title: The availability and use of out-of-hospital physiologic information to identify high-risk injured children in a multisite, population-based cohort.
abstract: OBJECTIVE
  The validity of using adult physiologic criteria to triage injured children in the out-of-hospital setting remains unproven. Among children meeting adult field physiologic criteria, we assessed the availability of physiologic information, the incidence of death or prolonged hospitalization, and whether age-specific criteria would improve the specificity of the physiologic triage step.
  
  
  METHODS
  We analyzed a prospective, out-of-hospital cohort of injured children aged < or =14 years collected from December 2005 through February 2007 by 237 emergency medical services (EMS) agencies transporting to 207 acute care hospitals (trauma and nontrauma centers) in 11 sites across the United States and Canada. Inclusion criteria were standard adult physiologic values: systolic blood pressure (SBP) < or =90 mmHg, respiratory rate < 10 or > 29 breaths/min, Glasgow Coma Scale (GCS) score < or =12, and field intubation attempt. Seven physiologic variables (including age-specific values) and three demographic and mechanism variables were included in the analysis. "High-risk" children included those who died (field or in-hospital) or were hospitalized > 2 days. The decision tree was derived and validated using binary recursive partitioning.
  
  
  RESULTS
  Nine hundred fifty-five children were included in the analysis, of whom 62 (6.5%) died and 117 (12.3%) were hospitalized > 2 days. Missing values were common, ranging from 6% (respiratory rate) to 53% (pulse oximetry), and were associated with younger age and high-risk outcome. The final decision rule included four variables (assisted ventilation, GCS score < 11, pulse oximetry < 95%, and SBP > 96 mmHg), which demonstrated improved specificity (71.7% [95% confidence interval (CI) 66.7-76.6%]) at the expense of missing high-risk children (sensitivity 76.5% [95% CI 66.4-86.6%]).
  
  
  CONCLUSIONS
  The incidence of high-risk injured children meeting adult physiologic criteria is relatively low and the findings from this sample do not support using age-specific values to better identify such children. However, the amount and pattern of missing data may compromise the value and practical use of field physiologic information in pediatric triage.
authors.affiliation: Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA. newgardc@ohsu.edu
authors.forename: Craig D
authors.initials: CD
authors.lastname: Newgard
authors.forename: Kyle
authors.initials: K
authors.lastname: Rudser
authors.forename: Dianne L
authors.initials: DL
authors.lastname: Atkins
authors.forename: Robert
authors.initials: R
authors.lastname: Berg
authors.forename: Martin H
authors.initials: MH
authors.lastname: Osmond
authors.forename: Eileen M
authors.initials: EM
authors.lastname: Bulger
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Davis
authors.forename: Martin A
authors.initials: MA
authors.lastname: Schreiber
authors.forename: Craig
authors.initials: C
authors.lastname: Warden
authors.forename: Thomas D
authors.initials: TD
authors.lastname: Rea
authors.forename: Scott
authors.initials: S
authors.lastname: Emerson
mesh_terms: D000293:Adolescent; D002170:Canada; D002648:Child; D002675:Child, Preschool; D004632:Emergency Medical Services; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D011446:Prospective Studies; D018570:Risk Assessment; D014193:Trauma Centers; D014218:Triage / Q000458:organization & administration*; D014481:United States; D014947:Wounds and Injuries / Q000503:physiopathology*