Introduction

Angelo Mikrogianakis MD, FRCPC

EPIDEMIOLOGY OF PEDIATRIC TRAUMATIC INJURY¹

Traumatic injury is the leading preventable health problem in children.
Trauma is the leading cause of death in children after infancy.
Most common causes of injury-related deaths are:
- Motor vehicle crashes.
- Submersion injury.
- Homicide.
- Suicide.
- Fires.
In 2003 there were 11,090 injury-related deaths in the United States in those less than 20 years old.²
10 million ED visits in those under 20 and >10 million primary care office visits yearly.³
Traumatic injury is the leading cause of childhood hospitalization.
- 300,000 hospitalizations yearly in the United States.⁴
Injury in children aged 5 to 14 is the leading cause of medical spending in the United States.
Billions of dollars are spent on direct and indirect expenses related to injury annually.
- Annual lifetime cost of injuries to children under 15: $254 billion in 1992.
- Medical care: $11 billion.⁴

TRAUMA IS NOT RANDOM

Injuries commonly referred to as “accidents.”
- But injuries are not random, unpredictable tragedies.⁵,⁶
Trauma has patterns, defined risk factors, and distinct preventative interventions.
Can identify high-risk populations and target interventions.⁷
Emergency physicians can engage in both improved acute care and prevention efforts of the severely injured child.

AGE

Bimodal distribution in injury death rates for children and teenagers.
- Reflects developmental and activity-related differences.
Infants at higher risk of inflicted trauma.
- Small size.
- Inability to protect themselves.
Teenagers
- Risks amplified from increased exposure to hazards (e.g., automobile travel).
- Increase in risk-taking behaviors (e.g., alcohol and drug use).⁸

SEX

Males at higher death risk from all types of injury.
Ratio of male-to-female deaths varies by injury mechanism.
Death rate from motorcycles crashes, firearms, and falls in teenage boys approximately tenfold greater than girls.
Pedestrian deaths only slightly higher in boys compared with girls.⁸

SOCIOECONOMIC STATUS AND RACE

Minority and low-income children have higher rates of fatal and nonfatal traumatic injury.⁹, ¹⁰ and ¹¹
Higher injuries in low-income neighborhoods related to educational and environmental factors.⁹

GEOGRAPHY

Injuries not randomly or equally distributed geographically.
Certain injuries more common in particular geographic locations due to differences in exposure to injury-associated natural features or hazards.¹²,¹³

TRAUMA TRIAGE SCORES¹⁴

Aid prehospital personnel to determine which patients require trauma center care.
Assist emergency physicians to determine level of trauma triage.
Should be easy to use and reliable.
Must accurately identify all patients requiring trauma center services.
Should reduce overtriage of minor trauma and minimize undertriage of major trauma.¹⁵
Trauma scores should not be used as sole determinant of injury triage.¹⁶

Revised Trauma Score (RTS) (Table 1-1)

Trauma triage scoring system.¹⁷
Elements of score are considered reliable:
- Respiratory rate (RR) (score 0-4).
- Systolic blood pressure (SBP) (score 0-4).
- Glasgow Coma Scale (GCS) (score 0-4).
Triage RTS used as prehospital triage score.
- The integer sum of the score’s three components.
  - Triage RTS has been incorporated into EMS trauma triage algorithms.¹⁸,¹⁹
  - Trauma patients with Triage RTS ≤11 should be taken to a trauma center.²⁰
- RTS calculated by multiplying each of the component scores by weighted coefficients:
  - RTS = 0.9368 (GCS value) + 0.7326 (SBP value) + 0.2908 (RR value).
- RTS
  - Ranges from 0 to 7.84.
  - Correlates well with survival.
  - Higher values more predictive of survival.
- RTS should NOT be used as sole predictor of mortality.²⁰,²¹

Pediatric Trauma Score (PTS) (Table 1-2)

Designed explicitly to triage pediatric trauma patients.
Calculated from six clinical variables:
- Weight (kg).
- Airway.
- Systolic blood pressure.
- Central nervous system.
- Open wound.
- Skeletal.
Accounts for pediatric trauma patients’ frequent cerebral and cardiopulmonary instability.
A PTS ≤8 requires triage to designated trauma center.
- Correlates well with risk of severe injury and mortality.²²
Using pediatric scores makes sense but some studies have failed to demonstrate significant advantage of the PTS over RTS or clinical judgment.²⁰,²³, ²⁴, ²⁵ and ²⁶

TABLE 1 – 1 Revised Trauma Score¹⁷

Clinical Parameter	Parameter Category	Score
Respiratory Rate (breaths/min)	10-24	4
	25-35	3
	>35	2
	<10	1
	0	0
Systolic Blood Pressure	>90	4
	70-89	3
	50-69	2
	<50	1
	0	0
Glasgow Coma Scale	14-15	4
	11-13	3
	8-10	2
	5-7	1
	3-4	0