INTRODUCTION — This topic will discuss the classification of pediatric trauma. The initial management of trauma in stable and unstable children is discussed separately. (See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)
BACKGROUND — Injuries are the leading cause of death for children and adolescents in the United States (table 1) and most high-income countries. Deaths from unintentional injuries account for more years of potential life lost before age 65 years than cancer, heart disease, or any other cause of death . For every injury death, an estimated 25 hospitalizations and 925 emergency department visits occur. Most of these injuries are caused by falls, motor vehicle collisions (MVCs), bicycle collisions, and burns; many are preventable. (See "Pediatric injury prevention: Epidemiology, history, and application" and "Prevention of falls and fall-related injuries in children".)
Due in large part to national injury prevention efforts, the overall unintentional injury death rate in United States children, aged 0 to 19 years, declined by 29 percent from 2000 to 2009 and has remained similar to 2009 levels in 2020. These injury prevention efforts include seat belt use, child safety seat and booster seat use, licensing requirements, vehicle design, and reductions in alcohol-impaired driving. (See "Pediatric injury prevention: Epidemiology, history, and application", section on 'Epidemiology'.)
However, even with these efforts, in 2020 MVCs were the second-leading cause of unintentional injury death among 15 to 19 year olds, second only to firearm-related injuries. Furthermore, the unintentional injury death rate for infants younger than one year of age has risen from 2000 to 2009 and has remained at similar levels through 2020 (see "Pediatric injury prevention: Epidemiology, history, and application", section on 'Injury prevention resources'). It is clear that additional injury prevention efforts, such as the National Action Plan for Child Injury Prevention , are needed to prevent these needless injuries and deaths.
INJURY PREVENTION — Types of prevention include:
●Primary injury prevention seeks to prevent the incident (eg, motor vehicle collision [MVC]) altogether. An example of primary prevention would be road construction that separates the directions of traffic with impregnable barriers so that head on collisions cannot occur.
●Secondary injury prevention decreases the likelihood of serious injury during a traumatic event. Seat belts or air bags would be an example of secondary prevention.
●Tertiary prevention minimizes further deterioration and reduces complications when injury is not prevented by primary or secondary means.
Tertiary prevention entails rapid identification of children with major trauma in the pre-hospital setting so that appropriate management, destination, and utilization of emergency department resources can be determined . In the United States, experts have developed a field triage guideline that identifies those patients who warrant direct pre-hospital transportation to a trauma center. This critical field transport decision requires the evaluation of vital signs, level of consciousness, injury anatomy, injury mechanism, and special patient or local emergency medical systems considerations. These guidelines recommend that children "should be triaged preferentially to pediatric-capable trauma centers" (algorithm 1) . Thus, seriously injured children require skillful assessment and treatment by clinicians experienced in pediatric trauma and rapid evacuation to a regional pediatric trauma center, when available [5,6]. (See "Trauma management: Approach to the unstable child".)
The introduction and spread of statewide trauma systems, the adoption of the American College of Surgeons' (ACS) Trauma Center verification for pediatric trauma hospitals (table 2), and the resulting development of trauma registries and databases have allowed for more accurate categorization of pediatric trauma patients and system evaluation. This work has directed increased attention to the resources required for managing trauma, especially pediatric trauma. The different types of pediatric trauma classification systems and their uses will be discussed here. Evaluation and management of pediatric trauma patients is discussed separately. (See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)
CLASSIFICATION OF TRAUMA
Overview — Multiple pediatric trauma classification systems are available to predict morbidity, mortality, and resource utilization (eg, diagnostic studies, specialized personnel, operative intervention) .
●One classification system is based upon three categories: body region (local or multiple), mechanism (blunt or penetrating), and severity (mild, moderate, or severe) .
●Other classification systems are based upon physiology, anatomy, or a combination of physiology and anatomy.
Objectives — There are two primary objectives for trauma classification :
Triage decision support — Triage decision support classification systems are often used in the pre-hospital setting to guide transport disposition. They are based upon rapidly obtainable clinical findings. They are designed to identify patients who have a high likelihood of critical injury that may require trauma center care for optimal outcomes. A systematic review of pediatric trauma triage criteria identified that pre-hospital triage criteria may reduce mortality by determining mode of transport (ground versus air) .
