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The Pediatric Trauma Score as a Predictor of Injury Severity in the Injured Child

By Joseph J. Tepas, III, Daniel L. Mollitt, James L. Talbert, and Michael Bryant

 

Jacksonville, Florida

Q The

ability

of

the

Pediatric

Trauma

Score

(PTS) to

system. Many field scoring systems have been devel-

accurately predict the degree of injury severity of the injured child was assessed by comparing two separate

groups of pediatric trauma victims. The first group con- sisted of 110 patients evaluated at a regional pediatric trauma center whose data was collected and assessed by a single investigator. The second group consisted of a similar matched cohort of 120 patients from the National Pediatric Trauma Registry whose data was collated from multiple

participating institutions.

In both cases,

a linear

relation-

ship between PTS and Injury Severity Score (ISS) was

documented that was statistically

significant

to

P

<

.001.

The linear regression coefficients of each group were

similar as was the distribution of PTS and ISS. This study documents the validity of the PTS as an initial assessment

tool and confirms its reliability severity.

9 1987

Grune & Stratton. Inc.

as

a

predictor

of

injury

INDEX WORDS: Pediatric trauma; injury severity.

T RAUMA CONTINUES to be the most common cause of death in the American pediatric popula-

tion. ~ This staggering fact becomes even more so when considered in light of the consistent finding that approximately 25% of non-central nervous system (CNS) traumatic deaths are potentially preventable) Because of this, trauma care has evolved into regional systems in which designated centers of expertise are available for the severely injured patient on an around the clock basis. An obvious factor in the proper func- tion of these systems is a means wherein correct field assessment and triage can ensure that the appropriate patient is referred to the appropriate facility. Thus, the most severely injured patients will be afforded the highest degree of trauma care expertise. Conversely, minimally injured patients will not overwhelm the resources of the more sophisticated trauma centers? Field trauma scoring is, therefore, a major compo- nent in proper function of a regional trauma care

From the Department of Surgery, Division of Pediatric Surgery, University of Florida, Jacksonvi[le. Supported in part by US Department of Education Grant No.

G-008300042.

Presented before the 17th Annual Meeting of the American Pediatric Surgical Association, Toronto, Ontario, May 14-17,

1986.

Address reprint requests to Joseph J. Tepas, III, MD, Division of

Pediatric Surgery, University Hospital of Jacksonville, 655 W Eighth St, Jacksonville, FL 32209. 9 1987 by Grune & Stratton, Inc.

0022-3468/87/2201-0005503.00/0

oped over the past few years, none of which have been consistently reliable, accurate, and easily employ-

able. 4~ Moreover, there have been no

trauma scoring

systems specifically developed for use in triage of the injured child. Because of this, the Pediatric Trauma Score (PTS) was developed as a means of providing rapid accurate assessment of the injured child in a manner that would insure comprehensive initial evalu- ation. It is a scoring system that includes six common determinants of clinical condition in the injured child. Each of the six determinants is assigned a grade consisting of either +2 (minimal or no injury), + 1 (minor or potentially major injury), or -1 (major or immediate life-threatening injury). The scoring system is arranged in a manner compatible with standard advanced trauma life support protocol and thereby also provides a quick assessment scheme (Table 1).7 As increased clinical data concerning trauma care has become available, the Injury Severity Score (ISS) was developed as a retrospective method for numeri- cally categorizing the overall severity of injury? Previ- ous reports have documented the direct correlation between ISS and mortality. This study was designed to assess the ability of the PTS to predict ISS in the injured child.

