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Factors affecting outcome in the pediatric patient with multiple trauma. Further experience with the modified injury
Insights
The Modification of Injury Severity Scale (MISS) accurately predicts outcomes in pediatric trauma patients. A MISS score below 25 indicates significantly lower mortality and disability rates, highlighting its predictive value.
Area of Science:
- Pediatric Trauma Research
- Injury Severity Scoring Systems
- Clinical Outcomes Assessment
Background:
- Pediatric multiple trauma presents complex challenges in predicting patient outcomes.
- Existing injury severity scales may not fully capture the nuances of neurological injury in children.
- Accurate prognostication is crucial for effective resource allocation and patient management in pediatric trauma.
Purpose of the Study:
- To evaluate the efficacy of the Modification of Injury Severity Scale (MISS) in predicting morbidity and mortality in pediatric patients with multiple trauma.
- To compare the predictive accuracy of MISS with neurological injury assessments, including the Glasgow Coma Scale (GCS).
- To identify key predictors of outcome in severe pediatric trauma cases.
Main Methods:
- A prospective study of 369 pediatric patients with multiple trauma over a 5-year period.
- Injury severity was assessed using the MISS, incorporating Abbreviated Injury Scale-1980 (AIS-80) and Glasgow Coma Scale (GCS) for neurological injuries.
- Statistical analysis was performed to correlate MISS scores and neurological status with mortality and disability rates.
Main Results:
- A mean MISS score of 23.8 was observed, with 33% of patients scoring above 25.
- MISS scores greater than 25 were associated with significantly higher mortality (44%) and disability (31%) compared to scores below 25 (0% mortality, 1% disability; p < 0.001).
- Head injury was the leading cause of death (86%), and severe head injury significantly increased mortality risk in multiple trauma patients compared to head injury alone.
Conclusions:
- The MISS is a reliable predictor of morbidity and mortality in pediatric trauma.
- A MISS score below 25 and the degree of neurological injury are the strongest predictors of favorable outcomes.
- The findings underscore the critical role of neurological assessment in managing pediatric trauma patients.
Abstract:
In a 5-year period of prospective study, 369 pediatric patients with multiple trauma (injury to at least two body areas) had injuries scored by a Modification of Injury Severity Scale (MISS). This scale uses the categories and rankings of the Abbreviated Injury Scale-1980 (AIS-80) except that the classification of neurological injuries are scored by the Glasgow Coma Scale (GCS) and other neurological findings (presence of a surgical mass lesion, pupillary light response, and oculocephalic reflexes). The MISS is calculated as the sum of the squares of the three most severely injured body areas. The mean MISS score was 23.8 with 33% of MISS scores greater than 25 and 67% less than 25. Among those with MISS scores greater than 25 there was a 44% mortality and 31% disability. In the group with MISS scores less than 25, there were no mortalities, and a 1% disability (p less than 0.001). Overall mortality was 14% with 9% disability. Mean MISS scores for death and disability were 35.1 and 29.6, respectively. Neurologic injuries were present in 274 patients (74%). 163 patients had severe head injury (coma greater than 6 h duration). 86% of all deaths were due to head injury and all but 2 deaths had some degree of head injury. The remaining 14% of deaths were due to chest and abdominal injuries. Patients with MISS grade 5 injury (critical, survival uncertain) had 74% mortality, while those with grades 4 and 3 injury had 8 and 1.5% mortality. In a comparison with pediatric patients with head injury only (coma greater than 6 h, no multiple trauma) there was found to be a 12% mortality in the head injury only group versus a 33% mortality in the multiple trauma plus head injury group. The MISS serves as an accurate predictor of morbidity and mortality in pediatric trauma. The best predictors of outcome were a MISS less than 25 and the degree of neurological injury.