Factors that predict the need for early surgeon presence in the setting of pediatric trauma

Prehospital Trauma Compendium: Pediatric Severe and Inflicted Trauma - A Position Statement and Resource Document of NAEMSP

Pediatric trauma patients have unique physiology and anatomy that impact the severity and patterns of injury. There is a need for updated, holistic guidance for Emergency Medical Services (EMS) clinicians and medical directors to optimize prehospital pediatric trauma guidelines based on evidence and best practice. This is especially pertinent to pediatric severe and inflicted trauma, where prehospital evaluation and management determine the overall quality of care and patient outcomes. This position statement addresses the prehospital evaluation and management of pediatric severe and inflicted trauma and is based on a thorough review and analysis of the current literature.

In Search of the Truth: Choice of Ground Truth for Predictive Modeling of Trauma Team Activation in Pediatric Trauma

BACKGROUND

Assigning trauma team activation (TTA) levels for trauma patients is a classification task that machine learning models can help optimize. However, performance is dependent on the "ground-truth" labels used for training. Our purpose was to investigate 2 ground truths, the Cribari matrix and the Need for Trauma Intervention (NFTI), for labeling training data.

STUDY DESIGN

Data were retrospectively collected from the institutional trauma registry and electronic medical record, including all pediatric patients (age <18 years) who triggered a TTA (January 2014 to December 2021). Three ground truths were used to label training data: (1) Cribari (Injury Severity Score >15 = full activation), (2) NFTI (positive for any of 6 criteria = full activation), and (3) the union of Cribari+NFTI (either positive = full activation).

RESULTS

Of 1,366 patients triaged by trained staff, 143 (10.47%) were considered undertriaged using Cribari, 210 (15.37%) using NFTI, and 273 (19.99%) using Cribari+NFTI. NFTI and Cribari+NFTI were more sensitive to undertriage in patients with penetrating mechanisms of injury (p = 0.006), specifically stab wounds (p = 0.014), compared with Cribari, but Cribari indicated overtriage in more patients who required prehospital airway management (p < 0.001), CPR (p = 0.017), and who had mean lower Glasgow Coma Scale scores on presentation (p < 0.001). The mortality rate was higher in the Cribari overtriage group (7.14%, n = 9) compared with NFTI and Cribari+NFTI (0.00%, n = 0, p = 0.005).

CONCLUSIONS

To prioritize patient safety, Cribari+NFTI appears best for training a machine learning algorithm to predict the TTA level.

Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma

Importance

Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments.

Objective

To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children.

Design, Setting, and Participants

This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023.

Exposure

Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP).

Main Outcome and Measures

Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset.

Results

A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample.

Conclusions and Relevance

These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.

Pediatric Age-adjusted Shock Index (SIPA): From Injury to Outcome in Blunt Abdominal Trauma

Purpose

The Shock Index Pediatric Age-Adjusted (SIPA) score is a useful tool for identifying pediatric trauma patients at a risk of poor outcomes and for triaging. We are studying the relationship between elevated SIPA score and specific outcomes in pediatric trauma patients.

Materials and Methods

A retrospective study was conducted in which case records of 58 pediatric patients with blunt abdominal trauma were evaluated and tabulated for their SIPA scores only at the time of their initial presentation and categorized into two groups - normal SIPA and elevated SIPA. The primary outcomes were need for blood transfusion, need for any intervention, and need for emergency surgery, and the secondary outcomes were need for computed tomography (CT) scan, need for a ventilator, intensive care unit (ICU) stay, length of hospital stay, and mortality. Statistical methods were applied to find a relationship between elevated SIPA score and the primary and secondary outcomes.

Results

An elevated SIPA score was noted in 27 (46%) patients. There was a significant relationship between elevated SIPA scores and patients needing blood transfusion (68.75%, n = 11) and length of hospital stay (10.48 ± 7.54 days). A significant relationship between elevated SIPA score and need for emergency surgery (54.54%, n = 6), need for a CT scan (56%, n = 14), and ICU stay (50%, n = 2) was not found.

Conclusion

We have seen in our study that elevated SIPA scores at presentation are significantly related to need for blood transfusion and length of hospital stay. In more than half of the patients, elevated SIPA was associated with need for emergency surgery and requirement of CT scan, but it was statistically not significant. Therefore, assessment of this parameter can help in identifying such poor outcomes.

Combining Cribari matrix and Need For Trauma Intervention (NFTI) to accurately assess undertriage in pediatric trauma

BACKGROUND/PURPOSE

The American College of Surgeons (ACS) Committee on Trauma targets undertriage (UT) rates of <5% to optimize the chances of survival. The Cribari Matrix (CM) has traditionally been employed to identify undertriage, but it likely overestimates actual undertriage. An innovative tool called "Need For Trauma Intervention" (NFTI), demonstrates a more accurate assessment of undertriage in adults. We hypothesized that using the combination of CM and NFTI would more accurately identify UT in pediatric trauma patients, compared to CM alone.

METHODS

We reviewed undertriage rates using CM and NFTI criteria. Univariate analysis was used to compare the need for surgical management, transfusion requirements, ventilator days, ICU length of stay (LOS), hospital LOS, and hospital costs between CM, NFTI, and the combination of CM and NFTI.

RESULTS

Undertriage rates were 8.2% with CM and 4.6% with NFTI. When CM and NFTI were combined, the UT rate was 2.7%. Pediatric patients categorized as UT by the combination of CM and NFTI had significantly longer ICU Length of Stay (LOS) (p < 0.001), hospital LOS (p < 0.001), higher mortality rates (p = 0.004), and higher hospitalization costs (p < 0.001).

CONCLUSIONS

The combination of CM and NFTI identified UT in children, more accurately than CM or NFTI alone. Injured children who are undertriaged had higher mortality, morbidity, and cost of care. The use of CM in combination with NFTI to evaluate undertriage rates led to the identification of risk factors that may modify the activation criteria for highest and modified level trauma team activations.

LEVEL OF EVIDENCE

III STUDY TYPE: Retrospective study without negative criteria (Therapeutic/Care Management).