Since trauma is a time-sensitive disease, early, goal-directed therapy and prompt referral and transport of injured children to the most appropriate level of care are critical to their survival, overall functional outcomes, and the efficient functioning of the trauma system. In highly evolved trauma systems, triage and transport may begin with pre-hospital providers. Physicians and public alike should insist on a high level of pediatric education through accredited training programs and accepted national credentialing for pre-hospital providers, thereby creating an essential foundation that assures optimal age-appropriate, competent resuscitation.
Severity of illness or mortality prediction — Severity of illness (SOI) or mortality prediction classification systems are often used retrospectively to standardize outcomes for research purposes. They may also serve as a prognostic indicator in individual patients. However, they are not used to guide early resuscitation, and their ability to predict morbidity and mortality varies widely .
Physiologic systems — Triage scoring systems typically are used in the field to determine physiologic risk and referral pattern for pre-hospital providers . They are designed to standardize the initial assessment of trauma patients, based upon the physiologic parameters, physical examination and/or injury mechanism.
Resource utilization — An emerging concept in the literature is that of developing triage criteria that accurately stratify patients based on their need for trauma center resources . For example, the injury severity alone may not be as meaningful as injury severity combined with the need for high-level resources such as endotracheal intubation, blood transfusion, fluid resuscitation, chest tube placement, or emergency operation.
The ideal triage score should be simple and easy to calculate but sensitive enough to include all patients who require a higher level of trauma services. Examples of triage scoring systems that have been validated for pediatric trauma populations include the Pediatric Glasgow Coma Scale (GCS), Trauma Score (TS), Revised Trauma Score (RTS), and the Pediatric Trauma Score (PTS) (table 3) [12-14]. These systems work best for triage purposes when combined with information about mechanism of injury and anatomic site of injury.
Each of the existing systems has strengths and weaknesses that derive from their components.
Glasgow Coma Scale — The GCS constitutes a widely applied scoring system for all trauma patients. Although commonly used for field triage decisions , the GCS is also an important component of many severity-of-illness scoring systems. Modification of the GCS to pediatric patients has been an important advance in the assessment of age-appropriate behavior in both verbal and preverbal children (table 4). The GCS has also been shown to have prognostic value in children, especially the motor and verbal component of the score [16-21].
Use of the motor component of the GCS (mGCS) instead of the entire scale (tGCS) has been proposed to simplify field triage for trauma patients. In a systematic review of 14 studies (4 pediatric and 10 mixed populations of children and adults) that evaluated the predictive utility of the two scores, the tGCS had significantly better predictive utility than the mGCS. However, all data was retrospective and the mGCS was derived from the tGCS in all patients which limits applicability of these findings . Further study is needed to determine if substitution of the mGCS for the tGCS during field evaluation impacts triage accuracy or clinical outcomes.
In addition, for both preverbal (<2 years old) and verbal (>2 years old) children, GCS correlates with the presence of traumatic brain injury (TBI) in patients with blunt head injury. As an example, in a prospective, multicenter observational study of over 40,000 children with blunt head trauma (most with minor head trauma) included in the above systematic review, the pediatric GCS in patients <2 years old and the standard GCS in patients >2 years old had similar accuracy for detecting clinically important TBI (ie, injury requiring neurosurgery, endotracheal intubation for >24 hours, hospitalization for 2 or more nights, or causing death) with good interobserver agreement . This study supports the continued use of the pediatric GCS for preverbal children.
Trauma Score — The TS includes five physiologic or physical examination components, including the GCS (table 3), that are scored and added together to determine the TS value and probability of survival. The TS is limited by the use of two subjective measurements (respiratory effort and capillary refill) and may underestimate the severity in the hemodynamically stable patient with an isolated head injury [6,23].
