Validation of the PRESTO score in injured children in a South-African quaternary trauma center

Abstract

IntroductionThe Pediatric RESuscitation and Trauma Outcome (PRESTO) model was developed for standardized risk-adjustment in pediatric trauma and is adapted to low-resource settings. It includes easily-accessible demographic and physiologic variables that are available at point of care in virtually any setting. The purpose of this study was to evaluate the PRESTO model's ability to predict in-hospital mortality in a South African pediatric trauma unit by comparing it to the widely used Injury Severity Score (ISS). MethodsData prospectively collected between 2007 and 2017 in the Inkosi Albert Luthuli Central Hospital Trauma Registry were retrospectively reviewed. Injured children younger than 14 years were included if they were admitted to hospital or died as a result of their injury. We excluded patients with minor injuries who were treated and discharged home and patients with incomplete hospital disposition data. Receiver-Operating Characteristic (ROC) curves were constructed for PRESTO and ISS, and the areas under the curve (AUCs) were compared using Delong's test. The sensitivity and specificity of PRESTO were calculated at different prognostic threshold values identified through literature review. ResultsWe identified 419 patients; 67 died in hospital (16%). The AUCs for PRESTO and ISS were 0.82 (95% confidence interval CI [0.76–0.87]) and 0.75 (CI [0.68–0.81]), respectively. This difference trended towards statistical significance (p = 0.07). Using the optimal threshold of 0.13 described in the original publication, PRESTO had a 97% sensitivity and 37% specificity, while a threshold of 0.50 yielded 90% sensitivity and 54% specificity. The mean predicted probability of in-hospital death among patients who died was 0.79. Using this value as a threshold yielded the 57% sensitivity and 85% specificity. ConclusionThis analysis has demonstrated the validity of the PRESTO model for in-hospital mortality prediction for pediatric trauma patients in the setting of a dedicated high-complexity trauma unit in a South African trauma referral center. Level of evidenceLevel III: Case–control.