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Pediatric adjusted reverse shock index multiplied by Glasgow Coma Scale as a prospective predictor for mortality in
Daniel T Lammers1, Christopher W Marenco, Woo S Do
1From the Department of General Surgery (D.T.L., C.W.M., W.S.D., J.R.C., J.D.H., J.R.B., M.J.E.), Madigan Army Medical Center, Tacoma, Washington; Department of Trauma and Acute Care Surgery (M.J.M.), Scripps Mercy Hospital, San Diego, California; and Department of Pediatric Surgery (M.A.E.), Mary Bridge Children's Hospital, Tacoma, Washington.
Insights
The reverse shock index multiplied by Glasgow Coma Scale (rSIG) score is a superior predictor of mortality in pediatric war zone injuries compared to the pediatric age-adjusted shock index (SIPA). This finding aids in refining early risk assessments for pediatric trauma patients.
Area of Science:
- Trauma Surgery
- Pediatric Critical Care
- Military Medicine
Background:
- Shock index and pediatric age-adjusted shock index (SIPA) predict mortality in trauma.
- Neurologic status significantly impacts trauma outcomes.
- Reverse shock index multiplied by Glasgow Coma Scale (rSIG) combines physiology and neurologic function.
Purpose of the Study:
- Compare rSIG and SIPA as predictors of mortality in pediatric war zone injuries.
- Evaluate the performance characteristics of rSIG against SIPA.
- Identify a superior tool for early risk assessment in pediatric trauma.
Main Methods:
- Retrospective review of the Department of Defense Trauma Registry (2008-2016).
- Included pediatric patients (<18 years) with vital signs and GCS on arrival.
- Used receiver operating characteristic analyses and multivariate logistic regression.
Main Results:
- Analyzed 2,007 pediatric patients; overall mortality was 7.1%.
- rSIG (34.1%) and SIPA (43.5%) were elevated in a significant portion of patients.
- rSIG was a superior independent predictor of early mortality (OR 4.054) compared to SIPA (OR 2.742).
Conclusions:
- rSIG more accurately identifies pediatric patients at high risk of death after war zone injuries than SIPA.
- Findings can refine early risk assessment, patient management, and resource allocation in austere settings.
- Further validation is needed for civilian populations.
Introduction:
Shock index and its pediatric adjusted derivative (pediatric age-adjusted shock index [SIPA]) have demonstrated utility as prospective predictors of mortality in adult and pediatric trauma populations. Although basic vital signs provide promise as triage tools, factors such as neurologic status on arrival have profound implications for trauma-related outcomes. Recently, the reverse shock index multiplied by Glasgow Coma Scale (GCS) score (rSIG) has been validated in adult trauma as a tool combining early markers of physiology and neurologic function to predict mortality. This study sought to compare the performance characteristics of rSIG against SIPA as a prospective predictor of mortality in pediatric war zone injuries.
Methods:
Retrospective review of the Department of Defense Trauma Registry, 2008 to 2016, was performed for all patients younger than 18 years with documented vital signs and GCS on initial arrival to the trauma bay. Optimal age-specific cutoff values were derived for rSIG via the Youden index using receiver operating characteristic analyses. Multivariate logistic regression was performed to validate accuracy in predicting early mortality.
Results:
A total of 2,007 pediatric patients with a median age range of 7 to 12 years, 79% male, average Injury Severity Score of 11.9, and 62.5% sustaining a penetrating injury were included in the analysis. The overall mortality was 7.1%. A total of 874 (43.5%) and 685 patients (34.1%) had elevated SIPA and pediatric rSIG scores, respectively. After adjusting for demographics, mechanism of injury, initial vital signs, and presenting laboratory values, rSIG (odds ratio, 4.054; p = 0.01) was found to be superior to SIPA (odds ratio, 2.742; p < 0.01) as an independent predictor of early mortality.
Conclusion:
Reverse shock index multiplied by GCS score more accurately identifies pediatric patients at highest risk of death when compared with SIPA alone, following war zone injuries. These findings may help further refine early risk assessments for patient management and resource allocation in constrained settings. Further validation is necessary to determine applicability to the civilian population.
Level Of Evidence:
Prognostic study, level IV.