MATERIALS AND METHODS

Two groups of injured children were assessed. For both groups, the admission PTS was plotted against the ISS calculated at discharge or autopsy. The regression coefficient was calculated for the distribution of points and then analyzed for significance. Group I consisted of 110 multiply injured encountered in the University of Florida Jacksonville Pediatric Trauma Unit during the 6 months extending from April 1, 1985 through Septembe 30, 1985. There were 78 males and 32 females with a mean age of 9.8 years. Mean PTS was 9.5 points. Mean ISS was 9.6. Mean number of diagnoses per patient utilized for calculation of the ISS was 2.8. Mortality for this group was 3%. Group II consists of the first 120 patients (80 male, 40 female) entered into the National Pediatric Trauma Registry. The National Pediatric Trauma Registry is a multiinstitutional study begun on April 1, 1985 and consisting of 33 participating institutions distrib- uted throughout the United States and Canada. Each institution submits blinded data to a central computer office located at Tufts New England Medical Center. This data, submitted on a standard form enables blinded calculation of admission PTS as well as analysis of ISS. In this manner, both the PTS and the ISS of each of these children are derived in an objective manner with no foreknowl- edge of possible mitigating circumstances. This particular group of 120 children represents the first group of records completed ade- quately to allow analysis. For this group, mean age was 8.6 years,

14

Journal of Pediatric Surgery, Vo122, No 1 (January), 1987: pp 14-18

THE PEDIATRIC TRAUMA

SCORE AND INJURY SEVERITY

 

Table 1.

Pediatric Trauma Score

 
 

Category

 

Component

+

2

+

1

-

1

Size

>-20 kg

10-20 kg

 

<10 kg

Airway

Normal

Maintainable

Unmaintainable

Systolic BP

--<-90 mmHg

90-50 mmHg

<50 mmHg

 

CNS

Awake

Obtunded/LOC

Coma/decerebrate

Open wound

None

Minor

Major/penetrating

Skeletal

None

Closed fracture

Open/multiple

 

fractures

 

Sum total points

mean PTS was 9.0 points, mean ISS was 12.7, and mean number of diagnoses used to calculated ISS was 2.4. The mortality rate for this group was 7%. Figures 1, 2, and 3 illustrate the distribution of age, PTS, and ISS of both groups.

RESULTS

The regression coefficients calculated from the dis- tribution of plots of PTS v ISS in groups I and II were -3.50 and -3.77, respectively (Figs 4 and 5). There was no statistically significant difference in this rela- tionship between the groups. (T test P > .5). A decreasing PTS was directly associated with an increasing ISS (P < .001). Within this distribution was an obvious threshold occurring at a PTS of six, below

which

injury severity increased

precipitously as did

potential for mortality. The mean ISS for children

whose PTS

was >6 was 6 points, while that for those

with a PTS

<6 rose to 30 points.

DISCUSSION

Appropriate triage of the multiply injured child mandates not only accurate initial assessment, but also an appreciation of those differences in pediatric physi- ology affecting potential morbidity. The first obvious differentiating feature in the pediatric trauma patient is size. The primary purpose of the size categorization in the PTS is the selection of the very small child who, by nature of his increased body surface to volume ratio

20

19

18

17

t6

15

14

13

  • 8- I I!I!

12

11

10

9

7-

6-

5-

4

3-

2-

SO-

70-

60-

SO-

A0-

15

o

,

n

,

q

p

r ~

r~,

~r?q

 

......

 

-e-5--4--3-2--1

 

0

1

2

3

4

S

6

7

S

g

10

11

12

 

PEDIATRIC

TRAUMA&SC CORE

 
 

Jacklonvllle

 

~

Notional

 

Fig 2.

Pediatric Trauma Score Distribution.

and potentially limited physiologic reserve, represents a greater threat of morbidity and mortality for a given injury than older and larger counterparts. Airway status is another differentiating factor, pri- marily because of its central importance to survival as well as the need for adequate management as correct initial treatment for other organ system injuries. The assessment system considers not so much the status of the airway on initial evaluation as much as a composite of the airway status and initial management required to protect it. Specifically, a child whose airway is completely within normal limits and requires no addi- tional supportive measures is categorized as a +2. A child whose airway is partially obstructed and who requires simple measures for protection such as head positioning, oral airway, or mask oxygen delivery is categorized as a + 1. The child whose airway requires more definitive management and demands a degree of expertise that will allow intubation, cricothyroidosto- my, or other invasive procedures, is categorized as an unmaintainable or - 1 category.

SO

70

S0-

50-

40-

.50

20,

  • 10 1

% N

1

-

o

~

0

5

10

lS

20

25

..

