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External Validation of the Surgical Intervention for Traumatic Injuries Scale in Children
Bergthor Jonsson1, Manu Madhok1, Shea Lammers1
1Departments of Pediatric Emergency Medicine.
Insights
The Surgical Intervention for Traumatic Injuries (SITI) scale effectively predicts neurosurgical intervention in children with traumatic brain injury (TBI). A SITI score below 2 suggests nonoperative management, but caution is advised for depressed skull fractures.
Area of Science:
- Pediatric Neurosurgery
- Trauma Surgery
- Clinical Decision Support
Background:
- Traumatic brain injury (TBI) is a significant cause of morbidity and mortality in children.
- Predicting the need for acute neurosurgical intervention is critical for timely management.
- The Surgical Intervention for Traumatic Injuries (SITI) scale was developed to assess the likelihood of surgical decompression in TBI patients.
Purpose of the Study:
- To evaluate the performance of the SITI score in predicting the need for acute neurosurgical intervention in pediatric TBI patients.
- To determine the accuracy of the SITI scale in identifying children requiring decompressive surgery.
Main Methods:
- A retrospective, observational study of pediatric TBI patients at a level 1 trauma center.
- Data collection included International Classification of Diseases codes and SITI scores, with outcomes assessed for decompressive craniotomy/craniectomy within 24 hours.
- Performance metrics included receiver operating characteristic (ROC) curves, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Main Results:
- Of 656 TBI encounters, 5.9% required surgical decompression.
- Mean SITI scores differed significantly between operative (4.15) and nonoperative (0.40) groups (P < 0.001).
- A SITI score cutoff of ≥2 demonstrated high performance (AUC 0.89), with sensitivity 0.79, specificity 0.90, PPV 0.34, and NPV 0.99. Sensitivity analysis for depressed skull fractures showed improved performance (AUC 0.98).
Conclusions:
- A SITI score <2 is associated with nonoperative management in pediatric TBI.
- The SITI scale is a valuable tool for predicting neurosurgical intervention in children with TBI.
- Clinicians must exercise caution with low SITI scores in patients with depressed skull fractures due to potential for missed surgical indications.
Objectives:
The Surgical Intervention for Traumatic Injuries (SITI) scale is intended to predict the likelihood of needing surgical decompression among patients with traumatic brain injury (TBI). We sought to examine the performance of the SITI score to predict likelihood of acute neurosurgical intervention for children with TBI.
Methods:
We conducted a cross-sectional, retrospective, observational study of children diagnosed with TBI as determined by International Classification of Diseases codes, presenting to a single level 1 pediatric trauma center, between June 1, 2003, and May 31, 2018. The main outcome was decompressive craniotomy or craniectomy within 24 hours of arrival. Data for SITI scoring were abstracted by research assistants, and all cases were scored by a physician who was blinded to the outcome. The SITI scale performance was evaluated using receiver operating characteristic curve and by calculating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV).
Results:
There were 656 encounters with TBI, of which 39 (5.9%) underwent surgical decompression. The mean SITI scores were 4.15 for the operative group and 0.40 for the nonoperative group ( P < 0.001). A cutoff of 2 or greater for a positive score gave the best performance with a sensitivity of 0.79, specificity of 0.90, PPV of 0.34, and NPV of 0.99. The area under the receiver operating characteristic curve was 0.89 (95% confidence interval, 0.83-0.96). In sensitivity analysis excluding 75 cases with depressed skull fractures, a score of 2 or greater had a sensitivity of 0.96, specificity of 0.91, PPV of 0.31, and NPV of 1.00. The area under the receiver operating characteristic curve was 0.98 (95% confidence interval, 0.97-1.00).
Conclusions:
A SITI score of less than 2 is associated with nonoperative management. However, clinicians should not be falsely reassured by a low score in patients with depressed skull fractures.
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