMS.SINAHOSPITAL.REC.1399.090). We confirm that all methods were performed in accordance with the relevant guidelines and regulations.

Trauma continues to be the leading cause of death in children, and the progress made in the field of pediatric trauma has closely paralleled advancements in adult trauma care. However, there is considerable disparity among trauma centers in regard to prehospital triage systems20,21. In this study, we analyzed various trauma scores of 6709 pediatric trauma patients, namely, AIS, ISS, NISS, RTS, GCS, PHI, TRISS, aTRISS, and NTRISS scores, to establish correlations between these scores and their respective clinical outcomes. The ROC curves demonstrated that the TRISS and its two derivatives, the aTRISS and NTRISS, respectively, possess the inherent capability to accurately distinguish patients who face an elevated likelihood of encountering unfavorable consequences, encompassing in-hospital mortality and ICU admission. These compelling findings underscore the utmost importance of incorporating these measures into clinical practice, thereby elevating the standard of patient care and prognosis. Furthermore, considering anatomical and physiological factors alone for the prediction of pediatric trauma cases may not seem sufficient; however, a combinatorial approach of utilizing both factors simultaneously may increase outcome prediction.

The Abbreviated Injury Scale (AIS) is a scoring system that categorizes injuries based on their severity. A six-point scale ranging from one (minor) to six (maximal) was used to classify injuries according to their relative severity in different body regions. Derived from expert consensus, this system has achieved global recognition22. Although intended for all age groups, the AIS does not encompass any specific AIS scores applicable solely to pediatric patients23.

In 1997. Osler et al. introduced the NISS, which comprises the cumulative value of the squared AIS score pertaining to the three most critical injuries sustained by a patient, irrespective of the affected anatomical region19. On the basis of retrospective examination of 6585 adult individuals affected by trauma, Osler et al. revealed that the NISS was better able to predict patient prognosis than the ISS. They used data from two datasets, 3136 patients from Albuquerque Center and 3449 patients from Emanuel Center. The AUC for ISS and NISS was 0.869 and 0.896 for the first center and 0.907 and 0.896 for the second center. They also stated that the difference between these two scoring systems was statistically significant despite overlapping confidence intervals. Our findings implied that there was no significant difference in the prediction of poorer outcomes between the NISS and ISS. Like our findings, in a study by Grisoni et al., which was conducted on 9151 pediatric trauma patients in four different regional trauma centers in the U.S., the disparities in the predictive capabilities of the two scoring systems were deemed inconsequential, and they concluded that in pediatric trauma patients, there are no notable disparities in the predictive capabilities between the ISS and NISS, as reported in studies involving adult trauma patients25.

The PHI components are SBP, PR, RR, level of consciousness, and nature of the injury (blunt or penetrating). The concept of the PHI was initially introduced by Koehler et al. and has since gained widespread use in medical triage17. The PHI previously exhibited an AUC of 0.9268 for the prediction of death following adult trauma.

The TRISS is extensively employed as the predominant tool for determining the likelihood of patient survival following traumatic injuries30. The coefficients of the currently utilized TRISS model were computed using the dataset obtained from the Major Trauma Outcome Study, which was coordinated by the American College of Surgeons Committee on Trauma between 1982 and 198731. Several studies have indicated that the TRISS model may not be appropriate for assessing survival outcomes due to its inadequacy in accurately considering factors such as the area, time period, and age range of the study population30,32,33. Many studies have performed statistical analysis to extract their own sets of coefficients for TRISS based on the local context30. In the present study, first, we used a conventional coefficient for calculating the probability of survival, named TRISS; second, we utilized another set of coefficients, employed in another interesting study by Domingues et al. and called it aTRISS9. Furthermore, we evaluated another scoring system, named the NTRISS, which was developed by Domingues in 2018 and establishes the SBP, NISS, and best motor response, instead of the RTS and ISS, in the conventional TRISS9. There were several concerns, given the use of the TRISS with conventional coefficients in children; nevertheless, in a recently published study in 2023 in which 11 models of the TRISS were evaluated for pediatric trauma, the authors concluded that the proposed models are not superior to conventional models30.

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