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    Pediatric Trauma BIG Score

    Stratifies severity of illness and predicts mortality in pediatric patients after trauma.
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    INSTRUCTIONS

    Use on admission in pediatric patients <18 years old who have sustained blunt or penetrating trauma or penetrating blast injury. Use lab values obtained on admission.

    When to Use
    Pearls/Pitfalls
    Why Use

    Pediatric patients under 18 years of age, after blunt or penetrating trauma or penetrating blast injury.

    • BIG is an acronym for the components of the score: base deficit, INR, and GCS.
    • Initial analysis (Borgman 2011) had more penetrating trauma and penetrating blast injuries, compared with the excluded patients who had more blunt injuries and burns. These were accounted for in the external validation, however.
    • May facilitate communication regarding prognosis with families and during patient transfer (Davis 2015).
    • If point of care testing is used, INR and base deficit results can be obtained in ~2 minutes (Borgman 2015).
    • Simple, rapid, and accurate scoring system to evaluate the severity of illness and predict mortality in children.
    • Can be applied to both blunt and penetrating traumatic injuries.
    • Useful in quantifying degree of physiological derangement beyond clinical appearance and GCS alone. Base deficit and INR are physiologic measures of hypoperfusion and trauma-induced coagulopathy, respectively, and both play critical roles in trauma-related mortality.
    mEq/L
    points

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    Next Steps
    Evidence
    Creator Insights

    Advice

    BIG Score alone should not direct clinical care because patients with BIG Scores <16 still require intensive care and trauma surgery services and should receive care at level 1 pediatric trauma centers (Davis 2015).

    Management

    Management of pediatric trauma patients depends on injuries diagnosed.

    Formula

    Pediatric BIG Score = (base deficit) + (2.5 × INR) + (15 - GCS)

    Facts & Figures

    Predicted in-hospital mortality = 1/(1 + e-B), where B = 0.2 × (BIG Score) – 5.208

    Note: Pediatric BIG Score of 26 (i.e., base deficit 10, INR 3.6, GCS 8) predicts a mortality of 50% with a positive predictive value of 65%, negative predictive value of 93%, and specificity of 99% (Borgman 2011).

    Davis et al (2015) report the optimal BIG Score cutoff as 16. Mortality with cutoff <16 was 3/496 (0.6%, 95% CI 0.001-0.007) vs ≥16 which was 47/125 (ROC 38%, 95% CI 0.15-0.7) with p <0.0001.

    Evidence Appraisal

    The Pediatric Trauma BIG Score was developed by Borgman et al in 2011 to rapidly assess the severity of illness and predict mortality in pediatric trauma patients. The model score derivation study used the Joint Theater Trauma Registry from 2002 to 2009, which contained pediatric military and civilian data from military treatment facilities in Iraq and Afghanistan. Univariate analyses were performed on multiple clinical and injury variables associated with mortality.

    Three variables, the base deficit, international normalized ratio (INR), and Glasgow Coma Scale (GCS) were found to be independently predictive of mortality. A model score was then derived using data from 707 pediatric patients and evaluated for mortality by using a receiver-operating curve (ROC) analysis. Overall mortality was 8.9% (63 of 707) with a median ISS of 10 (interquartile range: 5-19). The BIG Score yielded an area under the ROC of 0.89 (95% CI: 0.83-0.95), performing better than the Revised Trauma Score (AUROC 0.81, 95% CI:0.70-0.90), Age-Specific Pediatric Trauma Score (AUROC 0.81, 95% CI: 0.72-0.90), Pediatric Age-Adjusted Trauma (AUROC 0.75, 95% CI: 0.64-0.86), and Trauma and Injury Severity Score (AUROC 0.74, 95% CI: 0.62-0.85).

    Borgman et al then externally validated the BIG Score by conducting a separate retrospective analysis of the data of 1,101 pediatric patients obtained from the Trauma Registry of the Deutsche Gesellschaft für Unfallchirurgie from 2002 to 2007. The overall mortality in this population was 11.6% (128 of 1,101) with mean ISS of 24 (±15) and median ISS of 22 (interquartile range: 13-29). The ROC for mortality yielded an area under the curve nearly identical to the derivation study (0.89, 95% CI: 0.87-0.92).

    In 2015, Davis et al conducted a validation study of the BIG Score in 621 pediatric blunt trauma patients with ISS≥12 from a single level 1 trauma center in Ontario, Canada. This study adjusted for pre-hospital intubation and volume administration and the presence of hypotension and head injury. AUROC for mortality was 0.95 (95% CI: 0.93-0.98) with the optimal BIG cutoff of 16. Mortality with BIG Scores <16 was 3/496 (0.006, 95% CI 0.001-0.007) vs. 47/125 (0.38, 95% CI 0.15-0.7) for BIG Scores ≥16 with p <0.0001.

    The authors corroborated the studies by Borgman et al by concluding that the BIG Score remains predictive of mortality in a population of North American pediatric patients with blunt trauma independent of pre-hospital interventions and presence of head injury and hypotension.  

    Dr. Matthew A. Borgman

    About the Creator

    Matthew A. Borgman, MD, is a pediatric critical care physician at the Brooke Army Medical Center, Fort Sam Houston. He was previously an assistant professor in the pediatrics department at the Uniformed Services University of the Health Sciences. Dr. Borgman's research interests include pediatric trauma and trauma resuscitation simulation.

    To view Dr. Matthew A. Borgman's publications, visit PubMed

    Content Contributors
    • Jennie Kim, MD
    Reviewed By
    • Travis Polk, MD, FACS
    About the Creator
    Dr. Matthew A. Borgman
    Content Contributors
    • Jennie Kim, MD
    Reviewed By
    • Travis Polk, MD, FACS