, several trauma scoring systems have been validated for prediction of patient survival , new injury severity score ( niss ) is defined as the sum of the squares of the abbreviated injury scale ( ais ) of each of the patient 's most severe ais injuries irrespective of the body region in which they occur .
the pediatric trauma score ( pts ) was devised specifically for the triage of pediatric trauma patients .
the pediatric big score can be performed rapidly on admission to evaluate the severity of illness and to predict mortality in children with traumatic injuries . international normalization ratio ( inr )
is a measure of tissue factor - activated arm of the coagulation cascade , coagulopathy , as characterized by increased fibrin degradation products , has been shown to predict mortality in children with head trauma while base deficit is a measure of shock and acidosis
. a big score of < 12 points suggests a mortality of < 5% , whereas a cutoff of > 26 points corresponds to a mortality of > 50% .
the limitation of the big score is that it requires laboratory values to calculate it .
this study aimed at evaluation of pediatric trauma big score in comparison with niss and pts in tanta university emergency hospital .
the study was conducted as a prospective comparative study in a university emergency hospital in egypt for 1 year from february 2014 to february 2015 , on fifty multiple trauma pediatric patients admitted to the pediatric emergency department .
all pediatric patients between 1 and 18 years old and within 24 h after trauma were included in the study .
patients < 1 year old , patients who came to the hospital after 24 h of occurrence of trauma , burn , and electric shock without polytrauma , and patients with chronic diseases such as chronic renal failure , hepatic , hematologic , or neurologic diseases were excluded from the study .
data collected for each multiple trauma patient attended to emergency department , include history taking stressing on mechanism of injury , thorough clinical examination , especially systolic blood pressure ( sbp ) , pulse rate , respiratory rate , glasgow coma scale ( gcs ) , and laboratory investigations including arterial blood gas , prothrombin time , partial thromboplastin time , and inr .
pts was calculated by pts was calculated by summation of these variables [ table a ] .
variables for calculation of pediatric trauma score(pts ) ( citated from emergency medical journal 2011 ) niss was calculated by summation of square of ais score of the most three affected regions of body regardless site of injury as follows : niss = ( ais1 ) + ( ais2 ) + ( ais3 ) [ table b ] .
abbreviated injury scale of new injury severity score ( niss ) ( citated from emergency medical journal 2011 ) pediatric trauma big score then was calculated as follows : pediatric big score equation = ( admission base deficit ) + ( 2.5  inr ) + ( 15  gcs ) .
this equation can then be implemented into a mortality - predicting formula : predicted mortality = 1/(1 + e ) , where x = 0.2  ( big score )  5.208 .
testing the mortality prediction of the big score on our trauma patients and compared observed and expected mortality by big score . comparing between big score , pts , and niss as regard validity and observed outcome .
trauma management at patient arrival includes primary then secondary survey in the first 1015 min .
initial observations of the patient as he or she was being wheeled in by emergency medical service ( ems ) , airway was evaluated with cervical spine precautions , assisted bag valve mask ventilation may be indicated , assess the breathing .
evaluation of chest wall motion , lung sounds , respiratory rate , and oxygen saturation was done .
early intubation was done for poor respiratory effort , inadequate oxygenation , or gcs score of eight or less . for assessment of the circulation , examination of focused assessment sonography in trauma(fast ) and two large bore aintravenous acess were established .
routine imaging studies include chest x - ray , anteroposterior , pelvis , and lateral cervical spine . computed tomography scan of the cervical spine , fast or extended - fast to evaluate for intraperitoneal blood , pneumothorax , and hemothorax as well .
a foley catheter was placed for evaluation for hematuria as well as monitoring urine output .
rectal examination was done before placement to evaluate for signs of urethral injury such as high - riding prostate as well as blood at the urethral meatus .
secondary assessment is an organized , head - to - toe assessment , especially difficult to see areas such as the axillae and perineum .
signs / symptoms , allergies , medications , past medical history , last meal , and events history was obtained from the patient , family , or ems . by this time , the initial resuscitation and stabilization of most patients were completed , and the patient was ready to leave the trauma bay to ( a ) the operating room if immediate surgery was indicated , ( b ) the imaging suite if he or she was stable , ( c ) the intensive care unit if observation was the planned course of action , or ( d ) a regular gurney / stretcher in the emergency department for observation before discharge home . the collected data were analyzed using spss version 20 software ( spss inc . ,
chicago , il , usa ) and microstat - w software ( india , cnet download.com ) .
