{"paper_id":"34d88239-6651-43d4-bf27-b2d3966e07c8","body_text":"Predictive Value of Clinical and Trauma Scores for Life-Saving Interventions in Pediatric Trauma Patients: A Retrospecti̇ve Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Predictive Value of Clinical and Trauma Scores for Life-Saving Interventions in Pediatric Trauma Patients: A Retrospecti̇ve Cohort Study Emre Güngör, Ahmet Ziya Birbilen, Leman Akcan Yildiz, Ozlem Teksam This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9271487/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Early identification of pediatric trauma patients requiring life-saving interventions (LSIs) is fundamental for optimizing emergency triage and allocation planning. This study aimed to evaluate and compare the predictive effectiveness of the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score, and BIG score for determining LSI requirements in a pediatric emergency trauma population. Methods A retrospective observational study was conducted at the Pediatric Emergency Department of Hacettepe University, a Level I pediatric trauma center, between January 2019 and December 2022. Patients aged 0–18 years presenting within one hour of injury and observed for ≥ 8 hours were enrolled. Demographic, clinical, laboratory, and injury scoring data were systematically collected. Multivariable logistic regression analysis was performed to identify independent predictors of LSI requirement. Results A total of 560 patients were included (mean age 91.4 ± 70.3 months; 64.6% male), of whom 32.1% required LSIs. On multivariable analysis, higher AIS (AOR 6.39, 95% CI 3.79–10.79), higher ISS (AOR 1.23, 95% CI 1.16–1.31), elevated SIPA score (AOR 3.41, 95% CI 1.86–6.25), and elevated serum lactate (AOR 1.16, 95% CI 1.03–1.30) were independently associated with LSI requirement. Higher PTS (AOR 0.54) and higher GCS (AOR 0.54) were significantly associated with reduced odds of LSI. The BIG score did not demonstrate independent predictive significance after multivariable adjustment (p = 0.326). Overall mortality was 5.1%. Conclusion AIS, ISS, SIPA score, serum lactate, and GCS are reliable independent predictors of LSI requirement in pediatric trauma patients. The BIG score demonstrated limited utility for early LSI decision-making in this cohort. A multiparametric approach integrating injury severity, hemodynamic, metabolic, and neurological parameters provide a more solid framework for early risk stratification in pediatric emergency trauma management. Pediatric trauma life-saving interventions injury severity score SIPA score pediatric emergency medicine trauma scoring INTRODUCTION Childhood trauma remains a public health concern that continues to be one of the most significant causes of mortality and morbidity in children ( 1 ). The approach to injured children is very different from that of adult trauma patients and generally requires rapid and multidisciplinary management ( 2 ). Because children's anatomical and physiological characteristics and needs differ from those of adults, appropriate pediatric trauma care involves rapid assessment, prediction, and intervention, including pediatric-specific resuscitation techniques and equipment ( 3 ). At this point, early prediction and implementation of prehospital and in-hospital life-saving interventions (LSI) may be a key component of pediatric trauma care. Unlike in adults, LSI applications are quite rare in pediatric trauma patients; low rates of 0.2% have been reported in a cohort of 725,284 pediatric trauma patients ( 4 ). The most used interventions are securing an advanced airway, fluid resuscitation and inotropic drug support, vascular access (intravenous/intraosseous), hypothermia prevention, and bleeding control ( 4 , 5 ). Vascular access and hypothermia prevention are more frequently performed in the prehospital setting ( 6 ). In the management of critical conditions resulting from trauma in pediatric emergency departments, the timely and appropriate application of life-saving interventions plays a key role in reducing mortality and morbidity. In this process, relying solely on clinical experience and intuition is often insufficient. The need for decision-making under high stress requires the use of objective and reliable indicators. This study was designed on the hypothesis that clinical scoring systems, physiological parameters, and laboratory indicators used in trauma resuscitation can provide physicians with a quick, systematic roadmap, thereby helping predict which patients may require life-saving interventions. The primary objective of this study is to evaluate the distribution and accuracy of the AIS, ISS, PTS, SIPA score, and BIG scores in predicting the need for life-saving interventions in trauma patients. The secondary objectives are to examine the clinical characteristics of patients, the frequency of resource use, morbidity and mortality rates, and hospital and intensive care admission durations. MATERIAL AND METHODS Study Design and Setting This retrospective observational study was conducted in the Pediatric Emergency Department of Hacettepe University, a tertiary-level hospital and a Level I pediatric trauma center located in the capital city of Turkey. The department provides emergency care for approximately 80 000 pediatric patients annually. The study included all trauma cases admitted to the pediatric emergency department (PED) between January 1, 2019, and December 31, 2022. Eligible patients were those who were observed in the pediatric emergency observation unit for at least eight hours following trauma. Data were extracted from electronic medical records, trauma registries, and the hospital information system. Study Population The study population comprised pediatric patients aged 0–18 years who presented to the PED with trauma. Patients were enrolled consecutively and classified into two groups according to whether they required life-saving interventions (LSI) during their clinical course. Inclusion criteria were: Admission to the pediatric emergency observation unit and observation for ≥ 8 hours, Presentation within the first hour following trauma Exclusion criteria were: Incomplete or missing medical records Known chronic medical conditions and/or regular use of medications for chronic illnesses Presentation more than one hour after trauma Patients transferred from other centers who were admitted directly to inpatient wards without evaluation or observation in the PED Readmission within one month after initial discharge Patients discharged within < 8 hours and not monitored in the observation unit Trauma patients presenting as dead-on arrival Data Collection and Variables The following variables were collected: demographic data (age, sex), time of presentation, trauma mechanism, mode of arrival, Emergency Severity Index (ESI) triage level, vital signs, physical examination findings, Glasgow Coma Scale (GCS) score, laboratory parameters (blood gas analysis, lactate, pH, base deficit, INR), imaging findings (e-FAST ultrasonography, computed tomography), hospital characteristics, pediatric intensive care unit (PICU) admission and duration, length of hospital stay, morbidity and mortality. Trauma-related scores were calculated for each patient, including Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score and BIG score. Definition of Life-Saving Interventions Life-Saving Interventions (LSI) were defined as one or more of the following: Airway / Breathing: Assisted ventilation, endotracheal intubation, surgical airway, emergent non-invasive positive pressure ventilation. Electrical Therapy: Defibrillation, emergent cardioversion, external pacing. Procedures: Chest needle decompression, pericardiocentesis, open thoracotomy, intraosseous access. Hemodynamics: Significant intravenous fluid resuscitation (≥ 2 boluses of 10–20 mL/kg), blood product administration (red blood cell transfusions), control of external hemorrhage. Medications: Adenosine, atropine, dextrose, dopamine, epinephrine), naloxone. Cardiopulmonary Resuscitation. Outcomes The primary outcome of this study was to evaluate the distribution and predictive accuracy of trauma severity scores, including the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score, and the BIG score, in identifying parameters that can predict the need for life-saving interventions (LSIs) during the clinical