18/10/2016 Classification of trauma in children ­ UpToDate

Official reprint from UpToDate®

www.uptodate.com ©2016 UpToDate®

Classification of trauma in children

Authors: Tom Brazelton, MD, MPH, FAAP, Ankush Gosain, MD, PhD, FACS, FAAP
Section Editor: Richard G Bachur, MD
Deputy Editor: James F Wiley, II, MD, MPH

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Sep 06, 2016.

INTRODUCTION — This topic will discuss the classification of pediatric trauma. The initial management of
trauma in stable and unstable children is discussed separately. (See "Trauma management: Approach to the
unstable child" and "Approach to the initially stable child with blunt or penetrating injury".)

BACKGROUND — Injuries are the leading cause of death for children and adolescents in the United States
(table 1) and most high­income countries [1]. Deaths from unintentional injuries account for more years of
potential life lost before age 65 years than cancer, heart disease, or any other cause of death [2]. For every
injury death, an estimated 25 hospitalizations and 925 emergency department visits occur. Most of these
injuries are caused by falls, motor vehicle collisions (MVCs), bicycle collisions, and burns; many are
preventable. (See "Overview of pediatric injury prevention: Epidemiology; history; application" and "Prevention
of falls in children".)

Due in large part to national injury prevention efforts, the overall unintentional injury death rate in United
States children, aged 0 to 19 years, declined by 29 percent from 2000 to 2009. These injury prevention efforts
include seat belt use, child safety seat and booster seat use, licensing requirements, vehicle design, and
reductions in alcohol­impaired driving. (See "Overview of pediatric injury prevention: Epidemiology; history;
application", section on 'Epidemiology'.)

However, even with these efforts, MVCs remain the leading cause of unintentional injury death among 15 to
19 year olds. Furthermore, the unintentional injury death rate for infants younger than one year of age has
risen from 2000 to 2009. It is clear that ongoing injury prevention efforts, such as the National Action Plan for
Child Injury Prevention [3], are needed to prevent these needless injuries and deaths. (See "Overview of
pediatric injury prevention: Epidemiology; history; application", section on 'Injury prevention resources'.)

INJURY PREVENTION — Types of prevention include:

● Primary injury prevention seeks to prevent the incident (eg, motor vehicle collision [MVC]) altogether. An
example of primary prevention would be road construction that separates the directions of traffic with
impregnable barriers so that head on collisions cannot occur.

● Secondary injury prevention decreases the likelihood of serious injury during a traumatic event. Seat belts
or air bags would be an example of secondary prevention.

● Tertiary prevention minimizes further deterioration and reduces complications when injury is not
prevented by primary or secondary means.

Tertiary prevention entails rapid identification of children with major trauma in the pre­hospital setting so that
appropriate management, destination, and utilization of emergency department resources can be determined
[4]. In the United States, experts have developed a field triage guideline that identifies those patients who
warrant direct pre­hospital transportation to a trauma center. This critical field transport decision requires the
evaluation of vital signs, level of consciousness, injury anatomy, injury mechanism, and special patient or local
emergency medical systems considerations. These guidelines recommend that children "should be triaged

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 1/15
18/10/2016 Classification of trauma in children ­ UpToDate

preferentially to pediatric­capable trauma centers" (algorithm 1) [5]. Thus, seriously injured children require
skillful assessment and treatment by clinicians experienced in pediatric trauma and rapid evacuation to a
regional pediatric trauma center, when available [6,7]. (See "Trauma management: Approach to the unstable
child".)

The introduction and spread of statewide trauma systems, the adoption of the American College of Surgeons'
(ACS) Trauma Center verification for pediatric trauma hospitals (table 2), and the resulting development of
trauma registries and databases have allowed for more accurate categorization of pediatric trauma patients
and system evaluation. This work has directed increased attention to the resources required for managing
trauma, especially pediatric trauma. The different types of pediatric trauma classification systems and their
uses will be discussed here. Evaluation and management of pediatric trauma patients is discussed separately.
(See "Trauma management: Approach to the unstable child" and "Approach to the initially stable child with
blunt or penetrating injury".)

CLASSIFICATION OF TRAUMA

Overview — A number of pediatric trauma classification systems are used to predict morbidity, mortality, and
resource utilization (eg, diagnostic studies, specialized personnel, operative intervention) [8].

● One classification is based upon three categories: body region (local or multiple), mechanism (blunt or
penetrating), and severity (mild, moderate, or severe) [9].

● Other classification systems are based upon physiology, anatomy, or a combination of physiology and
anatomy.

Objectives — There are two primary objectives for trauma classification [8]:

Triage decision support — Triage decision support classification systems are often used in the pre­
hospital setting to guide transport disposition. They are based upon rapidly obtainable clinical findings. They
are designed to identify patients who have a high likelihood of critical injury that may require trauma center
care for optimal outcomes.

Since trauma is a time­sensitive disease, early, goal­directed therapy and prompt referral and transport of
injured children to the most appropriate level of care are critical to their survival, overall functional outcomes,
and the efficient functioning of the trauma system. In highly evolved trauma systems, triage and transport may
begin with pre­hospital providers. Physicians and public alike should insist on a high level of pediatric
education through accredited training programs and accepted national credentialing for pre­hospital providers,
thereby creating an essential foundation that assures optimal age­appropriate, competent resuscitation.

