Paramedic Judgment of the Need for Trauma Team Activation for Pediatric Patients

Abstract

Abstract. Objective: To determine the value of paramedic judgment in determining the need for trauma team activation (TTA) for pediatric blunt trauma patients. Methods: A prospective, observational study was conducted a t the ED of Children's Hospital Medical Center of Akron between July 12, 1996, and February 28,1997, in cooperation with Akron Fire Department emergency medical technician-paramedics (EMT-Ps). The ED provides on-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released a t the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgment, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of 210 feet were included in the study. TTA was defined as necessary if the patient was admitted to the intensive care unit (ICU) or operating room (OR) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hospital records were reviewed. Coroners' records as well as medical records of all trauma admissions during the study period were reviewed to ensure that the patients released a t the scene were not mistriaged. Results: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to need TTA were admitted to the ICU/OR, and neither of the patients identified by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have ITA deteriorated after arrival to the ED.Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for " A for pediatric blunt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0-93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the patients released at the scene was mistriaged based on the review of the coroners' and trauma admission records. Conclusion: Results of this investigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for pediatric blunt trauma patients is not sufficiently sensitive to be of clinical use. The low sensitivity is explained by the deterioration in the clinical condition of 2 initially stable patients. The paramedic disposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjured pediatric trauma patients. Injured pediatric trauma patients who appear to be stable may deteriorate shortly aft...

Prehospital Prediction of the Severity of Blunt Anatomic Injury

“…14 In contrast to our findings, a number of studies found that paramedic judgment was an inferior method to other criteria for identifying injury severity. 10,11,13,16 The conflicting results related to paramedic judgment may be caused by differences in the trauma populations studied, emergency medical service and trauma systems, research methodologies, and outcome measures. There are a number of different definitions for evaluating trauma triage methods, with no consensus on a gold standard.…”

“…2,12,14,17 Others found their ability to reliably identify overall injury severity a relatively poor indicator. 10,11,13,15,16 These conflicting findings may be partly caused by the variety of different outcome measures used to define injury severity across the studies. The studies also differed in terms of population (adult or pediatric), injury mechanism (blunt or penetrating), emergency medical service systems, and study size, potentially contributing to the conflicting findings.…”

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

“…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. Similarly, paramedic judgment in the field alone is not sufficiently sensitive to be of clinical use in defining the need for trauma team activation for pediatric blunt trauma patients [7].…”

How well do paramedics predict admission to the hospital? A prospective study

“…Some investigators have found EMS providers to be accurate in their ability to triage patients, whereas others have found accuracy rates to be unacceptable (2)(3)(4)(5)(6)(7)(8)(9). A number of publications have raised the question of whether paramedics can safely predict if a patient needs transport at all (4,10,11).…”