pediatric trauma triage: a pediatric trauma society ... · a priori questions identified by the pts...

Pediatric Trauma Triage:A Pediatric Trauma Society Research Committee

Systematic ReviewMC Mora MD1, LV Veras MD1, R Burke PhD2, L Cassidy PhD3, N Christopherson MS4, A Cunningham MD5, M Jafri MD5, E Marion BS3, K Lidsky MD6, N Yanchar

MD7, L Wu MLIS AHIP1, A Gosain MD PhD1,8

Affiliations: 1) Division of Pediatric Surgery, University of Tennessee Health Science Center, Memphis, TN; 2) Dept Preventive Medicine, Keck School of Medicine, USC, CA; 3) Medical College of Wisconsin, Milwaukee, WI; 4) Cohen Children’s Medical Center, New Hyde Park, NY; 5) Division of Pediatric Surgery, Doernbecher

Children’s Hospital / Oregon Health & Science University, Randall Children’s Hospital / Legacy Emanuel Medical Center, Portland OR; 6) Wolfson Children’s Hospital, University of Florida, Jacksonville, FL; 7)

Division of Pediatric Surgery, University of Calgary, Calgary, AB; 8) Children’s Foundation Research Institute, Le Bonheur Children’s Hospital, Memphis, TN

Nov 15, 2019

@LeBonheurChild @SurgeryUTHSC

Disclosures

I do not have any relationships with commercial interests to disclose.

I do not intend to reference unlabeled or unapproved uses of drugs or products in my presentation.

Background

1. Trauma is the leading cause of death in children

2. Despite research and recommendations from multiple professional organizations, significant variability in the triage of injured children exists

3. It is unknown if existing methods of triage beneficially impact morbidity or mortality

Aims

To define existing evidence for pediatric trauma triage and identify gaps in knowledge.

A priori questions identified by the PTS Research Committee:

1) Do prehospital triage criteria reduce mortality?

2) Do prehospital trauma scoring systems predict outcomes?

3) Do trauma center activation criteria predict outcomes?

4) Do activation criteria predict need for interventions?

5) Do trauma bay scoring systems predict outcomes?

6) What secondary triage criteria for transfer exist?

Pre-Hospital

Hospital

Secondary/Transfer

Methods

● Systematic review using PRISMA methodology● Eligibility criteria

● Children (<21 years of age)● Focus on use, development, evaluation and outcomes of trauma

triage criteria● Exclusion: mass casualty, war, burns only, or children not analyzed

separately from adults● Data extraction

● All abstracts & full articles independently reviewed by 2 reviewers; third reviewer used to resolve discrepancies on inclusion/exclusion

● Each article assigned to one or more of the 6 defined questions

MINORS Tool

• Methodological index for non-randomized studies: scoring system of 12 methodological items for non-comparative studies, and 4 additional items for comparative studies (24 points max)

PRISMA Flow Diagram

Scre

enin

gEl

igib

ility

Incl

ud

ed

Records identified through database searching (n=1545)

Additional records identified through other sources (n=16)

Records after duplicates removed (n=1482)

Records screened (n=1482) Records excluded (n=1038)

Full-text articles assessed for eligibility (n=444)

Full-text articles excluded, with reasons (n=410)

Studies included in qualitative analysis (n=33)

Prehospital n=11 Hospital n=18 Transfer n=4

1) Do prehospital triage criteria reduce mortality?

Study Study type MINORS Outcome

Newgard et al; 2016 P 14/24 National field triage guidelines not sensitive in identifying seriously injured children

Wang et al; 2001 R 12/24 Mechanism of injury did not reduce mortality

Walther et al; 2014 R 12/24 No difference noted in mortality when children treated at PTC versus ATC

Moront et al; 1996 R 12/24 GCS and HR more sensitive to identify severely injured children benefiting from air transport

R=Retrospective P=Prospective O=Observational PTC=Pediatric Trauma Center ATC=Adult Trauma Center

2) Do prehospital trauma scoring systems predict outcomes?*

➢ Newgard et al: RR and GCCS better predicted need for specialized trauma center (21/24 points)

➢ Engum et al: Institution scoring system better at predicting major trauma vs PTS and RTS system (15/24 points)

➢ Doud et al: Age predictor of more severe injuries in MVC (14/24 points)

➢ Ardolino et al: Prehospital triage tools fail to meet recommended criteria of overtriage (14/24 points)

*subset of data shown

3) Do trauma center activation criteria predict outcomes?*

➢ Camilloni et al: Triage activation criteria predicted probability of death (20/20 points)

➢ Wang et al: MOI did not accurately define mortality (20/20 points)

➢ Chen et al: Trauma activation system identified 100% of deaths in trauma stat group (20/20 points)

➢ Rehn et al: Formalizing TTA lowered undertriage rates. Mechanism of injury led to higher overtriage (19/20 points)


4) Do activation criteria predict need for interventions?*

➢ Dowd et al: Anatomic and physiologic signs more predictive of determining need for surgical intervention (21/21 points)

➢ Simon et al: mPTS identified all patients requiring urgent procedures (20/21 points)

➢ Chen et al: Both level of trauma activations had equal likelihood of undergoing surgery (20/21 points)

➢ Wang et al: Activation for height of fall did not accurately reflect need for surgery (20/21 points)


5) Do trauma bay scoring systems predict outcomes?



Potoka et al; 2001 R 20/24 Developed PTS more accurately predicted mortality

Simon et al; 2004 R 20/24 ISS, RTS, and GCS all predict mortality and multi-system organ failure

Dur et al; 2014 R 12/24 mPTS detected high risk group, and detected mortality

6) What secondary triage criteria for transfer exist?


Tarima et al; 2015 R 18/24 Predictors of transferred patients were age and penetrating trauma

Vogel et al; 2014 R 14/24 Pediatric transfers of longer distance needed pediatric trauma expertise. Transfers that were close by were in high volume suggesting inappropriate level of transfer

Patterson et al; 2006 P 12/24 Developed/implemented triage guidelines

Ross et al; 2012 R 12/24 Factors associated with increased likelihood of interfacility transfers: younger age, burns, non-

accidental trauma, head/neck injury, multiple injuries in younger children


Conclusions

● Few high quality studies are available which address trauma triage in children

● Research is needed in the following areas:● Define accurate prehospital triage criteria that may contribute to reducing

mortality.● Develop a trauma scoring system that is consistently accurate in predicting

morbidity and mortality● Delineate appropriate transfer criteria including mode of transportation● Define trauma activation parameters that predict morbidity & mortality● Determine if age-specific physiologic parameters can improve scoring system

accuracy● Development of secondary transfer criteria for more efficient care of trauma

patients

Acknowledgements

Members of PTS trauma triage workgroup:MC Mora MDR Burke PhDL Cassidy PhDN Christopherson MSA Cunningham MDM Jafri MDE Marion BSK Lidsky MDN Yanchar MDL Wu MLIS AHIPA Gosain MD PhD

pediatric trauma triage: a pediatric trauma society ... · a priori questions identified by the pts...

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