Citation

Brown JB, Gestring ML, Leeper CM, Sperry JL, Peitzman AB, Billiar TR, Gaines BA. J. Trauma Acute Care Surg. 2018; 85(4): 668-673.

Affiliation

Division of Pediatric General and Thoracic Surgery, Department of Surgery, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15224.

Copyright

(Copyright © 2018, Lippincott Williams and Wilkins)

DOI

10.1097/TA.0000000000001841

PMID

29462080

Abstract

BACKGROUND: Children suffering non-accidental trauma (NAT) are at high risk of death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as injury severity score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared to accidental trauma (AT).

METHODS: Pediatric patients age<16years from the Pennsylvania state trauma registry 2000-2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients. Similar models were performed for head AIS. Sensitivity analysis examined impaired functional independence at discharge as an alternate outcome.

RESULTS: 50,579 patients were included with 1,866 (3.7%) NAT patients. NAT patients had a similar rate of mortality at an ISS of 13 as an ISS of 25 for AT patients. NAT patients also have higher mortality for a given head AIS level (range 1.2-5.9-fold higher). ISS was a significantly greater predictor of mortality in AT patients (AOR 1.14; 95%CI 1.13-1.15, p<0.01) than NAT patients (AOR 1.09; 95%CI 1.07-1.12, p<0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR 3.48; 95%CI 1.54-8.32, p<0.01) than AT patients (AOR 1.21; 95%CI 0.95-1.45, p=0.12). NAT patients had a higher rate of impaired functional independence at any given ISS or head AIS level than AT patients.

CONCLUSIONS: NAT patients have higher mortality and impaired function at a given ISS/head AIS than AT patients. Conventional ISS thresholds may under-estimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking efforts that rely on ISS for injury characterization. LEVEL OF EVIDENCE: III, epidemiologic.

Language: en