categorical data were presented as number and percentages whereas quantitative data were expressed as a mean  standard deviation
. chi - square test , fisher 's exact test , z - test , student 's t - test , mann  whitney u - test , and mcnemar 's test were used as tests of significance .
receiver operating characteristic ( roc ) curve was used to determine cutoff values of the studied mortality scores with optimum sensitivity and specificity .
binary logistic regression model was used to detect the significant predictors of mortality and to design an equation for predicted mortality from big score .
the accepted level of significance in this work was stated at 0.05 ( p < 0.05 was considered significant ) .
p > 0.05 is nonsignificant , p < 0.05 is significant , and p  0.001 is highly significant .
all pediatric patients between 1 and 18 years old and within 24 h after trauma were included in the study .
patients < 1 year old , patients who came to the hospital after 24 h of occurrence of trauma , burn , and electric shock without polytrauma , and patients with chronic diseases such as chronic renal failure , hepatic , hematologic , or neurologic diseases were excluded from the study .
data collected for each multiple trauma patient attended to emergency department , include history taking stressing on mechanism of injury , thorough clinical examination , especially systolic blood pressure ( sbp ) , pulse rate , respiratory rate , glasgow coma scale ( gcs ) , and laboratory investigations including arterial blood gas , prothrombin time , partial thromboplastin time , and inr .
pts was calculated by pts was calculated by summation of these variables [ table a ] .
variables for calculation of pediatric trauma score(pts ) ( citated from emergency medical journal 2011 ) niss was calculated by summation of square of ais score of the most three affected regions of body regardless site of injury as follows : niss = ( ais1 ) + ( ais2 ) + ( ais3 ) [ table b ] .
abbreviated injury scale of new injury severity score ( niss ) ( citated from emergency medical journal 2011 ) pediatric trauma big score then was calculated as follows : pediatric big score equation = ( admission base deficit ) + ( 2.5  inr ) + ( 15  gcs ) .
this equation can then be implemented into a mortality - predicting formula : predicted mortality = 1/(1 + e ) , where x = 0.2  ( big score )  5.208 .
testing the mortality prediction of the big score on our trauma patients and compared observed and expected mortality by big score . comparing between big score , pts , and niss as regard validity and observed outcome .
trauma management at patient arrival includes primary then secondary survey in the first 1015 min .
initial observations of the patient as he or she was being wheeled in by emergency medical service ( ems ) , airway was evaluated with cervical spine precautions , assisted bag valve mask ventilation may be indicated , assess the breathing .
evaluation of chest wall motion , lung sounds , respiratory rate , and oxygen saturation was done .
early intubation was done for poor respiratory effort , inadequate oxygenation , or gcs score of eight or less . for assessment of the circulation , examination of focused assessment sonography in trauma(fast ) and two large bore aintravenous acess were established .
routine imaging studies include chest x - ray , anteroposterior , pelvis , and lateral cervical spine . computed tomography scan of the cervical spine , fast or extended - fast to evaluate for intraperitoneal blood , pneumothorax , and hemothorax as well .
a foley catheter was placed for evaluation for hematuria as well as monitoring urine output .
rectal examination was done before placement to evaluate for signs of urethral injury such as high - riding prostate as well as blood at the urethral meatus .
secondary assessment is an organized , head - to - toe assessment , especially difficult to see areas such as the axillae and perineum .
signs / symptoms , allergies , medications , past medical history , last meal , and events history was obtained from the patient , family , or ems . by this time
, the initial resuscitation and stabilization of most patients were completed , and the patient was ready to leave the trauma bay to ( a ) the operating room if immediate surgery was indicated , ( b ) the imaging suite if he or she was stable , ( c ) the intensive care unit if observation was the planned course of action , or ( d ) a regular gurney / stretcher in the emergency department for observation before discharge home .
chicago , il , usa ) and microstat - w software ( india , cnet download.com ) .
categorical data were presented as number and percentages whereas quantitative data were expressed as a mean  standard deviation .
chi - square test , fisher 's exact test , z - test , student 's t - test , mann  whitney u - test , and mcnemar 's test were used as tests of significance .
receiver operating characteristic ( roc ) curve was used to determine cutoff values of the studied mortality scores with optimum sensitivity and specificity .
binary logistic regression model was used to detect the significant predictors of mortality and to design an equation for predicted mortality from big score . the accepted level of significance in this work
p > 0.05 is nonsignificant , p < 0.05 is significant , and p  0.001 is highly significant .
all pediatric patients between 1 and 18 years old and within 24 h after trauma were included in the study .