course. Secondary outcomes included the assessment of patients’ clinical characteristics, frequency of resource utilization, morbidity and mortality rates, and length of hospital and intensive care unit stay. Statistical Analysis All statistical analyses were performed using JASP statistical software (Version 0.19.3 JASP Team, 2025). A p-value of < 0.05 was considered statistically significant. Continuous variables were tested for normality using the Shapiro–Wilk test and examination of histograms and Q–Q plots. Normally distributed variables were presented as mean ± standard deviation (SD), whereas non-normally distributed variables were expressed as median (interquartile range, IQR). Categorical variables were expressed as absolute numbers and percentages. Patients were stratified into two groups according to whether life-saving interventions (LSIs) were required. For continuous variables, the independent samples t-test was applied when normality assumptions were met, while the Mann–Whitney U test was used for non-parametric data. For categorical variables, the Pearson chi-square test or Fisher’s exact test was used. To identify predictors of LSI requirement: Univariable logistic regression analyses were first performed for each demographic, clinical, laboratory, and trauma score variable. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Variables with a p-value < 0.05 in univariable analysis were then entered into a multivariable logistic regression model using a backward stepwise likelihood ratio method. This allowed determination of independent predictors after adjusting for potential confounders. In addition to LSI requirement, morbidity, mortality, and length of stay in the PICU and hospital were compared between groups using the same methods described above. Ethical approval This retrospective observational study was approved by the Hacettepe University Non-Interventional Clinical Research Ethics Committee (session no: 2023/01, decision no: 2023/01–01; research no: GO 23/04; approval date: 24 January 2023). All study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki and its subsequent amendments. RESULTS The mean age of pediatric trauma patients was 91.4 ± 70.3 months. The cohort consisted of 362 males (64.6%) and 198 females (35.4%). Most of patients (80.4%) were transported to the emergency department via Emergency Medical Services (EMS), while 91 patients (16.2%) were referred from other hospitals, and 19 (3.4%) self-referrals or non-EMS presentation. With respect to arrival times, the evening shift (16:01–23:59) was the busiest, accounting for 312 patients (55.9%). The day shift (08:00–16:00) included 140 patients (25.0%), whereas 107 patients (19.1%) presented during the night shift (00:00–07:59). Falls were the most frequent mechanism of injury, observed in 248 cases (44.3%), followed by motor vehicle accidents in 231 cases (41.3%). Other mechanisms included bicycle accidents (5.4%), penetrating trauma (3.8%), blunt trauma (2.3%), assault (1.6%), firearm-related injuries (0.9%), and drowning (0.4%). At triage, nearly half of the patients were classified as Emergency Severity Index (ESI) Level 3 (49.2%), while 31.5% were Level 2 and 19.3% were Level 1. Tachycardia was documented in 37.8% of cases, and 10.9% presented with hypotension. Neurological assessment revealed that 59.1% of patients had a Glasgow Coma Scale (GCS) score of 14–15, 18.8% demonstrated moderate impairment (GCS 8–13), and 22.1% had severe impairment (GCS ≤ 8). Approximately one-third of the cohort (32.1%) required life-saving interventions. These included significant fluid resuscitation (27.9%), endotracheal intubation (25.9%), transfusion of packed red blood cells (18.9%), and inotropic support (12.5%). Cardiopulmonary resuscitation was performed in 3.3% of patients. The overall mortality rate was 5.1% (n = 29), while morbidity was documented in 10.1% (n = 57). Regarding disposition, most patients were admitted to the Pediatric Intensive Care Unit (45.9%) or the Surgical Observation Unit (38.9%). A smaller proportion were discharged directly from the emergency department (13.9%), and 1.3% were admitted to the General Pediatric Unit (Table 1). Comparison of clinical and laboratory parameters between patients requiring and not requiring life-saving interventions revealed distinct differences in injury severity and physiological status (Table 2). Patients in the LSI group had significantly higher Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) values compared to those not requiring interventions (p < 0.001 for both). Conversely, Pediatric Trauma Score (PTS) values were markedly lower in the LSI group, indicating more severe injury patterns (p < 0.001). Physiological parameters also differed substantially. Children requiring LSI had higher Pediatric Age-adjusted (SIPA) scores and lactate concentrations (p < 0.001), reflecting greater hemodynamic compromise. In contrast, Glasgow Coma Scale (GCS) scores were significantly reduced in this group (mean 7.6 vs. 14.1, p < 0.001), demonstrating more severe neurological impairment. Base deficit values were also more negative, suggesting profound metabolic acidosis (p < 0.001). No significant differences were observed between groups regarding BIG score, arterial pH, or INR values (p > 0.05). However, patients requiring LSI exhibited substantially longer Pediatric Intensive Care Unit (PICU) and overall hospital stays (p < 0.001). SIPA score, ISS, higher AIS, elevated lactate, and lower GCS emerged as the strongest independent predictors of the need for life-saving interventions. While the BIG score showed a modest association in univariable analysis, it lost its independent significance after adjustment for other variables. These findings highlight the clinical utility of the SIPA score as a more reliable predictor than the BIG score in estimating the requirement for critical interventions, particularly among trauma patients. In the multivariable logistic regression model, higher AIS (AOR = 6.39, 95% CI [3.79–10.79], p < .001), higher ISS (AOR = 1.23, 95% CI [1.16–1.31], p < .001), elevated SIPA score (AOR = 3.41, 95% CI [1.86–6.25], p < .001), and increased lactate levels (AOR = 1.16, 95% CI [1.03–1.30], p = .014) were independently associated with greater odds of requiring life-saving interventions. In contrast, higher pediatric trauma scores (AOR = 0.54, 95% CI [0.45–0.64], p < .001) and lower GCS (AOR = 0.54, 95% CI [0.45–0.64], p < .001) were linked to significantly reduced odds. The BIG score, however, did not retain statistical significance in the adjusted analysis (p = .326) (Table 3). DISCUSSION In our study, we found that higher AIS and ISS scores, higher SIPA scores and lactate levels, and lower GCS and PTS were the strongest indicators for the need for life-saving interventions in children with trauma. Our results show that measurements of trauma severity, along with physiological and metabolic data, directly impact the patient's clinical course. In our study, 85.6% of patients came in after falls or motor vehicle accidents. Half were classified as emergent or urgent. These rates seem high compared to the literature that includes all trauma patients ( 7 ) but our study focused only on those needing observation. This led to a more similar group, with almost one-third needing life-saving interventions. In this situation, more patients arrived by emergency medical services, which was expected ( 7 , 8 ). he age and gender distribution in our group was similar to that in other European studies, supporting the consistency of our findings with the literature ( 4 , 9 , 10 ). Both AIS and ISS are among the strongest and most independent predictors of whether trauma patients will need life-saving intervention (LSI). In our study, AIS predicted LSI demonstrated superior ISS. As trauma severity increases, both scores go up. In turn, the likelihood of requiring critical intervention also rises significantly ( 11 , 12 ). For pediatric trauma patients, vital signs and the Glasgow Coma Scale (GCS) are the most important physiological and neurological signs for predicting LSI. The GCS shows the patient's neurological status and has a strong inverse link with the need for LSI ( 13 ). In our study, patients who needed LSI had much lower average GCS scores. This shows that severe neurological impairment is closely related to needing critical intervention. GCS