Characterizing Injury Severity In Non-accidental Trauma: Does Injury Severity Score Miss The Mark?
Joshua B Brown1, Mark L Gestring2, Christine M Leeper1, Jason L Sperry1, Andrew B Peitzman1, Timothy R Billiar1, *Barbara A Gaines1
1University of Pittsburgh, Pittsburgh, PA;2University of Rochester, Rochester, NY
Background: Children with non-accidental trauma (NAT) are at high risk for death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as injury severity score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared to accidental trauma (AT).
Methods: Pediatric patients age<16years from the Pennsylvania state trauma registry 2000-2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients.
Results: 50,579 patients were included with 1,866 (3.7%) NAT patients. NAT patients have higher mortality for a given ISS (FIGURE). NAT patients also have higher mortality for a given head AIS level (range 1.2-5.9 fold higher). ISS was a significantly greater predictor of mortality in AT patients (AOR 1.14; 95%CI 1.13—1.15, p<0.01) than NAT patients (AOR 1.09; 95%CI 1.07—1.12, p<0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR 3.48; 95%CI 1.54—8.32, p<0.01) than AT patients (AOR 1.21; 95%CI 0.95—1.45, p=0.12).
Conclusions: NAT patients have higher mortality at a given ISS/head AIS than AT patients. Conventional ISS thresholds may underestimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking.
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