~0

35

40

45

50

S5

60

SS

70

75

 

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

 

JacklonvHle

 

AGE:

(yr~)[~

National

 

J.ck

....

111NJURY

SLrVERITY

r~

ORE: Nat, ....

 

Fig 1.

 

Age distribution.

 

Fig 3.

Injury Severity Distribution.

16

80

70-

60

50

40

30

20

lO

110

Children

o

o

o

o"~,,.,

o

fl

8

o

o

o

-6

,

i

,

-4

'

-'2

J

J

F

2

,

,

4

,

p

6

,

,

8

PEDIATRIC TRAUMA SCORE

,

i

10

i

,

12

Fig 4.

Jacksonville Pediatric Trauma Registry.

The child's systolic blood pressure is assessed to provide an initial evaluation of cardiovascular status. A systolic blood pressure of 90 mmHg or greater suggests that adequate circulating volume is present at

that time. Likewise, a child whose systolic blood pres-

sure is 50 mmHg

or less, regardless of size, is accu-

rately considered to be in immediate jeopardy for evolving hemorrhagic shock. A child whose blood pressure falls between 90 and 50 mmHg may be in early stages of hypotension or hemorrhage, or may have a blood pressure appropriate for age. This group obviously represents a high risk group and, as such, is

designated as a + 1 category. In the absence of ade-

quate

sized blood pressure cuffs, the blood pressure

assessment can be substituted by scoring palpation of

the

pulse at the

wrist as

+ 2, palpation

of the pulse

in

the neck or groin as + 1, and absence of a palpable

pulse as a -

1.

The field evaluation of the child's CNS orients itself specifically to level of consciousness. While the Glas- gow Coma Score is an effective initial neurologic assessment tool, in reality, the level of consciousness is

TEPAS

ET

AL

the most important factor in determining initial neuro-

logic status. 9'1~ The child

who has sustained no loss of

consciousness and is fully awake is graded as + 2, while

a child who is totally nonresponsive is graded

as

-1.

Any child who has any degree of obtundation or who

has sustained a loss of consciousness no matter how

transient, is graded + 1 indicating potential risk.

Because of the frequency of associated skeletal injuries with blunt pediatric trauma and their additive

effect on overall morbidity, an assessment of both the skeletal and cutaneous systems is included in this

scoring scheme. The child who has no evidence of a

fracture is

graded as

+ 2. A child with a single closed

fracture or a suspicion thereof is graded as + 1. A child who has multiple closed fractures or any open fracture is categorized as - 1. In regards to cutaneous injuries, the child who presents with absolutely no evidence of

external

trauma is graded

as

+ 2, while

the

child who

presents with abrasions or minor cutaneous injuries is graded as +1. Any child who presents with any penetrating injury regardless of location or a major avulsion or laceration is graded as - 1. The PTS is then the arithmetic sum of the grade assigned to each of the above six categories. It can range between a - 6 and + 12 and, when utilized in the manner described in Table 1, can provide a compre- hensive assessment protocol modeled after the Ameri- can College of Surgeons' Advanced Trauma Life Sup- port Course assessment scheme. 7 Once appropriately assessed, proper management of the severely injured child mandates referral to a center that has the necessary capabilities to handle many of the special requirements of pediatric care. 11 While each individual injury may not cause significant increase in potential mortality, the combination of them, especially if inadequately or incorrectly handled, can provide a significant increase in morbidity, hospi- talization, and long-term rehabilitative needs. 12 Effec-

120 Children 80- 79" 60- 50- ~( 30- o o 20- o o o o o
120
Children
80-
79"
60-
50-
~(
30-
o
o
20-
o
o
o
o
o
8o
o
10-
P
I
06
--4
--2
2
4
6
8
I0
12
P[OIATRIC
TRAUMA SCORE

Fig 5.

National Pediatric Trauma Registry.

