小儿创伤中损伤严重度评分的价值：是时候重新定义重伤了吗？
The value of the injury severity score in pediatric trauma: Time for a new definition of severe injury?
作者信息
Brown Joshua B, Gestring Mark L, Leeper Christine M, Sperry Jason L, Peitzman Andrew B, Billiar Timothy R, Gaines Barbara A
机构信息
From the Division of Trauma and General Surgery, Department of Surgery (J.B.B., C.M.L., J.L.S., A.B.P., T.R.B.), University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; Division of Acute Care Surgery, Department of Surgery (M.L.G.), University of Rochester Medical Center, Rochester, New York; Golisano Children's Hospital (M.L.G.), University of Rochester, Rochester, New York; and Division of Pediatric General and Thoracic Surgery, Department of Surgery (C.M.L., B.A.G.), Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
出版信息
J Trauma Acute Care Surg. 2017 Jun;82(6):995-1001. doi: 10.1097/TA.0000000000001440.
BACKGROUND
The Injury Severity Score (ISS) is the most commonly used injury scoring system in trauma research and benchmarking. An ISS greater than 15 conventionally defines severe injury; however, no studies evaluate whether ISS performs similarly between adults and children. Our objective was to evaluate ISS and Abbreviated Injury Scale (AIS) to predict mortality and define optimal thresholds of severe injury in pediatric trauma.
METHODS
Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as younger than 16 years. Logistic regression predicted mortality from ISS for children and adults. The optimal ISS cutoff for mortality that maximized diagnostic characteristics was determined in children. Regression also evaluated the association between mortality and maximum AIS in each body region, controlling for age, mechanism, and nonaccidental trauma. Analysis was performed in single and multisystem injuries. Sensitivity analyses with alternative outcomes were performed.
RESULTS
Included were 352,127 adults and 50,579 children. Children had similar predicted mortality at ISS of 25 as adults at ISS of 15 (5%). The optimal ISS cutoff in children was ISS greater than 25 and had a positive predictive value of 19% and negative predictive value of 99% compared to a positive predictive value of 7% and negative predictive value of 99% for ISS greater than 15 to predict mortality. In single-system-injured children, mortality was associated with head (odds ratio, 4.80; 95% confidence interval, 2.61-8.84; p < 0.01) and chest AIS (odds ratio, 3.55; 95% confidence interval, 1.81-6.97; p < 0.01), but not abdomen, face, neck, spine, or extremity AIS (p > 0.05). For multisystem injury, all body region AIS scores were associated with mortality except extremities. Sensitivity analysis demonstrated ISS greater than 23 to predict need for full trauma activation, and ISS greater than 26 to predict impaired functional independence were optimal thresholds.
CONCLUSION
An ISS greater than 25 may be a more appropriate definition of severe injury in children. Pattern of injury is important, as only head and chest injury drive mortality in single-system-injured children. These findings should be considered in benchmarking and performance improvement efforts.
LEVEL OF EVIDENCE
Epidemiologic study, level III.
背景
损伤严重度评分（ISS）是创伤研究和基准评估中最常用的损伤评分系统。传统上，ISS大于15定义为重伤；然而，尚无研究评估成人和儿童的ISS表现是否相似。我们的目的是评估ISS和简明损伤定级标准（AIS）以预测儿科创伤患者的死亡率并确定重伤的最佳阈值。
方法
纳入2000 - 2013年宾夕法尼亚创伤登记处的患者。儿童定义为年龄小于16岁。采用逻辑回归分析预测儿童和成人因ISS导致的死亡率。确定儿童中使诊断特征最大化的死亡率的最佳ISS临界值。回归分析还评估了每个身体部位的死亡率与最大AIS之间的关联，并对年龄、受伤机制和非意外创伤进行了控制。对单系统损伤和多系统损伤分别进行分析。采用替代结局进行敏感性分析。
结果
纳入352,127名成人和50,579名儿童。儿童ISS为25时的预测死亡率与成人ISS为15时的预测死亡率相似（5%）。儿童的最佳ISS临界值为大于25，其阳性预测值为19%，阴性预测值为99%；而ISS大于15预测死亡率时，阳性预测值为7%，阴性预测值为99%。在单系统损伤的儿童中，死亡率与头部（比值比，4.80；95%置信区间，2.61 - 8.84；p < 0.01）和胸部AIS（比值比，3.55；95%置信区间，1.81 - 6.97；p < 0.01）相关，但与腹部、面部、颈部、脊柱或四肢AIS无关（p > 0.05）。对于多系统损伤，除四肢外，所有身体部位的AIS评分均与死亡率相关。敏感性分析表明，ISS大于23可预测全面创伤启动的需求，ISS大于26可预测功能独立性受损，这是最佳阈值。
结论
ISS大于25可能是儿童重伤更合适的定义。损伤模式很重要，因为在单系统损伤的儿童中，只有头部和胸部损伤会导致死亡。在基准评估和绩效改进工作中应考虑这些发现。
证据水平
流行病学研究，III级。
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