Revised Trauma Score — The RTS was developed to address some of the limitations of the TS; the subjective components no longer are incorporated (table 3) . Pediatric trauma experts have expressed concern that the RTS is derived from adult data and that the components may not be directly applicable to children. However, comparison of the RTS with the PTS has not shown any major disadvantage to using the RTS in injured children .
Pediatric Trauma Score — The PTS is patterned after the evaluation process of the Advanced Trauma Life Support (ATLS) course and is specifically designed for triage of the child with traumatic injury . It is the sum of six measures incorporating size as a surrogate for age and vital signs plus organ-specific injury data (table 3). The PTS correlates well with injury severity, mortality, resource utilization, and the need for transport to a pediatric trauma center. However, it can be a poor predictor of liver and spleen injuries for children with isolated blunt abdominal trauma .
Age-specific pediatric trauma score — The age-specific pediatric trauma score (ASPTS) age adjusts blood pressure, pulse, and respiratory rate and combines these with the GCS to predict injury severity and mortality . This score has lower sensitivity than the RTS but is more specific. The ASPTS has two major drawbacks. First, the user must know the range of normal vital signs for children of all ages. This significantly limits the usefulness of the ASPTS in the field setting. Second, the ASPTS has not been validated in pediatric trauma patients.
Anatomic systems — In comparison with triage scoring systems, injury scoring systems are based upon anatomic injury and are only accurate after all injuries have been diagnosed. Injury scores remain constant once all injuries have been identified. They are used primarily for comparisons of injury severity among trauma populations, but they may accurately predict risk for adverse outcome. Examples of injury scoring systems include the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Anatomic Profile (AP). The latter two scoring systems are based on calculations derived from the AIS.
Abbreviated Injury Scale — The AIS was designed to categorize the injuries of victims of motor vehicle collisions (MVCs) . It scores injury severity from 1 (least severe) to 5 (survival uncertain) within six body regions: head/neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. Nonsurvivable conditions are assigned an AIS of 6. The AIS does not accurately measure the effects of multiple injuries. It is used in coding injuries for other scoring systems or for outcome analysis systems .
Injury Severity Score — The ISS is calculated from the highest AIS for the three most severely injured regions as follows :
ISS = (AIS1) squared + (AIS2) squared + (AIS3) squared
The utility of the ISS is limited by its inability to adjust for the cumulative effect of coexisting injuries in one region (eg, concomitant subdural hematoma and intraparenchymal hemorrhage), the lack of a direct linear relationship between increasing score and severity, and the lack of consideration of preexisting conditions that may affect outcomes [30,31]. The ISS should be thought of as an ordinal scale, not a quantitative scale; ie, a score of 50 is not twice as lethal as a score of 25. Nonetheless, the ISS is a valid predictor of mortality, length of stay in the hospital or intensive care unit, and cost of trauma care.
While an ISS >15 has traditionally been considered a marker for severe injuries, an observational study that evaluated trauma registry records for over 50,000 children identified ISS >25 as a better discriminator to identify children at higher risk of severe injury regardless of whether one or more body systems were traumatized .
Anatomic profile — The anatomic profile was developed as an alternative to the ISS and gives equal weight to injuries regardless of body region. The AP uses the AIS descriptors of severity but uses only four body regions: head/brain/spinal cord, thorax/neck, all other serious injuries, and all non-serious injuries .
Mechanism of injury — Mechanism of injury is used for field classification of severity of injury and need for transportation to a designated trauma center (algorithm 1). In an observational study of 35,097 pediatric trauma patients (age 2 to 18 years), the mechanism of injury was also associated with mortality and functional outcomes with the greatest likelihood of mortality occurring in victims of penetrating trauma when compared with blunt mechanisms (eg, falls, motor vehicle collisions [MVCs], bicycle crashes, pedestrians struck by a motor vehicle) and the greatest functional morbidity occurring in pedestrians struck by a motor vehicle .
Combination systems — Outcome analysis systems use both physiologic and anatomic data to estimate morbidity and mortality for an individual patient or for trauma populations . Examples of trauma outcome analysis systems include the Trauma Injury Severity Score (TRISS), a severity characterization of trauma, and pediatric risk of mortality.