patients < 1 year old , patients who came to the hospital after 24 h of occurrence of trauma , burn , and electric shock without polytrauma , and patients with chronic diseases such as chronic renal failure , hepatic , hematologic , or neurologic diseases were excluded from the study .
data collected for each multiple trauma patient attended to emergency department , include history taking stressing on mechanism of injury , thorough clinical examination , especially systolic blood pressure ( sbp ) , pulse rate , respiratory rate , glasgow coma scale ( gcs ) , and laboratory investigations including arterial blood gas , prothrombin time , partial thromboplastin time , and inr .
pts was calculated by pts was calculated by summation of these variables [ table a ] .
variables for calculation of pediatric trauma score(pts ) ( citated from emergency medical journal 2011 ) niss was calculated by summation of square of ais score of the most three affected regions of body regardless site of injury as follows : niss = ( ais1 ) + ( ais2 ) + ( ais3 ) [ table b ] .
abbreviated injury scale of new injury severity score ( niss ) ( citated from emergency medical journal 2011 ) pediatric trauma big score then was calculated as follows : pediatric big score equation = ( admission base deficit ) + ( 2.5  inr ) + ( 15  gcs ) .
this equation can then be implemented into a mortality - predicting formula : predicted mortality = 1/(1 + e ) , where x = 0.2  ( big score )  5.208 .
testing the mortality prediction of the big score on our trauma patients and compared observed and expected mortality by big score . comparing between big score , pts , and niss as regard validity and observed outcome .
trauma management at patient arrival includes primary then secondary survey in the first 1015 min .
initial observations of the patient as he or she was being wheeled in by emergency medical service ( ems ) , airway was evaluated with cervical spine precautions , assisted bag valve mask ventilation may be indicated , assess the breathing .
evaluation of chest wall motion , lung sounds , respiratory rate , and oxygen saturation was done .
early intubation was done for poor respiratory effort , inadequate oxygenation , or gcs score of eight or less . for assessment of the circulation , examination of focused assessment sonography in trauma(fast ) and two large bore aintravenous acess were established .
routine imaging studies include chest x - ray , anteroposterior , pelvis , and lateral cervical spine . computed tomography scan of the cervical spine , fast or extended - fast to evaluate for intraperitoneal blood , pneumothorax , and hemothorax as well .
a foley catheter was placed for evaluation for hematuria as well as monitoring urine output .
rectal examination was done before placement to evaluate for signs of urethral injury such as high - riding prostate as well as blood at the urethral meatus .
secondary assessment is an organized , head - to - toe assessment , especially difficult to see areas such as the axillae and perineum . signs / symptoms , allergies , medications , past medical history , last meal , and events history was obtained from the patient , family , or ems . by this time
, the initial resuscitation and stabilization of most patients were completed , and the patient was ready to leave the trauma bay to ( a ) the operating room if immediate surgery was indicated , ( b ) the imaging suite if he or she was stable , ( c ) the intensive care unit if observation was the planned course of action , or ( d ) a regular gurney / stretcher in the emergency department for observation before discharge home .
chicago , il , usa ) and microstat - w software ( india , cnet download.com ) .
categorical data were presented as number and percentages whereas quantitative data were expressed as a mean  standard deviation .
chi - square test , fisher 's exact test , z - test , student 's t - test , mann  whitney u - test , and mcnemar 's test were used as tests of significance .
receiver operating characteristic ( roc ) curve was used to determine cutoff values of the studied mortality scores with optimum sensitivity and specificity .
binary logistic regression model was used to detect the significant predictors of mortality and to design an equation for predicted mortality from big score . the accepted level of significance in this work
table 1 shows that there was a significant decrease in the age , body weight , sbp , and gcs and a significant increase in both inr and base excess of nonsurvivor patients when compared to survivor patients .
demographic , clinical , and laboratory variables as regard patient outcomes table 2 and figure 1 show trauma characteristics of the studied children as regard systems injured by trauma , regarding airway , 11 patients were with patent airway , 28 patients with maintainable airway , and 11 patients unmaintainable airway .
trauma characteristics of the studied children as regard patient outcomes comparison between airway and central nervous system status among studied patients regarding level of consciousness , 17 patients were awake and 33 patients were comatosed .
table 2 also and figure 2 show that the most common mechanism of injury among studied patients was fall from height by 44% , and motorcycle was the least common mechanism of injury by 16% .
they show also that the most favorable prognosis was in fall from height , and the poorest prognosis was in both pedestrian collision and motorcycle .