is also an independent predictor of LSI ( 13 , 14 ). When examining the relationship between vital signs and LSI, abnormalities in vital signs such as pulse, blood pressure, and oxygen saturation were frequently observed in the triage assessment of patients in our cohort in the emergency department. However, the relationship between vital signs and LSI was established more clearly and reliably using the age-adjusted shock index (SIPA) score than with individual parameters. The SIPA score is an integrated measurement of basic vital signs, such as heart rate and blood pressure, and reflects hemodynamic deterioration in children with high sensitivity ( 15 ). There is still no consensus or common language for physiological thresholds ( 16 ). Physiological deviations in the patient's vital signs (hemodynamic deterioration measured by SIPA score) and deterioration in neurological status (low GCS) constitute the most fundamental and objective findings that determine the need for life-saving intervention in pediatric trauma at an early stage ( 17 , 18 ). The patient group identified by SIPA score is the group that will require LSI ( 19 ). The BIG score is commonly used by trauma physicians because it is easier to apply than scoring systems such as AIS, ISS, and SIPA score, and can be used in centers with limited resources ( 20 ). Studies in the literature have shown that the BIG score predicts mortality and morbidity outcomes as well as those predicted by traditionally used scores ( 20 – 22 ). In our study, however, the BIG score failed to retain its predictive value for LSI, unlike other markers such as AIS, ISS, SIPA score, and lactate, and was insufficient to determine the need for critical intervention in pediatric trauma management. The most fundamental reason may be that the BIG score was primarily developed to predict mortality and a poor overall prognosis ( 21 ), whereas the LSI reflects the need for acute, early intervention. In other words, the two outcomes do not measure the same clinical axis. Even if a score predicts mortality well, it may not predict the need for early intubation, massive transfusion, emergency surgery, or resuscitation with the same success. Therefore, more pediatric studies are needed on this topic. Furthermore, if LSI is considered an “early” outcome, mortality/morbidity is a later and multifactorial outcome. Our findings support that lactate may be the most reliable parameter for independently predicting the need for LSI. It serves as an indicator of tissue hypoperfusion and hemodynamic compromise. In traumatized children, lactate may indicate tissue hypoperfusion earlier. It can be used to predict patient prognosis, length of stay, and mortality ( 23 , 24 ). In this context, lactate levels can act as a metabolic 'alarm signal' for predicting LSI ( 25 ). Although using base excess may seem reasonable, physicians should note that persistent or worsening negative base excess, especially if not isolated, may alert them to a deteriorating physiological and metabolic state requiring rapid and aggressive treatment or LSI ( 26 , 27 ). CONCLUSION Our findings show that early risk assessment in pediatric trauma should be based not just on how the injury happened, but also on a thorough clinical check. Simple, clear measurements taken right at the start help find patients who might need urgent help. Higher AIS, ISS, and SIPA scores, as well as higher lactate levels and lower GCS, These indicators stand out as reliable signs that pediatric trauma patients may require LSI. While the BIG score was important in monitoring the patient, it proved less useful when tested alongside other factors. This means that the BIG score can help predict overall outcomes, but it is not enough on its own for quick treatment LSI decisions in pediatric trauma. Our results suggest using a scoring method that looks at injury severity, blood circulation, metabolism, and nervous system status together. This integrated approach may provide a more accurate framework for early risk stratification and clinical decision-making in pediatric trauma emergency management, and further prospective and multicenter studies in children are needed. Declarations Participant consent statement: This study was reviewed and approved by the relevant Institutional Review Board / Ethics Committee. Written informed consent was obtained from the participants and/or their legal guardians prior to enrollment. In cases where the requirement for informed consent was waived, the waiver was granted by the approving Ethics Committee Competing interests The authors declare no competing interests. Funding: The authors received no financial support for the research, authorship, and/or publication of this article. Author Contribution E.G. made the principal contribution to this work and served as the primary author of the manuscript. E.G. contributed to the conceptualization and design of the study, coordinated the study process, performed data collection, conducted the formal data analysis, interpreted the findings, and wrote the main manuscript text. A.Z.B. contributed to data collection, data interpretation, and critical revision of the manuscript. L.A.Y. contributed to data collection, data analysis, and revision of the manuscript for important intellectual content. O.T. contributed to the conceptualization and design of the study, supervised the overall research process, participated in data interpretation, and critically revised the manuscript. All authors reviewed the manuscript and approved the final version. Acknowledgement We extend our gratitude to all healthcare professionals who dedicate their efforts to ensuring that children live in a safer world. Data Availability The datasets generated and/or analyzed during the current study are not publicly available due to institutional and ethical restrictions regarding patient confidentiality but are available from the corresponding author on reasonable request, subject to approval by the relevant institutional authorities. References Petrosyan M, Guner YS, Emami CN, Ford HR. Disparities in the delivery of pediatric trauma care. J Trauma. 2009;67(2 Suppl):S114–9. Harfouche M, Higgins K, Waibel E, Slidell MB, Nasr I, Nace GW, et al. Who will be the bastions of pediatric trauma care? Trauma Surg Acute Care Open. 2025;10(Suppl 3):e001573. Tosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg. 2016;42(3):297–301. Swendiman RA, Sharoky CE, Russell KW, Goldshore MA, Blinman TA, Nance ML. Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience. J Trauma Acute Care Surg. 2019;87(6):1321–7. Phattharapornjaroen P, Sittichanbuncha Y, Atiksawedparit P, Sawanyawisuth K. Characteristics of Pediatric Emergency and Risk Factors for Life-saving Interventions. Glob Pediatr Health. 2021;8:2333794x21990340. Reeves LK, Savell SC, Maddry JK, Samsey KM, Mora AG, Lairet JR. Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study. Pediatr Crit Care Med. 2020;21(7):e407–13. Larsson G, Larsson S, Strand V, Magnusson C, Andersson Hagiwara M. Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes. Scand J Trauma Resusc Emerg Med. 2024;32(1):51. Cintean R, Eickhoff A, Zieger J, Gebhard F, Schütze K. Epidemiology, patterns, and mechanisms of pediatric trauma: a review of 12,508 patients. Eur J Trauma Emerg Surg. 2023;49(1):451–9. Buschmann C, Kühne CA, Lösch C, Nast-Kolb D, Ruchholtz S. Major trauma with multiple injuries in German children: a retrospective review. J Pediatr Orthop. 2008;28(1):1–5. Hansen OM, Mikkelsen R, Eskol JR, Brink O. Characteristics and outcomes of paediatric patients admitted to a Danish level-1 trauma centre. Dan Med J. 2020;67:7. Feldhaus I, Carvalho M, Waiz G, Igu J, Matthay Z, Dicker R, et al. Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review. Trauma Surg Acute Care Open. 2020;5(1):e000424. Hatchimonji JS, Luks VL, Swendiman RA, Allukian M 3rd, Nance ML, Nace GW. Jr. Settling the Score: Injury Severity Score Fails to Capture Nuances in Pediatric Trauma. Pediatr Emerg Care. 2022;38(2):e828–32. Reppucci ML, Cooper E, Nolan MM, Lyttle BD, Gallagher LT, Jujare S, et al. Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care. J Trauma Acute Care Surg. 2023;95(3):347–53. DiBrito SR, Cerullo M, Goldstein SD, Ziegfeld S, Stewart D, Nasr IW. Reliability of Glasgow Coma Score in pediatric trauma patients. J Pediatr Surg. 2018;53(9):1789–94. McCormick T, Haukoos J, Hopkins E, Trent S, Adelgais K, Cohen M, et al. Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children. J Trauma Acute Care Surg. 2023;94(2):295–303. Andrews T, Meadley B, Gabbe B, Beck B, Dicker B, Cameron P. Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand. Emerg Med Australas. 2024;36(2):197–205. Yoon SH, Shin SJ, Kim H, Roh YH. Shock index and shock index, pediatric age-adjusted as predictors of mortality in pediatric patients with trauma: A systematic review and meta-analysis. PLoS ONE. 2024;19(7):e0307367. Raythatha JH, Aulakh H, Yang S, Mok C, Soundappan SV. Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale. Injury. 2022;53(4):1438–42. Sheff ZT, Zaheer MM, Sinclair MC, Engbrecht BW. Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia. Am J Emerg Med. 2024;83:59–63. Bolstridge J, O'Neil ER, Aden JK, Muisyo T, Spinella PC, Borgman MA. Use of the BIG score to predict mortality in pediatric trauma. Am J Emerg Med. 2021;45:472–5. Davis AL, Wales PW, Malik T, Stephens D, Razik F, Schuh S. The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma. J Pediatr. 2015;167(3):593–e81. Az A, Dogan Y, Sogut O, Akdemir T. Comparison of the BIG Score and Pediatric Trauma Score for Predicting Mortality. Pediatr Emerg Care. 2024;40(12):839–43. Huh Y, Ko Y, Hwang K, Jung K, Cha Y-h, Choi YJ, et al. Admission Lactate and Base Deficit in Predicting Outcomes of Pediatric Trauma. Shock. 2021;55(4):495–500. Belu A, Filip N, Trandafir LM, Spoială EL, Țarcă E, Zamosteanu D et al. Lactate, an Essential Metabolic Marker in the Diagnosis and Management of Pediatric Conditions. Diagnostics (Basel). 2025;15(7). Martín-Rodríguez F, Sanz-Garcia A, Zalama-Sánchez D, de Santos Castro P, Silva Alvarado E, Gracia Villar S, et al. Novel prehospital lactate cut-off estimation for mortality: a multicentre observational study. BMJ Open. 2024;14(12):e091789. Berend K. Diagnostic Use of Base Excess in Acid-Base Disorders. N Engl J Med. 2018;378(15):1419–28. Langer T, Brusatori S, Gattinoni L. Understanding base excess (BE): merits and pitfalls. Intensive Care Med. 2022;48(8):1080–3. Tables Table 1 to 3 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files 3Table1.docx 4Table2.docx 5table3.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-9271487\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Research Article\",\"associatedPublications\":[],\"authors\":[{\"id\":616666393,\"identity\":\"e8b26da0-2753-4825-bd4c-8dfa1cd02edb\",\"order_by\":0,\"name\":\"Emre Güngör\",\"email\":\"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7klEQVRIiWNgGAWjYJADxgcQOoF4LcwGcC0HiNTCJkGUFn6xsw8fMPw6nCfv3vus4sOvwwz87DkGzB/34NYiOTvd2ICx73Cx4ZnjZjdn9h1mkOx5Y8Bw4BluLQa309gkGHsOJ26ckcZ2m7fnMIPBjRygFjwus7+dxv4DpqUYpMWekBYD6TQ2BoYfhxPnS6SxMfP8ANoiQUCLxO00ZonEhvTEDTzHmCVnNqTzSJx5VnDgDB4t/LPTGD98+GOdOL+9DcyQ429P3vigAo8WMEhsA7oQpIixjYEHJEBIAxD8YWCQb4AyRsEoGAWjYBSgAwB9QVaOy/8koQAAAABJRU5ErkJggg==\",\"orcid\":\"\",\"institution\":\"Eskişehir Osmangazi University\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Emre\",\"middleName\":\"\",\"lastName\":\"Güngör\",\"suffix\":\"\"},{\"id\":616666394,\"identity\":\"cb9848a0-7ab4-47fe-8ca9-974b5bd031e5\",\"order_by\":1,\"name\":\"Ahmet Ziya Birbilen\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hacettepe University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ahmet\",\"middleName\":\"Ziya\",\"lastName\":\"Birbilen\",\"suffix\":\"\"},{\"id\":616666395,\"identity\":\"141c2b82-f127-4130-811d-f259aa30f229\",\"order_by\":2,\"name\":\"Leman Akcan Yildiz\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hacettepe University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Leman\",\"middleName\":\"Akcan\",\"lastName\":\"Yildiz\",\"suffix\":\"\"},{\"id\":616666396,\"identity\":\"bd427ff1-f882-438d-9b08-b6f306b82e80\",\"order_by\":3,\"name\":\"Ozlem Teksam\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Hacettepe University\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Ozlem\",\"middleName\":\"\",\"lastName\":\"Teksam\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2026-03-30 19:23:31\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-9271487/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-9271487/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":108181056,\"identity\":\"48aa9166-2849-4efc-a698-8770611b3f5b\",\"added_by\":\"auto\",\"created_at\":\"2026-04-30 08:56:44\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":177604,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9271487/v1/9b86e6d5-34da-44eb-9cd1-f24b9b971dff.pdf\"},{\"id\":106331916,\"identity\":\"a1328986-9df1-42fd-8d42-8707543a5cbf\",\"added_by\":\"auto\",\"created_at\":\"2026-04-07 14:12:23\",\"extension\":\"docx\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":22644,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"3Table1.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9271487/v1/d91b1b3da5c03b57fd4de5c7.docx\"},{\"id\":106331977,\"identity\":\"295bcc57-6425-409a-8ee7-a8944082de57\",\"added_by\":\"auto\",\"created_at\":\"2026-04-07 14:12:46\",\"extension\":\"docx\",\"order_by\":1,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":19944,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"4Table2.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9271487/v1/63e6cf65e81c34035ca0a41e.docx\"},{\"id\":106331974,\"identity\":\"e94bb274-095d-4b41-8889-0c23f6d14bd3\",\"added_by\":\"auto\",\"created_at\":\"2026-04-07 14:12:43\",\"extension\":\"docx\",\"order_by\":2,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"supplement\",\"size\":20317,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"5table3.docx\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-9271487/v1/5e3b009a9bb430b6ac8683ca.docx\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"\\u003cp\\u003ePredictive Value of Clinical and Trauma Scores for Life-Saving Interventions in Pediatric Trauma Patients: A Retrospecti̇ve Cohort Study\\u003c/p\\u003e\",\"fulltext\":[{\"header\":\"INTRODUCTION\",\"content\":\"\\u003cp\\u003eChildhood trauma remains a public health concern that continues to be one of the most significant causes of mortality and morbidity in children (\\u003cspan citationid=\\\"CR1\\\" class=\\\"CitationRef\\\"\\u003e1\\u003c/span\\u003e). The approach to injured children is very different from that of adult trauma patients and generally requires rapid and multidisciplinary management (\\u003cspan citationid=\\\"CR2\\\" class=\\\"CitationRef\\\"\\u003e2\\u003c/span\\u003e). Because children's anatomical and physiological characteristics and needs differ from those of adults, appropriate pediatric trauma care involves rapid assessment, prediction, and intervention, including pediatric-specific resuscitation techniques and equipment (\\u003cspan citationid=\\\"CR3\\\" class=\\\"CitationRef\\\"\\u003e3\\u003c/span\\u003e). At this point, early prediction and implementation of prehospital and in-hospital life-saving interventions (LSI) may be a key component of pediatric trauma care. Unlike in adults, LSI applications are quite rare in pediatric trauma patients; low rates of 0.2% have been reported in a cohort of 725,284 pediatric trauma patients (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e). The most used interventions are securing an advanced airway, fluid resuscitation and inotropic drug support, vascular access (intravenous/intraosseous), hypothermia prevention, and bleeding control (\\u003cspan citationid=\\\"CR4\\\" class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan citationid=\\\"CR5\\\" class=\\\"CitationRef\\\"\\u003e5\\u003c/span\\u003e). Vascular access and hypothermia prevention are more frequently performed in the prehospital setting (\\u003cspan citationid=\\\"CR6\\\" class=\\\"CitationRef\\\"\\u003e6\\u003c/span\\u003e).\\u003c/p\\u003e \\u003cp\\u003eIn the management of critical conditions resulting from trauma in pediatric emergency departments, the timely and appropriate application of life-saving interventions plays a key role in reducing mortality and morbidity. In this process, relying solely on clinical experience and intuition is often insufficient. The need for decision-making under high stress requires the use of objective and reliable indicators.