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The Value of ISS in Pediatric Trauma: Time for a New Definition of Severe Injury?
Joshua B. Brown, MD, MSc1, Mark L. Gestring, MD2, Christine M. Leeper, MD1,3, Jason L. Sperry, MD, MPH1, Andrew B. Peitzman, MD1, Timothy R. Billiar, MD1, Barbara A. Gaines, MD1,3. 1University of Pittsburgh, Pittsburgh, PA, 2University of Rochester Golisano Children's Hospital, Rochester, NY, 3Children's Hospital of Pittsburgh, Pittsburgh, PA.

Background: Injury severity score (ISS)>15 historically defines severe injury; however, no studies evaluate whether ISS performs similarly between children and adults. Our objective was to evaluate ISS for identification of severely injured children.

Methods: Patients from the Pennsylvania trauma registry 2000-2013 were included. Children were defined as age<16years. Logistic regression predicted mortality from ISS for children and adults. Optimal ISS cut-off for mortality was determined in children. Regression also evaluated association between mortality and maximum AIS in each body-region, controlling for age, mechanism, non-accidental trauma. Analysis was performed in single and multisystem injuries.

Results: 352,127 adults and 50,579 children were included. Children had similar mortality at ISS=25 as adults at ISS=15 (Figure). Optimal ISS cut-off in children was ISS>25 and had better diagnostic characteristics compared to ISS>15 (AUC 0.89; 95%CI 0.88-0.91 vs. AUC 0.82; 95%CI 0.81-0.84, p<0.01). In children with single system injury, increased mortality was associated with head (OR 4.80; 95%CI 2.61-8.84, p<0.01) and chest maximum AIS (OR 3.55; 95%CI 1.81-6.97, p<0.01), but not abdomen/face/neck/spine/extremity AIS (p>0.05). For multisystem injury, all body region AIS were associated with mortality except extremities.

Conclusions: ISS>25 may be a more appropriate definition of severe injury in children. Only head and chest injury drive mortality in children with single system injury. Mortality may not universally be the optimal endpoint in children. These findings should be considered in benchmarking/performance improvement.

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