Maximizing the Sensitivity and Specificity of Pediatric Trauma Team Activation Criteria

Abstract

Abstract. Background: Care of the severely injured child requires the rapid assembly of personnel trained in pediatric trauma care. Trauma team activation criteria, which are highly sensitive and maximally specific for identifying the child who requires resuscitation, are necessary to provide rapid care to all who need it, while using resources efficiently. Objective: To determine the sensitivity and specificity of the standard trauma team activation (TTA) criteria for identifying patients who receive resuscitation in the emergency department. Methods: A one-year study was conducted of all patients transported by emergency medical out-of-hospital services for a trauma-related complaint. For all patients, out-ofhospital medical control operators recorded whether patients met TTA criteria and, if so, which criteria were met. Criteria included standard physiologic, anatomic, and mechanism parameters. Sensitivity and specificity for the outcome of resuscitation (volume restoration, assisted ventilation or intubation, chest tube insertion/needle decompression, operative intervention) were calcuated. Results: A total of 492 patients met the case definition. Two-thirds were male, the mean age was 8 years (Ϯ4.8 SD), and the Injury Severity Score was Ն15 in 9.3%. Trauma team activation criteria were met by 179 patients (36.4%) and, of these, 107 met mechanism criteria only. A resuscitative intervention was received by 54 (10.9%) of the total and none in the mechanism-only group. Sensitivity and specificity of the TTA criteria for predicting receipt of a resuscitation procedure were 98.1% and 71.2%, respectively. When mechanism criteria were excluded, the sensitivity remained 98.1% and the specificity increased to 95.7%. Conclusions: Criteria for TTA that include patients who meet mechanism criteria only are not specific for identifying patients who receive a resuscitative intervention. Use of anatomic and physiologic criteria only results in an increase in specificity, thereby reducing overtriage while retaining a high sensitivity.

Outcomes in Pediatric Trauma Care in the Stockholm Region

“…The study also found that injury mechanism was less accurate as a triage criterion, as were the Pediatric Trauma Score [36] and Revised Trauma Score systems of triage [37]. Studies in the United States and Denmark report similar findings [38,39]. These studies also found that the use of anatomic and physiologic criteria retains a high sensitivity for identifying children in need of resuscitative interventions and reduces overtriage.…”

Pediatric major resuscitation—respiratory compromise as a criterion for mandatory surgeon presence

“…This study did not use the minimum criteria defined by the Committee on Trauma nor did it attempt to look at specific criteria for accurately triaging patients. Mechanism of injury has not been shown to be a good predictor of patients who need level I activation [5,6]. Dowd et al [5] pointed out that using anatomic and physiological criteria for trauma team activation reduced over triage yet maintained the sensitivity of the outcome of resuscitation.…”

“…Mechanism of injury has not been shown to be a good predictor of patients who need level I activation [5,6]. Dowd et al [5] pointed out that using anatomic and physiological criteria for trauma team activation reduced over triage yet maintained the sensitivity of the outcome of resuscitation. This study points out that criteria for determining the level of activation must take into account over and under triage, both of which may result in a suboptimal patient outcome.…”

Physiologically focused triage criteria improve utilization of pediatric surgeon-directed trauma teams and reduce costs

“…Other authors have correlated physiologically focused trauma activation criteria with other outcomes such as the need for fluid resuscitation or any surgical intervention [14]. However, these end points do not necessarily predict outcome.…”

“…Triage criteria based on Glasgow coma scale, hypotension, tachypnea, hypoventilation, or need for endotracheal intubation in the prehospital setting have been found to be safe while reducing overtriage in adult blunt trauma patients [12,13]. Furthermore, eliminating mechanism-based triage criteria for blunt trauma has been shown to be safe in children [14]. Intubation and respiratory derangement, including tachypnea, predicted outcome for pediatric blunt trauma patients [15] and battlefield trauma victims [16], but not the necessity for surgical trauma team activation (S-TTA) [17,18].…”