Trauma injury severity score — TRISS analysis combines TS or RTS (physiologic) and ISS (anatomic) data and age to estimate the probability of patient survival [34,35].
Pediatric age-adjusted trauma injury severity score (PAAT) — The PAAT combines the age-specific pediatric trauma score with the injury severity score . This score was shown to better predict survival than the trauma injury severity score (TRISS) and the "a severity characterization of trauma score" (ASCOT) in a retrospective analysis of 7138 pediatric patients from a regional trauma database.
A severity characterization of trauma (ASCOT) — ASCOT combines RTS (physiologic) and Anatomic Profile (anatomic) data to calculate probability of survival .
Pediatric Risk of Mortality (PRISM III) — The PRISM III score is a scoring system used in Pediatric intensive care units (ICUs) to control for severity of illness or injury when comparing patients within and between ICUs but is not designed to compare individual patients. It is the only validated predictor of critical care outcome in pediatrics and incorporates information regarding cardiovascular and neurologic parameters, as well as acid-base, electrolyte, and hematologic values . In a retrospective study of 125 pediatric trauma patients, PRISM was a better predictor of resource utilization than was ISS, but it underestimated mortality . PRISM III is proprietary and available only through membership.
Pediatric Index of Mortality 3 (PIM3) — The PIM3 is an updated version of the Pediatric Index of Mortality 2 (PIM2) score which has shown good performance during validation [40,41]. These scores have been shown to predict mortality with high discrimination using a limited number of variables. The PIM2 score has been shown to have comparable performance to PRISM III in certain countries and was found to be easier to use [42,43]. The PIM3 score requires only one hour of information while a PRISM III score needs 12 to 24 hours of data. Of note, both the PRISM III and PIM3 scores were developed using general Pediatric ICU patients, rather than a trauma-specific subset, and have not yet been validated for pediatric trauma patients outside of an ICU setting.
International classification injury severity score (ICISS) — The ICISS is based on the anatomic injury diagnosis from the international classification of disease, ninth revision (ICD-9) and thus uses objective criteria rather than more subjective physiologic metrics. A survival risk ratio is calculated for a population based on the proportion of fatalities for each diagnosis. The probability of survival is then derived by the product of survival risk ratios from the three most severe injuries in an individual patient. Large observational studies using data derived from large registries indicate that the ICISS has shown good validity for prediction of mortality and resource use in adult  and pediatric  trauma patients.
However, in a single center observational study of almost 2000 pediatric trauma patients, the expert consensus-derived Trauma Injury Severity Score (TRISS) was superior to the ICISS in predicting mortality, possibly due to a loss of discrimination from the lack of physiologic parameters in the ICISS .
Pediatric trauma BIG score — The BIG score is calculated from the admission base deficit, international normalized ratio (INR), and GCS as follows :
BIG score = (base deficit) + [2.5 x INR] + [15 – GCS]
It was derived and validated in children and appears to predict mortality well regardless of whether the victims have blunt or penetrating mechanism of trauma. When retrospectively applied to a sample of 707 children, of whom most had penetrating or blast injury, the BIG score was more accurate in predicting mortality than the revised trauma score, injury severity score, age-specific pediatric trauma score, or pediatric age-adjusted TRISS . In a separate, retrospective validation study in 621 children (mortality 8 percent), the BIG score predicted fatality after blunt trauma with high discrimination independent of prehospital interventions, presence of head injury, or hypotension [48,49]. In this study, a BIG score <16 was associated with a high likelihood of survival.
Shock Index Pediatric-Adjusted (SIPA) — Shock index (heart rate/systolic blood pressure) has been adapted to the pediatric population . For children, the cutoffs associated with higher morbidity or mortality by age using reference values for maximum heart rate and minimum systolic blood pressure cutoffs taken from the Nelson Textbook of Pediatrics are [51,52]:
●1 to 3 years – >1.2
●4 to 6 years – >1.2
●7 to 12 years – >1
●Older than 12 years – >0.9 (adult cutoff)
SIPA is superior to age-adjusted hypotension in identifying children that require emergency intervention such as emergency surgery or endotracheal intubation [52,53]. In a prospective validation study that included almost 400 children with blunt liver or spleen trauma, SIPA had a high sensitivity but low specificity for predicting the need for blood transfusion, operation, and mortality .