\\u003c/p\\u003e \\u003cp\\u003eThis study was designed on the hypothesis that clinical scoring systems, physiological parameters, and laboratory indicators used in trauma resuscitation can provide physicians with a quick, systematic roadmap, thereby helping predict which patients may require life-saving interventions. The primary objective of this study is to evaluate the distribution and accuracy of the AIS, ISS, PTS, SIPA score, and BIG scores in predicting the need for life-saving interventions in trauma patients. The secondary objectives are to examine the clinical characteristics of patients, the frequency of resource use, morbidity and mortality rates, and hospital and intensive care admission durations.\\u003c/p\\u003e\"},{\"header\":\"MATERIAL AND METHODS\",\"content\":\"\\u003cdiv id=\\\"Sec3\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStudy Design and Setting\\u003c/h2\\u003e \\u003cp\\u003eThis retrospective observational study was conducted in the Pediatric Emergency Department of Hacettepe University, a tertiary-level hospital and a Level I pediatric trauma center located in the capital city of Turkey. The department provides emergency care for approximately 80 000 pediatric patients annually. The study included all trauma cases admitted to the pediatric emergency department (PED) between January 1, 2019, and December 31, 2022. Eligible patients were those who were observed in the pediatric emergency observation unit for at least eight hours following trauma. Data were extracted from electronic medical records, trauma registries, and the hospital information system.\\u003c/p\\u003e \\u003c/div\\u003e\\n\\u003ch3\\u003eStudy Population\\u003c/h3\\u003e\\n\\u003cp\\u003eThe study population comprised pediatric patients aged 0\\u0026ndash;18 years who presented to the PED with trauma. Patients were enrolled consecutively and classified into two groups according to whether they required life-saving interventions (LSI) during their clinical course.\\u003c/p\\u003e \\u003cp\\u003eInclusion criteria were:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eAdmission to the pediatric emergency observation unit and observation for \\u0026ge;\\u0026thinsp;8 hours,\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePresentation within the first hour following trauma\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e \\u003cp\\u003eExclusion criteria were:\\u003c/p\\u003e \\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eIncomplete or missing medical records\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eKnown chronic medical conditions and/or regular use of medications for chronic illnesses\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePresentation more than one hour after trauma\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePatients transferred from other centers who were admitted directly to inpatient wards without evaluation or observation in the PED\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eReadmission within one month after initial discharge\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003ePatients discharged within \\u0026lt;\\u0026thinsp;8 hours and not monitored in the observation unit\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eTrauma patients presenting as dead-on arrival\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003eData Collection and Variables\\u003c/h3\\u003e\\n\\u003cp\\u003eThe following variables were collected: demographic data (age, sex), time of presentation, trauma mechanism, mode of arrival, Emergency Severity Index (ESI) triage level, vital signs, physical examination findings, Glasgow Coma Scale (GCS) score, laboratory parameters (blood gas analysis, lactate, pH, base deficit, INR), imaging findings (e-FAST ultrasonography, computed tomography), hospital characteristics, pediatric intensive care unit (PICU) admission and duration, length of hospital stay, morbidity and mortality.\\u003c/p\\u003e \\u003cp\\u003eTrauma-related scores were calculated for each patient, including Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score and BIG score.\\u003c/p\\u003e\\n\\u003ch3\\u003eDefinition of Life-Saving Interventions\\u003c/h3\\u003e\\n\\u003cp\\u003e \\u003cul\\u003e \\u003cli\\u003e \\u003cp\\u003eLife-Saving Interventions (LSI) were defined as one or more of the following:\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eAirway / Breathing: Assisted ventilation, endotracheal intubation, surgical airway, emergent non-invasive positive pressure ventilation.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eElectrical Therapy: Defibrillation, emergent cardioversion, external pacing.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eProcedures: Chest needle decompression, pericardiocentesis, open thoracotomy, intraosseous access.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eHemodynamics: Significant intravenous fluid resuscitation (\\u0026ge;\\u0026thinsp;2 boluses of 10\\u0026ndash;20 mL/kg), blood product administration (red blood cell transfusions), control of external hemorrhage.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eMedications: Adenosine, atropine, dextrose, dopamine, epinephrine), naloxone.\\u003c/p\\u003e \\u003c/li\\u003e \\u003cli\\u003e \\u003cp\\u003eCardiopulmonary Resuscitation.\\u003c/p\\u003e \\u003c/li\\u003e \\u003c/ul\\u003e \\u003c/p\\u003e\\n\\u003ch3\\u003eOutcomes\\u003c/h3\\u003e\\n\\u003cp\\u003eThe primary outcome of this study was to evaluate the distribution and predictive accuracy of trauma severity scores, including the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score, and the BIG score, in identifying parameters that can predict the need for life-saving interventions (LSIs) during the clinical course. Secondary outcomes included the assessment of patients\\u0026rsquo; clinical characteristics, frequency of resource utilization, morbidity and mortality rates, and length of hospital and intensive care unit stay.\\u003c/p\\u003e \\u003cdiv id=\\\"Sec8\\\" class=\\\"Section2\\\"\\u003e \\u003ch2\\u003eStatistical Analysis\\u003c/h2\\u003e \\u003cp\\u003eAll statistical analyses were performed using JASP statistical software (Version 0.19.3 JASP Team, 2025). A p-value of \\u0026lt;\\u0026thinsp;0.05 was considered statistically significant. Continuous variables were tested for normality using the Shapiro\\u0026ndash;Wilk test and examination of histograms and Q\\u0026ndash;Q plots. Normally distributed variables were presented as mean\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;standard deviation (SD), whereas non-normally distributed variables were expressed as median (interquartile range, IQR). Categorical variables were expressed as absolute numbers and percentages. Patients were stratified into two groups according to whether life-saving interventions (LSIs) were required. For continuous variables, the independent samples t-test was applied when normality assumptions were met, while the Mann\\u0026ndash;Whitney U test was used for non-parametric data. For categorical variables, the Pearson chi-square test or Fisher\\u0026rsquo;s exact test was used.\\u003c/p\\u003e \\u003cp\\u003eTo identify predictors of LSI requirement: Univariable logistic regression analyses were first performed for each demographic, clinical, laboratory, and trauma score variable. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Variables with a p-value\\u0026thinsp;\\u0026lt;\\u0026thinsp;0.05 in univariable analysis were then entered into a multivariable logistic regression model using a backward stepwise likelihood ratio method. This allowed determination of independent predictors after adjusting for potential confounders. In addition to LSI requirement, morbidity, mortality, and length of stay in the PICU and hospital were compared between groups using the same methods described above.\\u003c/p\\u003e \\u003c/div\\u003e\\u003cp\\u003e \\u003ch2\\u003eEthical approval\\u003c/h2\\u003e \\u003cp\\u003eThis retrospective observational study was approved by the Hacettepe University Non-Interventional Clinical Research Ethics Committee (session no: 2023/01, decision no: 2023/01\\u0026ndash;01; research no: GO 23/04; approval date: 24 January 2023). All study procedures were conducted in accordance with the ethical principles of the Declaration of Helsinki and its subsequent amendments.