Development and Validation of a Pre-Hospital Clinical Nomogram for Predicting Functional Outcome in Pediatric Patients With Severe Traumatic Brain Injury

Introduction: Traumatic brain injury (TBI) is the leading cause of injury related death and neurologic morbidity in pediatric patients. This study aimed to develop a prognostic nomogram for assessing functional outcome in pediatric TBI based on pre-hospital interventions and clinical data collected during transport.

Methods: We retrospectively reviewed pediatric patients admitted to a single quaternary PICU from 2015-2023 with severe TBI (Glasgow Coma Scale, GCS ≤ 8). A total of 110 eligible patients were enrolled, and pre-hospital emergency medical service (EMS) transport logs was analyzed. Least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression were employed to identify independent prognostic factors of poor functional outcome at 6 months post-hospital discharge, defined as Glasgow Outcome Scale-Extended (GOS-E) ≤ 4. A prognostic nomogram was then constructed, validated, and assessed on discrimination, calibration, and clinical impact through receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA).

Results: From the LASSO regression model, 9 potential predictors were identified. On multivariate logistic analysis, GCS at scene, mechanism of injury, concomitant limb injury, and ISS were identified as independent predictors of poor functional outcome in children with severe TBI (p < 0.05). Incorporating these prognostic factors, a nomogram was developed and achieved a mean AUC of 0.951 [95% CI 0.8125 1] on calibration analysis and 0.961 on ROC. Additionally, the nomogram demonstrated net benefit over a wide risk threshold from 0 to 0.99 based on DCA.

Conclusion : The proposed nomogram demonstrated excellent predictive accuracy for poor functional outcomes, with GCS at scene, mechanism of injury, concomitant limb injury, and ISS emerging as critical pre-hospital prognostic factors. These findings highlight the tool’s potential to enhance early risk stratification and clinical decision-making in children with severe TBI transported by EMS. Further external validation and prospective studies are warranted to confirm the generalizability of the tool.