Objectives: While it is generally agreed that pediatric trauma patients exposed to high-risk injury mechanisms should be sent to trauma centers, many patients seen with full trauma alerts are determined to have minimal injury. The purpose of this study was to develop and test a clinical tool to safely triage a group of pediatric trauma patients for initial evaluation by the emergency department (ED) within the trauma center.
Methods: The pediatric trauma score (PTS) was used as the basis for development of a simplified, user-friendly assessment tool called the modified pediatric trauma score (mPTS). It used basic physiologic and anatomic signs identified at ED triage. This tool was retrospectively tested against the outcomes of 1112 pediatric trauma patients as determined by their final injury severity scores (ISS) and the need for urgent interventions.
Results: Our tool would have triaged 58% of patients to ED preevaluaton resulting in significant resource savings. Concurrently, 99% of patients with an ISS greater than 10 and all patients who needed urgent interventions would have remained full trauma alert patients. The positive predictive value of our tool was only 0.32. indicating that a safe level of overtriage was maintained.
Conclusion: This study serves as further support for the concept of multitiered triage systems within trauma centers. In such settings, initial evaluations of select pediatric patients can be safely performed by emergency medicine staff with deferral of full trauma team alerts.
The validity of transport of pediatric patients to trauma centers based on preestablished criteria is well supported. 1 Yet, immediate trauma team activation based on mechanism of injury alone, in the absence of anatomic or physiologic signs, may be overused in the initial workup of the injured child for fear of missed injuries.
The association today of many trauma centers with academic emergency medicine departments experienced in trauma care and pediatrics might allow for safe evaluation of selected pediatric patients without immediate trauma team activation. The goal of this study was to develop a clinical tool to reliably triage a group of pediatric trauma patients for initial evaluation by the emergency department (ED) within the trauma center.
A brief review of our trauma registry data revealed that 85% of the patients treated with full pediatric trauma team activation had injury severity scores (ISS) 2 of <10. In fact, 24% of such patients (266/963) were discharged to home from the trauma room, indicating significant overtriage and a high level of confidence that injuries were trivial. Other authors have reported similar figures. 3 Although we do not collect the reasons for activation of the trauma team in our data, patients were not found to have serious injuries on their final assessment made it seem likely that many of the trauma activations for these low ISS patients were based on the mechanism of the injury alone. Conversely, only 7 patients with ISS > 10 were identified in the 10-year preliminary review who entered our system through the general ED, thus representing undertriage. These patients were in essence missed by our current criteria. Thus, the current triage criteria had an acceptable sensitivity of 96% (undertriage rate of 4%). Based on these preliminary finding, we hypothesized that we might be able to apply a secondary triage tool based on physiologic parameters and physical findings to identify those patients meeting the American College of Surgeons (ACS) criteria for trauma activation that, in reality, had low likelihood of serious injury. Such patients could be treated in the ED with deferral of full trauma activation.