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Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma
Jillian K Gorski1, Pradip P Chaudhari2, Ryan G Spurrier3
1Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
Insights
Empirically derived vital signs offer a balanced approach for identifying major pediatric trauma, improving upon existing Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) criteria. These new criteria may better identify children at high risk for severe outcomes.
Area of Science:
- Pediatric Trauma Care
- Emergency Medicine
- Clinical Triage
Background:
- Vital signs are crucial for assessing injured children during triage.
- Current trauma assessment protocols like Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) utilize specific vital sign criteria.
Purpose of the Study:
- To compare the effectiveness of ATLS and PALS vital sign criteria against empirically derived criteria for identifying major trauma in pediatric patients.
- To determine which set of criteria best balances sensitivity and specificity in pediatric trauma triage.
Main Methods:
- Retrospective cohort study utilizing 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data.
- Analysis included pediatric patients (<18 years) with severe injuries, comparing initial vital signs (heart rate, respiratory rate, SBP) against major trauma outcomes.
- Performance was evaluated using receiver operating characteristic curves, with validation on the 2019 TQIP dataset.
Main Results:
- Empirically derived criteria demonstrated a sensitivity of 80.0% and specificity of 48.7%, outperforming ATLS criteria (54.5% sensitivity, 72.9% specificity) and showing similar performance to PALS criteria (88.4% sensitivity, 25.1% specificity).
- The area under the receiver operating characteristic curve for empirically derived criteria (70.9%) was superior to ATLS (65.4%) and comparable to PALS (69.6%).
- Validation on the 2019 dataset confirmed the consistent performance of these findings.
Conclusions:
- Empirically derived vital sign criteria provide a superior balance of sensitivity and specificity for identifying major pediatric trauma compared to ATLS criteria.
- These findings suggest that empirically derived criteria can enhance the identification of children at significant risk for trauma-related morbidity and mortality.
- The study highlights the potential for improved pediatric trauma triage through data-driven vital sign assessments.
Importance:
Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments.
Objective:
To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children.
Design, Setting, And Participants:
This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023.
Exposure:
Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP).
Main Outcome And Measures:
Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset.
Results:
A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample.
Conclusions And Relevance:
These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.
Related Concept Videos
01:25Introduction to Vital Signs
Vital signs help healthcare professionals assess an individual's well-being and detect any functional changes...
01:19Guidelines For Measuring Vital Signs
Before taking a patient's vital signs, a nurse would consider and assess the patient's comfort level and ensure appropriate equipment is available.
01:20Assessment of Ventilation I: Respiratory Rate
A Ventilation assessment is critical for monitoring a patient's health status. Respiration, one of the most accessible vital signs, provides insights into the function of numerous body systems and can indicate serious health issues, such as brainstem injuries from head trauma.
Critical Guidelines for Assessing Ventilation: