title: Pediatric trauma patients with isolated airway compromise or Glasgow Coma Scale less than 8: does immediate attending surgeon's presence upon arrival make a difference?
abstract: OBJECTIVE
  Optimal trauma care requires an attending pediatric surgeon to head a trauma team for the most severely injured patients. Recently, the American College of Surgeons-Committee on Trauma has added "Glasgow Coma Scale (GCS) <8" and "airway compromise" to the existing anatomical and physiological criteria for immediate attending presence. This report analyzes the outcome of children who met these isolated criteria and were treated before the change in guidelines was made.
  
  
  METHODS
  The trauma registry of this level I trauma center was queried for all pediatric patients with GCS <8 or airway compromise. Age, sex, initial GCS, Revised Trauma Score, Injury Severity Score, outcome, and probability of survival (TRISS methodology) were recorded. The subgroup of patients for whom an attending surgeon was not immediately present was further analyzed.
  
  
  RESULTS
  Over a 5-year period, 2895 trauma patients (aged 0-16 years) were admitted. One hundred fifteen patients had a GCS <8 and/or airway compromise. In 61 cases, an attending surgeon was not present upon patient arrival. Of these patients, 24 died (group D), 15 were discharged to a rehabilitation facility (group R), and 22 were discharged home (group H). Ten patients with a probability of survival of lower than 0.5 survived. Only 4 of the 24 patients who died had a probability of survival of >0.5 (mean, 0.697). All 4 had an Injury Severity Score >25 and a GCS < or =4. All deaths were reviewed through a quality improvement program and were deemed nonpreventable by objective reviewers. Patient outcome was not affected by the presence or absence of an attending surgeon upon patient arrival.
  
  
  CONCLUSIONS
  Outcome of severely injured children with GCS <8 or airway compromise met and, in some cases, exceeded expectations of survival according to the TRISS methodology. The lack of immediate attending surgeon's presence does not appear to have negatively influenced the outcome in these children. Based on this series, there is no evidence to justify mandatory immediate presence of an attending surgeon for these 2 criteria alone.
authors.affiliation: Division of Pediatric Surgery, Brown Medical School and Hasbro Children's Hospital, Providence, RI 02905, USA.
authors.forename: Felix
authors.initials: F
authors.lastname: Lui
authors.forename: Paula
authors.initials: P
authors.lastname: Gormley
authors.forename: Donald L
authors.initials: DL
authors.lastname: Sorrells
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Arlet G
authors.initials: AG
authors.lastname: Kurkchubasche
authors.forename: Thomas F
authors.initials: TF
authors.lastname: Tracy
authors.forename: Francois I
authors.initials: FI
authors.lastname: Luks
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D015600:Glasgow Coma Scale / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D015601:Injury Severity Score; D008505:Medical Staff, Hospital / Q000706:statistics & numerical data*; D010043:Outcome and Process Assessment, Health Care; D005791:Patient Care / Q000706:statistics & numerical data*; D010348:Patient Care Team; D012042:Registries; D012131:Respiratory Insufficiency / Q000209:etiology / Q000628:therapy; D012189:Retrospective Studies; D012237:Rhode Island / Q000453:epidemiology; D016019:Survival Analysis; D013997:Time Factors; D014193:Trauma Centers / Q000706:statistics & numerical data*; D000078329:Workforce; D014947:Wounds and Injuries / Q000150:complications / Q000453:epidemiology*