Use of different reference values for maximum heart rate and minimum systolic blood pressures may further improve test characteristics for SIPA. For example, in a retrospective observational study of nearly 600,000 patients reported to the American College of Surgeons Trauma database, use of ATLS-based or Pediatric Advanced Life Support (PALS)-based vital signs resulted in higher positive predictive values for mortality but similar negative predictive values compared with the original SIPA when the mortality prevalence was both low (0.9 percent) and high (18.7 percent) .
PREDICTIVE VALUE — The abilities of 11 trauma severity scoring systems to predict survival, duration of intensive and overall care, and persistent disability were compared in a retrospective study of 261 children with multiple injuries; the mortality rate was 26 percent . The major findings are summarized below:
●Physiologic scores were better able to predict survival than were anatomic scores (79 to 86 percent versus 73 to 79 percent); combined scores offered no additional benefit to predicting survival (75 to 80 percent).
●The combination of physiologic systems and the ISS (TRISS) increase the ability to predict morbidity.
●Trauma scores designed for pediatric use (eg, Pediatric Trauma Score [PTS]) were no better than trauma scores in general (eg, Trauma Score [TS], Revised Trauma Score [RTS]).
In a comprehensive systematic review examining the existing evidence surrounding pediatric trauma triage , the Pediatric Trauma Society found that:
●Prehospital triage criteria may decrease mortality by determining the mode of transportation, but further investigation is required to define accurate prehospital triage criteria that may contribute to reducing mortality.
●Although no individual prehospital trauma scoring system has been shown to be consistently accurate, certain variables have been associated with morbidity and mortality. The Glasgow Coma Scale (GCS) was found in multiple studies to predict mortality. In multiple studies, mechanism of injury alone did not predict morbidity and mortality.
●Trauma center activation criteria can predict patients with higher mortality. The criteria vary from center to center, but physiologic criteria appear to be the most useful in predicting morbidity and mortality.
●Trauma center activation criteria appear to predict the need for procedural and surgical intervention. Physiologic criteria were again noted to be more predictive compared with mechanism of injury.
●Trauma scoring systems can predict mortality; however, further studies are required to determine if age-specific physiologic parameters can improve scoring system accuracy.
Development of standardized secondary transfer protocols is needed for more effective and efficient care of pediatric trauma patients.
●Triage decision support systems – Triage decision support classification systems are often used in the pre-hospital setting to guide transport disposition. By necessity, they are based upon rapidly obtainable clinical findings. They are designed to identify patients that have a high likelihood of critical injury that requires trauma center care for optimal outcomes. (See 'Triage decision support' above and 'Physiologic systems' above.)
•Glasgow Coma Scale (GCS) (table 4)
•Trauma score (TS)
•Revised trauma score (RTS) (table 3)
•Pediatric trauma score (PTS) (table 3)
●Outcome prediction systems – Severity of illness (SOI) or mortality prediction classification systems are often used retrospectively to standardize outcomes for research purposes. They may also serve as a prognostic indicator in individual patients. However, they usually are not used to guide early resuscitation. These scores are based upon anatomic site of injury with or without other clinical data. (See 'Severity of illness or mortality prediction' above.)
●Anatomic systems – Anatomic systems are calculated once all diagnoses are known. These scores remain constant over time. They are used primarily for comparisons of injury severity among trauma populations, but they may accurately predict risk for adverse outcome. Examples include the Abbreviated Injury Scale (AIS) and the Injury Severity Score (ISS). (See 'Anatomic systems' above.)
●Combination systems – Combination systems use both physiologic and anatomic data to estimate morbidity and mortality for an individual patient or for trauma populations. (See 'Combination systems' above.)
•International classification injury severity score (ICISS)
•Trauma score and injury severity score (TRISS)
•A severity characterization of trauma (ASCOT)
•Pediatric risk of mortality (PRISM III)
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