\\u003c/p\\u003e\"},{\"header\":\"RESULTS\",\"content\":\" \\u003cp\\u003eThe mean age of pediatric trauma patients was 91.4 ± 70.3 months. The cohort consisted of 362 males (64.6%) and 198 females (35.4%). Most of patients (80.4%) were transported to the emergency department via Emergency Medical Services (EMS), while 91 patients (16.2%) were referred from other hospitals, and 19 (3.4%) self-referrals or non-EMS presentation. With respect to arrival times, the evening shift (16:01–23:59) was the busiest, accounting for 312 patients (55.9%). The day shift (08:00–16:00) included 140 patients (25.0%), whereas 107 patients (19.1%) presented during the night shift (00:00–07:59). Falls were the most frequent mechanism of injury, observed in 248 cases (44.3%), followed by motor vehicle accidents in 231 cases (41.3%). Other mechanisms included bicycle accidents (5.4%), penetrating trauma (3.8%), blunt trauma (2.3%), assault (1.6%), firearm-related injuries (0.9%), and drowning (0.4%). At triage, nearly half of the patients were classified as Emergency Severity Index (ESI) Level 3 (49.2%), while 31.5% were Level 2 and 19.3% were Level 1. Tachycardia was documented in 37.8% of cases, and 10.9% presented with hypotension. Neurological assessment revealed that 59.1% of patients had a Glasgow Coma Scale (GCS) score of 14–15, 18.8% demonstrated moderate impairment (GCS 8–13), and 22.1% had severe impairment (GCS ≤ 8). Approximately one-third of the cohort (32.1%) required life-saving interventions. These included significant fluid resuscitation (27.9%), endotracheal intubation (25.9%), transfusion of packed red blood cells (18.9%), and inotropic support (12.5%). Cardiopulmonary resuscitation was performed in 3.3% of patients. The overall mortality rate was 5.1% (n = 29), while morbidity was documented in 10.1% (n = 57). Regarding disposition, most patients were admitted to the Pediatric Intensive Care Unit (45.9%) or the Surgical Observation Unit (38.9%). A smaller proportion were discharged directly from the emergency department (13.9%), and 1.3% were admitted to the General Pediatric Unit (Table\\u0026nbsp;1).\\u003c/p\\u003e \\u003cp\\u003eComparison of clinical and laboratory parameters between patients requiring and not requiring life-saving interventions revealed distinct differences in injury severity and physiological status (Table\\u0026nbsp;2). Patients in the LSI group had significantly higher Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS) values compared to those not requiring interventions (p \\u0026lt; 0.001 for both). Conversely, Pediatric Trauma Score (PTS) values were markedly lower in the LSI group, indicating more severe injury patterns (p \\u0026lt; 0.001). Physiological parameters also differed substantially. Children requiring LSI had higher Pediatric Age-adjusted (SIPA) scores and lactate concentrations (p \\u0026lt; 0.001), reflecting greater hemodynamic compromise. In contrast, Glasgow Coma Scale (GCS) scores were significantly reduced in this group (mean 7.6 vs. 14.1, p \\u0026lt; 0.001), demonstrating more severe neurological impairment. Base deficit values were also more negative, suggesting profound metabolic acidosis (p \\u0026lt; 0.001). No significant differences were observed between groups regarding BIG score, arterial pH, or INR values (p \\u0026gt; 0.05). However, patients requiring LSI exhibited substantially longer Pediatric Intensive Care Unit (PICU) and overall hospital stays (p \\u0026lt; 0.001).\\u003c/p\\u003e \\u003cp\\u003eSIPA score, ISS, higher AIS, elevated lactate, and lower GCS emerged as the strongest independent predictors of the need for life-saving interventions. While the BIG score showed a modest association in univariable analysis, it lost its independent significance after adjustment for other variables. These findings highlight the clinical utility of the SIPA score as a more reliable predictor than the BIG score in estimating the requirement for critical interventions, particularly among trauma patients. In the multivariable logistic regression model, higher AIS (AOR = 6.39, 95% CI [3.79–10.79], p \\u0026lt; .001), higher ISS (AOR = 1.23, 95% CI [1.16–1.31], p \\u0026lt; .001), elevated SIPA score (AOR = 3.41, 95% CI [1.86–6.25], p \\u0026lt; .001), and increased lactate levels (AOR = 1.16, 95% CI [1.03–1.30], p = .014) were independently associated with greater odds of requiring life-saving interventions. In contrast, higher pediatric trauma scores (AOR = 0.54, 95% CI [0.45–0.64], p \\u0026lt; .001) and lower GCS (AOR = 0.54, 95% CI [0.45–0.64], p \\u0026lt; .001) were linked to significantly reduced odds. The BIG score, however, did not retain statistical significance in the adjusted analysis (p = .326) (Table\\u0026nbsp;3).\\u003c/p\\u003e\"},{\"header\":\"DISCUSSION\",\"content\":\"\\u003cp\\u003eIn our study, we found that higher AIS and ISS scores, higher SIPA scores and lactate levels, and lower GCS and PTS were the strongest indicators for the need for life-saving interventions in children with trauma. Our results show that measurements of trauma severity, along with physiological and metabolic data, directly impact the patient's clinical course.\\u003c/p\\u003e\\u003cp\\u003eIn our study, 85.6% of patients came in after falls or motor vehicle accidents. Half were classified as emergent or urgent. These rates seem high compared to the literature that includes all trauma patients (\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e) but our study focused only on those needing observation. This led to a more similar group, with almost one-third needing life-saving interventions. In this situation, more patients arrived by emergency medical services, which was expected (\\u003cspan class=\\\"CitationRef\\\"\\u003e7\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e8\\u003c/span\\u003e). he age and gender distribution in our group was similar to that in other European studies, supporting the consistency of our findings with the literature (\\u003cspan class=\\\"CitationRef\\\"\\u003e4\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e9\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e10\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eBoth AIS and ISS are among the strongest and most independent predictors of whether trauma patients will need life-saving intervention (LSI). In our study, AIS predicted LSI demonstrated superior ISS. As trauma severity increases, both scores go up. In turn, the likelihood of requiring critical intervention also rises significantly (\\u003cspan class=\\\"CitationRef\\\"\\u003e11\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e12\\u003c/span\\u003e). For pediatric trauma patients, vital signs and the Glasgow Coma Scale (GCS) are the most important physiological and neurological signs for predicting LSI. The GCS shows the patient's neurological status and has a strong inverse link with the need for LSI (\\u003cspan class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e). In our study, patients who needed LSI had much lower average GCS scores. This shows that severe neurological impairment is closely related to needing critical intervention. GCS is also an independent predictor of LSI (\\u003cspan class=\\\"CitationRef\\\"\\u003e13\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e14\\u003c/span\\u003e).