Introduction: The Glasgow Coma Scale (GCS) has been effective in describing the severity of traumatic brain injury (TBI) but is inadequate for predicting the potential need for surgical intervention. A previously described scoring system in adults is the Surgical Intervention for Traumatic Injury (SITI) scale. The SITI scale has not been evaluated in children.
Methods: We conducted a retrospective cohort study of all children with a TBI diagnosis presenting to a single pediatric trauma center between 1/1/2010 and 1/1/2014. The SITI score was calculated using presenting GCS (trauma registry), presence of a unilateral enlarged pupil (initial ED provider exam), and radiographic findings (initial radiology report) of midline shift, temporal pathology and presence of an epidural hematoma. Mean SITI scores of children treated with medical management and children treated with craniotomy within 24 hours of presentation were compared using a two-tailed unpaired t-test.
Results: There were 964 children in the trauma registry during the observation period. 49 of these children had no cranial imaging and were excluded. Of the included 915 children, 880 were managed non-operatively and 35 required operative intervention. The mean SITI scores (Figure 1) for these groups were 0.47±0.03 and 4.74±0.36, respectively (p<0.0001).
Conclusions: SITI score was developed as a means to stratify risk for emergent intervention among head-injured adults. In this population of head-injured children, the SITI score on presentation also correlates with subsequent decompressive craniotomy. The SITI score warrants prospective evaluation for use as a risk-assessment tool in children with head injury.
Patient Care: While operative intervention in the setting of pediatric TBI is relatively uncommon, any delays between evaluation in the emergency department and surgical decompression can have devastating consequences. In an effort to expedite the communication between emergency department physicians and neurosurgeons, a scoring system incorporating clinical and radiographic findings was developed to correlate with the likelihood of urgent surgical intervention. This scale pinpoints key findings that can expedite patients through the health care system when emergent surgery is needed.
Learning Objectives: By the conclusion of this session, participants should be able to:
1) Describe the importance of a diagnostic tool to predict need for emergent surgical intervention in a pediatric population
2) Discuss, in small groups, the utility of such a tool in their daily practice
3) Identify new ways to implement this tool in their health care setting
References: Sribnick EA, Hanfelt JJ, Dhall SS. A clinical scale to communicate surgical urgency for traumatic brain injury: A preliminary study. Surgical Neurology International. 2015;6:1. doi:10.4103/2152-7806.148541.