80-

70 SO MEAN l.s.s. 50 o ,0 +- 4O +. ~l],s.s. 6 g I 1 a
70
SO
MEAN l.s.s.
50
o
,0
+-
4O
+.
~l],s.s.
6
g
I
1
a
a
-4
2
o
'
~
'
~
'
~
'
-'
'
~'o
12
PEDIATRIC TRAUMA SCORE
o
Notlonol
+
Jk~:klmnvllle
Fig
6.
Comparison
of
PTS
vlSS.

THE PEDIATRIC TRAUMA SCORE AND INJURY SEVERITY

17

tive triage of the injured child thus requires consider- ation of both morbidity and mortality. Accurate determination of the prognostic value of the PTS necessitates an accepted standard for compar- ison. The ISS is an established effective tool in the analysis of trauma care. The documented relationship between ISS and mortality provides the valid basis for evaluating the utility of the PTS as a method of predicting not only injury severity, but subsequent outcome in the pediatric trauma victim. This study documents the inverse linear relationship between the PTS and the ISS. This relationship was constant in both groups evaluated (Fig 6). In group I, all patients were treated at the same facility, and the data concerning each patient collected and calculated by a single investigator (J.J.T.). In group II, all of the components utilized in the determination of the PTS and the ISS were provided from objective assessment by a variety of observers. The constancy of the rela- tionship of the PTS to ISS in both groups further confirms the effectiveness and utility of the PTS as a predictor of pediatric injury severity. Of perhaps greater importance is the threshold value of 6 in the PTS scoring system, below which the mean ISS was 30

points (Fig 6). When the mortality rate for each PTS cohort was evaluated, it likewise demonstrated that children with a PTS of 6 and below have an increased potential for mortality as well as morbidity. Moreover, the mortality rate for children whose PTS fell below 2 was 100%. By providing guidelines for rapid assessment and an arithmetic number that is predictive of injury severity, the PTS can be used for triage and referral of the patient to the appropriate center. It is also a common descriptor that will allow accurate transmission of information concerning degree of injury from one element to another in the typical regional trauma referral system. Finally, it may provide a means of objective quality assurance. On periodic review of the scores obtained on injured children in regard to mortal- ity experienced, it is easy to identify deaths that seem inappropriate or potentially preventable. In summary, the PTS is a quick and simple mecha- nism wherein the child can be rapidly assessed and accurately evaluated. In this regard, it serves as an efficient rescue tool that will hopefully help ensure that the injured child receives appropriate comprehensive therapy as expeditiously as possible.

REFERENCES

1. Gallagher SS,

Finison K, Guyer

B,

et

al: The incidence of

injuries among 87,000 Massachusetts children and adolescents.

AJPH 74:1340-1347, 1984

2.

Cales RH, Trunkey DD: Preventable trauma deaths. JAMA

254:1059-1063, 1985

 

3.

Champion HR,

Sacco W J, Lepper RL,

et

al:

An

anatomic

index of injury severity. J Trauma 20:197-202, 1980

 

4.

Champion HR, Sacco W J, Hannan DS, et al: Assessment of

injury severity: The triage index. Crit Care Med 8:201-208, 1980

5.

Kirkpatrick J, Youmaris R: Trauma

index: An

aid

in

the

evaluation of injury victims. J Trauma 11:711, 1971

 

6.

Gormican SP: CRAMS scale field triage of trauma victims.

Ann Emerg Med 11:132-135, 1982

  • 7. American College of Surgeons Committee on Trauma Instruc-

tor Syllabus of Advanced Trauma Life Support. Copyright 1984

  • 8. Baker SP, O'Neill B: The injury severity score: An update. J

Trauma 16:882-885, 1976

  • 9. Young B, Rapp RP, Norton RN, et al: Early prediction of

outcome in head-injured patients. J Neurosurg 54:300-303, 1981

  • 10. Stablein DM, Miller JD, Choi SC, et al: Statistical methods

for determining prognosis in severe head injuries. J Neurosurg

6:243-248, 1980

  • 11. Seidel JS, Horbein M, Yoshiyama K, et al: Emergency

medical services in the pediatric patient: Are the needs being met? Pediatrics 73:769-772, 1984