\\u003c/p\\u003e\\u003cp\\u003eWhen examining the relationship between vital signs and LSI, abnormalities in vital signs such as pulse, blood pressure, and oxygen saturation were frequently observed in the triage assessment of patients in our cohort in the emergency department. However, the relationship between vital signs and LSI was established more clearly and reliably using the age-adjusted shock index (SIPA) score than with individual parameters. The SIPA score is an integrated measurement of basic vital signs, such as heart rate and blood pressure, and reflects hemodynamic deterioration in children with high sensitivity (\\u003cspan class=\\\"CitationRef\\\"\\u003e15\\u003c/span\\u003e). There is still no consensus or common language for physiological thresholds (\\u003cspan class=\\\"CitationRef\\\"\\u003e16\\u003c/span\\u003e). Physiological deviations in the patient's vital signs (hemodynamic deterioration measured by SIPA score) and deterioration in neurological status (low GCS) constitute the most fundamental and objective findings that determine the need for life-saving intervention in pediatric trauma at an early stage (\\u003cspan class=\\\"CitationRef\\\"\\u003e17\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e18\\u003c/span\\u003e). The patient group identified by SIPA score is the group that will require LSI (\\u003cspan class=\\\"CitationRef\\\"\\u003e19\\u003c/span\\u003e). The BIG score is commonly used by trauma physicians because it is easier to apply than scoring systems such as AIS, ISS, and SIPA score, and can be used in centers with limited resources (\\u003cspan class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e). Studies in the literature have shown that the BIG score predicts mortality and morbidity outcomes as well as those predicted by traditionally used scores (\\u003cspan class=\\\"CitationRef\\\"\\u003e20\\u003c/span\\u003e–\\u003cspan class=\\\"CitationRef\\\"\\u003e22\\u003c/span\\u003e). In our study, however, the BIG score failed to retain its predictive value for LSI, unlike other markers such as AIS, ISS, SIPA score, and lactate, and was insufficient to determine the need for critical intervention in pediatric trauma management. The most fundamental reason may be that the BIG score was primarily developed to predict mortality and a poor overall prognosis (\\u003cspan class=\\\"CitationRef\\\"\\u003e21\\u003c/span\\u003e), whereas the LSI reflects the need for acute, early intervention. In other words, the two outcomes do not measure the same clinical axis. Even if a score predicts mortality well, it may not predict the need for early intubation, massive transfusion, emergency surgery, or resuscitation with the same success. Therefore, more pediatric studies are needed on this topic. Furthermore, if LSI is considered an “early” outcome, mortality/morbidity is a later and multifactorial outcome.\\u003c/p\\u003e\\u003cp\\u003eOur findings support that lactate may be the most reliable parameter for independently predicting the need for LSI. It serves as an indicator of tissue hypoperfusion and hemodynamic compromise. In traumatized children, lactate may indicate tissue hypoperfusion earlier. It can be used to predict patient prognosis, length of stay, and mortality (\\u003cspan class=\\\"CitationRef\\\"\\u003e23\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e24\\u003c/span\\u003e). In this context, lactate levels can act as a metabolic 'alarm signal' for predicting LSI (\\u003cspan class=\\\"CitationRef\\\"\\u003e25\\u003c/span\\u003e). Although using base excess may seem reasonable, physicians should note that persistent or worsening negative base excess, especially if not isolated, may alert them to a deteriorating physiological and metabolic state requiring rapid and aggressive treatment or LSI (\\u003cspan class=\\\"CitationRef\\\"\\u003e26\\u003c/span\\u003e, \\u003cspan class=\\\"CitationRef\\\"\\u003e27\\u003c/span\\u003e).\\u003c/p\\u003e\"},{\"header\":\"CONCLUSION\",\"content\":\"\\u003cp\\u003eOur findings show that early risk assessment in pediatric trauma should be based not just on how the injury happened, but also on a thorough clinical check. Simple, clear measurements taken right at the start help find patients who might need urgent help. Higher AIS, ISS, and SIPA scores, as well as higher lactate levels and lower GCS, These indicators stand out as reliable signs that pediatric trauma patients may require LSI. While the BIG score was important in monitoring the patient, it proved less useful when tested alongside other factors. This means that the BIG score can help predict overall outcomes, but it is not enough on its own for quick treatment LSI decisions in pediatric trauma. Our results suggest using a scoring method that looks at injury severity, blood circulation, metabolism, and nervous system status together. This integrated approach may provide a more accurate framework for early risk stratification and clinical decision-making in pediatric trauma emergency management, and further prospective and multicenter studies in children are needed.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e\\u003cb\\u003eParticipant consent statement:\\u003c/b\\u003e This study was reviewed and approved by the relevant Institutional Review Board / Ethics Committee. Written informed consent was obtained from the participants and/or their legal guardians prior to enrollment. In cases where the requirement for informed consent was waived, the waiver was granted by the approving Ethics Committee\\u003c/p\\u003e\\u003cp\\u003e\\u003cb\\u003eCompeting interests\\u003c/b\\u003e\\u003cp\\u003eThe authors declare no competing interests.\\u003c/p\\u003e\\u003ch2\\u003eFunding:\\u003c/h2\\u003e\\u003cp\\u003eThe authors received no financial support for the research, authorship, and/or publication of this article.\\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eE.G. made the principal contribution to this work and served as the primary author of the manuscript. E.G. contributed to the conceptualization and design of the study, coordinated the study process, performed data collection, conducted the formal data analysis, interpreted the findings, and wrote the main manuscript text. A.Z.B. contributed to data collection, data interpretation, and critical revision of the manuscript. L.A.Y. contributed to data collection, data analysis, and revision of the manuscript for important intellectual content. O.T. contributed to the conceptualization and design of the study, supervised the overall research process, participated in data interpretation, and critically revised the manuscript. All authors reviewed the manuscript and approved the final version.\\u003c/p\\u003e\\u003ch2\\u003eAcknowledgement\\u003c/h2\\u003e\\u003cp\\u003eWe extend our gratitude to all healthcare professionals who dedicate their efforts to ensuring that children live in a safer world.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eThe datasets generated and/or analyzed during the current study are not publicly available due to institutional and ethical restrictions regarding patient confidentiality but are available from the corresponding author on reasonable request, subject to approval by the relevant institutional authorities.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\u003cli\\u003e\\u003cspan\\u003ePetrosyan M, Guner YS, Emami CN, Ford HR. Disparities in the delivery of pediatric trauma care. J Trauma. 2009;67(2 Suppl):S114\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHarfouche M, Higgins K, Waibel E, Slidell MB, Nasr I, Nace GW, et al. Who will be the bastions of pediatric trauma care? Trauma Surg Acute Care Open. 2025;10(Suppl 3):e001573.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eTosounidis TH, Giannoudis PV. Paediatric trauma resuscitation: an update. Eur J Trauma Emerg Surg. 2016;42(3):297\\u0026ndash;301.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSwendiman RA, Sharoky CE, Russell KW, Goldshore MA, Blinman TA, Nance ML. Life-saving interventions in pediatric trauma: A National Trauma Data Bank experience. J Trauma Acute Care Surg. 2019;87(6):1321\\u0026ndash;7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003ePhattharapornjaroen P, Sittichanbuncha Y, Atiksawedparit P, Sawanyawisuth K. Characteristics of Pediatric Emergency and Risk Factors for Life-saving Interventions. Glob Pediatr Health. 2021;8:2333794x21990340.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReeves LK, Savell SC, Maddry JK, Samsey KM, Mora AG, Lairet JR. Prehospital Life-Saving Interventions Performed on Pediatric Patients in a Combat Zone: A Multicenter Prospective Study. Pediatr Crit Care Med. 2020;21(7):e407\\u0026ndash;13.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLarsson G, Larsson S, Strand V, Magnusson C, Andersson Hagiwara M. Pediatric trauma patients in Swedish ambulance services -a retrospective observational study of assessments, interventions, and clinical outcomes. Scand J Trauma Resusc Emerg Med. 2024;32(1):51.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eCintean R, Eickhoff A, Zieger J, Gebhard F, Sch\\u0026uuml;tze K. Epidemiology, patterns, and mechanisms of pediatric trauma: a review of 12,508 patients. Eur J Trauma Emerg Surg. 2023;49(1):451\\u0026ndash;9.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBuschmann C, K\\u0026uuml;hne CA, L\\u0026ouml;sch C, Nast-Kolb D, Ruchholtz S. Major trauma with multiple injuries in German children: a retrospective review. J Pediatr Orthop. 