table 2 also shows that the most common diagnosis of cause of death among studied patients was central nervous system lesion ( brain death ) ( 20% ) , followed by hemorrhagic shock ( 6% ) while respiratory failure and multiple system organ failure were the least common diagnosis of cause of death ( 2% for each ) .
mechanism of injury among studied patients figure 3 shows no significant difference between mean value of niss among died and survived patients , whereas there was a significant increase in mean value of pts among survived patients and a significant decrease in mean value of big score among survived patients .
comparing survivors and nonsurvivors regarding trauma scores figure 4 compares roc curve for validity of the three studied trauma scores ( big , pts , and niss ) in prediction of mortality , big score 12.7 has sensitivity 86.7% , specificity 71.4% , positive predictive value ( ppv ) 56.5% , negative predictive value ( npv ) 92.6% , and confidence index ( ci ) 0.770.97 , whereas pts at value 3.5 has sensitivity 63.3% , specificity 68.6% , ppv 42.2% , npv 77.4% , and ci 0.570.85 and niss at value 39.5 has sensitivity 53.3% , specificity 54.3% , ppv 33.3% , npv 73.1% , and ci 0.480.79 . hence , the highest sensitivity and specificity of the three studied scores was to big score at cutoff value of 12.7 , while the lowest sensitivity and specificity was to niss at cutoff value niss 39.5 , while pts showing moderate specificity and sensitivity at cutoff value 3.5 .
figure 4 shows also that areas under the roc curve of niss , pts , and big were 0.87 , 0.71 , and 0.63 respectively .
receiver operating characteristic curves for the validity of big , pediatric trauma score , and new injury severity score trauma scores in prediction of mortality table 3 and figure 5 show relation of big score to observed mortality rate , there was a significant positive correlation between big score values and mortality rates as the higher the value of big score , the higher the incidence of mortality . comparing observed and predicted mortality by big score relation of big score to observed mortality rate
easy - to - use trauma scoring systems inform physicians of the severity of trauma in patients and help them decide the course of trauma management .
the use of trauma scoring systems can be used before the patient reaches the hospital , to decide whether to send the patient to a trauma center , and can also be used for clinical decision - making when the trauma patient has just arrived at the emergency department ( ed ) .
when the patient is in the ed , trauma scoring systems can be used to prepare the patient for surgery , to call on medical staff for trauma support , and to inform the family of the severity of the patient 's condition in the early stage . in the present prospective comparative study , pediatric trauma big score , pts , and niss scale , has been conducted on fifty polytraumatized pediatric patients attended to tanta emergency university hospital . in this study , we choose to register the subjects from only one center to avoid the possible variability in the triage system in different settings .
as regarding mechanism of injury , we found that fall from height was the most common cause of admission in polytraumatized pediatric patients ( 44% ) and this coincide with the study done by fiorentino et al . in hospital de nio  ricardo gutirrez  in sao paolo ( 54% ) .
another study made by derakhshanfar et al . found that pedestrian car accidents and falling down were the most common causes of injuries ( 23.3% and 21.3% ) , respectively .
letts et al . in their study on the children 's hospital of eastern ontario ,
a major pediatric trauma center , found that fall from height was the third common cause of trauma in children was by 14% and the most common cause was motor car accidents by 38.9% . in this study as regarding the age of patients , there was a significant decrease in age of nonsurvivors when compared to survivors ( p = 0.01 ) .
. concluded that survival after childhood injury is independent on the age groups in their study after controlling injury severity . in the present study as regarding body weight
, there was a significant decrease in body weight in nonsurvivors and when compared to survivors ( p = 0.011 ) .
it was against the study made by derakhshanfar et al . who found that there was no significant relation between body weight of patients and their outcome .
as regarding sbp , we found a significant decrease in sbp in nonsurvivors when compared to survivors ( p = 0.004 ) .
conducted their cross - sectional study included injured children from 34 emergency services showed that when compared with children with normal relative risk ( rr ) and sbp , children with an abnormal sbp and rr had a 5.0 ( 95% ci : 3.96.4 ) and 2.2 ( 95% ci : 1.53.1 ) times higher odds of death , respectively .
derakhshanfar et al . conducted their study in tehran , iran , on 151 pediatric trauma patients and showed that the mean sbp was 96  11 mmhg .
there have been several previous studies on the importance of be in evaluating trauma patients , but only a few examined its importance in the pediatric population .
those studies suggested that be was a good indicator of injury severity in pediatric trauma patients . in this work
, we found that there was a significant increase in be in nonsurvivors when compared to survivors ( p = 0.039 ) .