  • 12. Hailer JA, Shorter N, Miller DM, et al: Organization and

function of a pediatric trauma center. J Trauma 23:691-696, 1983

Discussion

M.L. Ramenofsky (Mobile, AL): In Dale Johnson's

Presidential Address yesterday, he exorted this organi- zation to provide data and information that when looked at over time will significantly improve the health care provided and survival of children. I think that this particular paper, which Dr Tepas has worked so hard on and provided such good data on, is just such an entity. The fact that the pediatric trauma score is now being used on a nationwide basis is extremely helpful, will provide us with specific accurate informa- tion in terms of severity of injury, but it will also do one other major thing for those of you who are interested in trauma. It gives you a method to have the most

severely injured children, the children who have the highest propensity for dying, to be sent to your institu- tion rather than to anywhere else general down the street which may or may not have pediatric expertise in their hospital. What methods do you propose to val- idate this very important study? Can the score be validated? What is the patient number that we need? How long before we will have that result?

  • M. Eichelberger (Washington, DC): I agree with Dr

Tepas and Dr Ramenofsky that this is an important area, the prehospital triage of patients. Several things I think have to be addressed. First of all, there are some questions about the operational definitions that are

18

TEPAS ET AL

used to derive the pediatric trauma

score. Second, I

think of extreme importance is the score reliability, meaning that the doctors, paramedics, and EMTs in

different

areas of the country will be using the same

weighted values. The operational definitions become important because if we are going to add to established methodology, for example the issue of fractures whether they be epiphyseal or the definition of obtun- dation, then I think we have got to be very specific about what we are talking about because it is very easy to add a bias into this whole concept. The other thing I think that I would like to know is how many patients had an injury severity score of 16 or above, which is accepted presently in the community at large as being a patient score that requires triage to a trauma center? Also I would like to know if you have given any thought to the potential of over or under triage using this

particular methodology?

J.A. Haller (Baltimore,

MD):

I got two messages

from this paper. One is that it is possible to modify our

scoring system now using your data and observations

into a new type of score that will be helpful to us

specifically for children.

We

know that

the one

for

adults has been helpful. The second message is that it seems possible to do this in the field, and I think everyone here has been waiting for something like that

because we need to be able to give simplified informa- tion and a system to our EMTs so that children will be

brought

into appropriate centers; and if that

can

be

done at the site then I think we have an important tool.

A question I have about the score itself is that it looks to me like those patients who do not have head injuries could be very nicely served with this score because it would select them. But for those who have head

injuries, if I read the data

correctly, it looks to me like

that is so important and weighted that if there is a head

injury, you do not need to worry about other injury.

I

would like to ask you if you have look at it from a standpoint of those children who have severe head

injuries and if that is not enough to determine that they should come into a specific pediatric trauma center?

J.J. Tepas (closing): I thank all the discussants. Taking your questions in lumps, no trauma score will be any better than the ability of the individual who first encounters the patient to use it and use it effectively. Therefore, I will answer the question about validation and answer Dr Eichelberger's question about score utilization by different components. The score is designed, if you will, as a microapproach similar to the advanced trauma life support protocols advocated by the Committee on Trauma of the American College of Surgeons. Paramedics, EMTs, and emergency medical physicians who are our referring physicians have accepted this score very well. How are we documenting that? We presently have a countrywide study going on right now where we are looking at the score assigned in the field and the score assigned in the emergency room. We are relating that to the injury severity score at

discharge or autopsy. Our initial data, and it is very preliminary,

evaluation of this is that the scores

match to a degree of

within 1 point. In answer to the

specific question about the distribution of ISS, approx- imately 30% of the patients had an ISS >16. Specifi- cally, the group distribution spiked in the 5 to 10 category and then dropped off logrythmically thereaf- ter. In regard to Dr Haller's question about head injury, there is no question that it plays a major role, but there are two factors that we have to keep in mind. First is the primary head injury that occurs at the instant of impact, and second there is the morbidity that occurs because of inadequate initial resuscitation, inappropriate triage, and improper care. In reality, the pediatric trauma score, if used correctly, can go no higher than 7 for a child with a head injury. They get a -1 for the head and they should get a -1 for the airway. Our experience thus far has been that it has been extremely effective.