2008;28(1):1\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHansen OM, Mikkelsen R, Eskol JR, Brink O. Characteristics and outcomes of paediatric patients admitted to a Danish level-1 trauma centre. Dan Med J. 2020;67:7.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eFeldhaus I, Carvalho M, Waiz G, Igu J, Matthay Z, Dicker R, et al. Thefeasibility, appropriateness, and applicability of trauma scoring systems in low and middle-income countries: a systematic review. Trauma Surg Acute Care Open. 2020;5(1):e000424.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHatchimonji JS, Luks VL, Swendiman RA, Allukian M 3rd, Nance ML, Nace GW. Jr. Settling the Score: Injury Severity Score Fails to Capture Nuances in Pediatric Trauma. Pediatr Emerg Care. 2022;38(2):e828\\u0026ndash;32.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eReppucci ML, Cooper E, Nolan MM, Lyttle BD, Gallagher LT, Jujare S, et al. Use of prehospital reverse shock index times Glasgow Coma Scale to identify children who require the most immediate trauma care. J Trauma Acute Care Surg. 2023;95(3):347\\u0026ndash;53.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDiBrito SR, Cerullo M, Goldstein SD, Ziegfeld S, Stewart D, Nasr IW. Reliability of Glasgow Coma Score in pediatric trauma patients. J Pediatr Surg. 2018;53(9):1789\\u0026ndash;94.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMcCormick T, Haukoos J, Hopkins E, Trent S, Adelgais K, Cohen M, et al. Adding age-adjusted shock index to the American College of Surgeons' trauma team activation criteria to predict severe injury in children. J Trauma Acute Care Surg. 2023;94(2):295\\u0026ndash;303.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAndrews T, Meadley B, Gabbe B, Beck B, Dicker B, Cameron P. Review article: Pre-hospital trauma guidelines and access to lifesaving interventions in Australia and Aotearoa/New Zealand. Emerg Med Australas. 2024;36(2):197\\u0026ndash;205.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eYoon SH, Shin SJ, Kim H, Roh YH. Shock index and shock index, pediatric age-adjusted as predictors of mortality in pediatric patients with trauma: A systematic review and meta-analysis. PLoS ONE. 2024;19(7):e0307367.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eRaythatha JH, Aulakh H, Yang S, Mok C, Soundappan SV. Predicting morbidity and mortality in Australian paediatric trauma with the Paediatric Age-Adjusted Shock Index and Glasgow Coma Scale. Injury. 2022;53(4):1438\\u0026ndash;42.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eSheff ZT, Zaheer MM, Sinclair MC, Engbrecht BW. Predicting severe outcomes in pediatric trauma patients: Shock index pediatric age-adjusted vs. age-adjusted tachycardia. Am J Emerg Med. 2024;83:59\\u0026ndash;63.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBolstridge J, O'Neil ER, Aden JK, Muisyo T, Spinella PC, Borgman MA. Use of the BIG score to predict mortality in pediatric trauma. Am J Emerg Med. 2021;45:472\\u0026ndash;5.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eDavis AL, Wales PW, Malik T, Stephens D, Razik F, Schuh S. The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma. J Pediatr. 2015;167(3):593\\u0026ndash;e81.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eAz A, Dogan Y, Sogut O, Akdemir T. Comparison of the BIG Score and Pediatric Trauma Score for Predicting Mortality. Pediatr Emerg Care. 2024;40(12):839\\u0026ndash;43.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eHuh Y, Ko Y, Hwang K, Jung K, Cha Y-h, Choi YJ, et al. Admission Lactate and Base Deficit in Predicting Outcomes of Pediatric Trauma. Shock. 2021;55(4):495\\u0026ndash;500.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBelu A, Filip N, Trandafir LM, Spoială EL, Țarcă E, Zamosteanu D et al. Lactate, an Essential Metabolic Marker in the Diagnosis and Management of Pediatric Conditions. Diagnostics (Basel). 2025;15(7).\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eMart\\u0026iacute;n-Rodr\\u0026iacute;guez F, Sanz-Garcia A, Zalama-S\\u0026aacute;nchez D, de Santos Castro P, Silva Alvarado E, Gracia Villar S, et al. Novel prehospital lactate cut-off estimation for mortality: a multicentre observational study. BMJ Open. 2024;14(12):e091789.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eBerend K. Diagnostic Use of Base Excess in Acid-Base Disorders. N Engl J Med. 2018;378(15):1419\\u0026ndash;28.\\u003c/span\\u003e\\u003c/li\\u003e \\u003cli\\u003e\\u003cspan\\u003eLanger T, Brusatori S, Gattinoni L. Understanding base excess (BE): merits and pitfalls. Intensive Care Med. 2022;48(8):1080\\u0026ndash;3.\\u003c/span\\u003e\\u003c/li\\u003e\\u003c/ol\\u003e\"},{\"header\":\"Tables\",\"content\":\"\\u003cp\\u003eTable 1 to 3 are available in the Supplementary Files section.\\u003c/p\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":true,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"Pediatric trauma, life-saving interventions, injury severity score, SIPA score, pediatric emergency medicine, trauma scoring\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-9271487/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-9271487/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003ch2\\u003ePurpose\\u003c/h2\\u003e \\u003cp\\u003eEarly identification of pediatric trauma patients requiring life-saving interventions (LSIs) is fundamental for optimizing emergency triage and allocation planning. This study aimed to evaluate and compare the predictive effectiveness of the Abbreviated Injury Scale (AIS), Injury Severity Score (ISS), Pediatric Trauma Score (PTS), Shock Index Pediatric Age-Adjusted (SIPA) score, and BIG score for determining LSI requirements in a pediatric emergency trauma population.\\u003c/p\\u003e\\u003ch2\\u003eMethods\\u003c/h2\\u003e \\u003cp\\u003eA retrospective observational study was conducted at the Pediatric Emergency Department of Hacettepe University, a Level I pediatric trauma center, between January 2019 and December 2022. Patients aged 0\\u0026ndash;18 years presenting within one hour of injury and observed for \\u0026ge;\\u0026thinsp;8 hours were enrolled. Demographic, clinical, laboratory, and injury scoring data were systematically collected. Multivariable logistic regression analysis was performed to identify independent predictors of LSI requirement.\\u003c/p\\u003e\\u003ch2\\u003eResults\\u003c/h2\\u003e \\u003cp\\u003eA total of 560 patients were included (mean age 91.4\\u0026thinsp;\\u0026plusmn;\\u0026thinsp;70.3 months; 64.6% male), of whom 32.1% required LSIs. On multivariable analysis, higher AIS (AOR 6.39, 95% CI 3.79\\u0026ndash;10.79), higher ISS (AOR 1.23, 95% CI 1.16\\u0026ndash;1.31), elevated SIPA score (AOR 3.41, 95% CI 1.86\\u0026ndash;6.25), and elevated serum lactate (AOR 1.16, 95% CI 1.03\\u0026ndash;1.30) were independently associated with LSI requirement. Higher PTS (AOR 0.54) and higher GCS (AOR 0.54) were significantly associated with reduced odds of LSI. The BIG score did not demonstrate independent predictive significance after multivariable adjustment (p\\u0026thinsp;=\\u0026thinsp;0.326). Overall mortality was 5.1%.\\u003c/p\\u003e\\u003ch2\\u003eConclusion\\u003c/h2\\u003e \\u003cp\\u003eAIS, ISS, SIPA score, serum lactate, and GCS are reliable independent predictors of LSI requirement in pediatric trauma patients. The BIG score demonstrated limited utility for early LSI decision-making in this cohort. A multiparametric approach integrating injury severity, hemodynamic, metabolic, and neurological parameters provide a more solid framework for early risk stratification in pediatric emergency trauma management.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Predictive Value of Clinical and Trauma Scores for Life-Saving Interventions in Pediatric Trauma Patients: A Retrospecti̇ve Cohort Study\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2026-04-07 14:12:03\",\"doi\":\"10.21203/rs.3.rs-9271487/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"1a6063ce-1e08-407c-9e13-c69b3fd21864\",\"owner\":[],\"postedDate\":\"April 7th, 2026\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[],\"tags\":[],\"updatedAt\":\"2026-04-19T08:40:10+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2026-04-07 14:12:03\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-9271487\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-9271487\",\"identity\":\"rs-9271487\",\"version\":[\"v1\"]},\"buildId\":\"XKTyCvWXoU3ODBz1xrDgd\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}