randolph et al . found that admission be was a strong indicator of injury severity , and a be below 5 was predictive of severe injury and mortality . in severely injured children ( all requiring mechanical ventilation ) ,
be < 8 predicted a higher incidence of infectious complications and a less favorable outcome .
borgman et al . reported that admission base deficit was also found to be an independent predictor of mortality in 707 children injured in iraq and afghanistan .
gcs is the most widely used scoring system for the evaluation of disorder of consciousness .
the modified gcs is used for infants and young children to obtain the most accurate score . in this study
, there was a significant decrease in gcs of nonsurvivor patients when compared to survivor patients .
most of the cases of death ( 66% ) were due to head trauma , so gcs work better in these cases than other causes of death such as other , hemorrhagic shock , respiratory failure , or multiple system organ injury .
that proved that gcs provides a prediction about morbidity and mortality after head injury . in this study , there was a significant increase in inr of nonsurvivor patients when compared to survivor patients .
verma and kole study showed that inr is indeed a good predictor of mortality in trauma patients , with a high diagnostic accuracy . in this study , pts showing moderate specificity and sensitivity at cutoff value 3.5 with sensitivity 63.3% and specificity 68.6% .
there are conflicting reports on the effectiveness of the pts as a tool for assessing prognosis and in identifying those who will need a transfer to a pediatric trauma center .
studied the prognostic value of pts in pediatric trauma patients on 151 pediatric patients in tehran and found it to be an independent predictor of morbidity .
reported that the pts has no advantage in children , even in children younger than 14 years .
another study made by eichelberger et al . has reported no difference between the predictive capabilities of the trauma score and the pts in identifying severely injured children .
further refinements of the pts include the age - specific pts and the triage age - specific pts .
these scoring systems , however , have not yet been validated and are rarely used . in 1997 , a simple modification of injury severity score ( iss ) was formulated by osler et al . and referred to as the niss , in the present study , we found that niss at cutoff value 39.5 has sensitivity 53.3% and specificity 54.3% for predicting mortality .
sullivan et al . found that the niss performs as well as the iss in predicting mortality in pediatric trauma patients who are not severely injured ( iss < 24 ) .
it is not intended to reflect patient outcomes , but only to score an individual injury . an adult trauma study made by brockamp et al .
, to compare the big score with other trauma scores revealed that big score is a good predictor of mortality in the adult trauma population , and they added that in a penetrating trauma population , the big score performed better than in a population with blunt trauma .
the big score has the advantage of being available shortly after admission and may be used to predict clinical prognosis or as a research tool to risk stratify trauma patients into clinical trials . in the present study , we found that pediatric trauma big score was more sensitive and specific and easily applicable score in predicting mortality than pts and niss , and this coincides with the study done by borgman et al .
paediatric trauma big score may be applied as a mortality prediction tool in pediatric emergency for its ease and simplicity of application at the time of entry at the emergency department .
this would also help in evaluating for early invasive monitoring and treatment decisions in the intensive care unit .
we recommend that leaflets for big score be formed and calculated easily in the emergency department to help predicting mortality and decision - making regarding polytraumatized pediatric patients .
we recommend that leaflets for big score be formed and calculated easily in the emergency department to help predicting mortality and decision - making regarding polytraumatized pediatric patients .
we recommend that leaflets for big score be formed and calculated easily in the emergency department to help predicting mortality and decision - making regarding polytraumatized pediatric patients .
 background : trauma is a worldwide health problem and the major cause of death and disability , particularly affecting the young population . it is important to remember that pediatric trauma care has made a significant improvement in the outcomes of these injured children.aim of the work : this study aimed at evaluation of pediatric trauma big score in comparison with new injury severity score ( niss ) and pediatric trauma score ( pts ) in tanta university emergency hospital.materials and methods : the study was conducted in tanta university emergency hospital to all multiple trauma pediatric patients attended to the emergency department for 1 year . 
 pediatric trauma big score , pts , and niss scores were calculated and results compared to each other and to observed mortality.results:big score 12.7 has sensitivity 86.7% and specificity 71.4% , whereas pts at value 3.5 has sensitivity 63.3% and specificity 68.6% and niss at value 39.5 has sensitivity 53.3% and specificity 54.3% . 
 there was a significant positive correlation between big score value and mortality rate.conclusion:the pediatric big score is a reliable mortality - prediction score for children with traumatic injuries ; it uses international normalization ratio ( inr ) , base excess ( be ) , and glasgow coma scale ( gcs ) values that can be measured within a few minutes of sampling , so it can be readily applied in the pediatric emergency department , but it can not be applied on patients with chronic diseases that affect inr , be , or gcs . 