Severity of illness or mortality prediction — Severity of illness (SOI) or mortality prediction

classification systems are often used retrospectively to standardize outcomes for research purposes. They
may also serve as a prognostic indicator in individual patients. However, they are not used to guide early
resuscitation.

Physiologic systems — Triage scoring systems typically are used in the field to determine physiologic risk
and referral pattern for pre­hospital providers [10]. They are designed to standardize the initial assessment of
trauma patients, based upon the physiologic parameters, physical examination and/or injury mechanism.

The ideal triage score should be simple and easy to calculate but sensitive enough to include all patients who
require a higher level of trauma services. Examples of triage scoring systems that have been validated for
pediatric trauma populations include the Pediatric Glasgow Coma Score (GCS), Trauma Score (TS), Revised
Trauma Score (RTS), and the Pediatric Trauma Score (PTS) (table 3) [11­13]. These systems work best for
triage purposes when combined with information about mechanism of injury and anatomic site of injury.

Each of the existing systems has strengths and weaknesses that derive from their components.

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 2/15
18/10/2016 Classification of trauma in children ­ UpToDate

Glasgow Coma Scale — The GCS constitutes a widely applied scoring system for all trauma patients.
Although commonly used for field triage decisions [14], the GCS is also an important component of many
severity­of­illness scoring systems. Modification of the GCS to pediatric patients has been an important
advance in the assessment of age­appropriate behavior in both verbal and preverbal children (table 4). The
GCS has also been shown to have prognostic value in children, especially the motor and verbal component of
the score [15­20].

In addition, for both preverbal (<2 years old) and verbal (>2 years old) children, GCS correlates with the
presence of traumatic brain injury (TBI) in patients with blunt head injury. As an example, in a prospective,
multicenter observational study of over 40,000 children with blunt head trauma (most with minor head
trauma), the pediatric GCS in patients <2 years old and the standard GCS in patients >2 years old had similar
accuracy for detecting clinically important TBI (ie, injury requiring neurosurgery, endotracheal intubation for
>24 hours, hospitalization for 2 or more nights, or causing death) with good interobserver agreement [20].
This study supports the continued use of the pediatric GCS for preverbal children.

Trauma Score — The TS includes five physiologic or physical examination components, including the
GCS (table 3), that are scored and added together to determine the TS value and probability of survival. The
TS is limited by the use of two subjective measurements (respiratory effort and capillary refill) and may
underestimate the severity in the hemodynamically stable patient with an isolated head injury [7,21].

Revised Trauma Score — The RTS was developed to address some of the limitations of the TS; the
subjective components no longer are incorporated (table 3) [21]. Pediatric trauma experts have expressed
concern that the RTS is derived from adult data and that the components may not be directly applicable to
children. However, comparison of the RTS with the PTS has not shown any major disadvantage to using the
RTS in injured children [22].

Pediatric Trauma Score — The PTS is patterned after the evaluation process of the Advanced Trauma
Life Support Course and is specifically designed for triage of the child with traumatic injury [10]. It is the sum of
six measures incorporating size as a surrogate for age and vital signs plus organ­specific injury data (table 3).
The PTS correlates well with injury severity, mortality, resource utilization, and the need for transport to a
pediatric trauma center. However, it can be a poor predictor of liver and spleen injuries for children with
isolated blunt abdominal trauma [23].

Age­specific pediatric trauma score — The age­specific pediatric trauma score (ASPTS) age adjusts
blood pressure, pulse, and respiratory rate and combines these with the GCS to predict injury severity and
mortality [24]. This score has lower sensitivity than the RTS but is more specific. The ASPTS has two major
drawbacks. First, the user must know the range of normal vital signs for children of all ages. This significantly
limits the usefulness of the ASPTS in the field setting. Second, the ASPTS has not been validated in pediatric
trauma patients.

Anatomic systems — In comparison to triage scoring systems, injury scoring systems are based upon
anatomic injury and are only accurate after all injuries have been diagnosed. Injury scores remain constant
once all injuries have been identified. They are used primarily for comparisons of injury severity among trauma
populations, but they may accurately predict risk for adverse outcome. Examples of injury scoring systems
include the Abbreviated Injury Scale (AIS), the Injury Severity Score (ISS), and the Anatomic Profile (AP).
The latter two scoring systems are based on calculations derived from the AIS.

Abbreviated Injury Scale — The AIS was designed to categorize the injuries of victims of motor vehicle
collisions (MVCs) [25]. It scores injury severity from 1 (least severe) to 5 (survival uncertain) within six body
regions: head/neck, face, chest, abdominal/pelvic contents, extremities, and skin/general. Nonsurvivable
conditions are assigned an AIS of 6. The AIS does not accurately measure the effects of multiple injuries. It is
used in coding injuries for other scoring systems or for outcome analysis systems [26].

Injury Severity Score — The ISS is calculated from the highest AIS for the three most severely injured
regions as follows [27]:
https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 3/15
18/10/2016 Classification of trauma in children ­ UpToDate

ISS = (AIS1) squared + (AIS2) squared + (AIS3) squared

The utility of the ISS is limited by its inability to adjust for the cumulative effect of coexisting injuries in one
region (eg, concomitant subdural hematoma and intraparenchymal hemorrhage), the lack of a direct linear
relationship between increasing score and severity, and the lack of consideration of preexisting conditions that
may affect outcomes [28,29]. The ISS should be thought of as an ordinal scale, not a quantitative scale; ie, a
score of 50 is not twice as lethal as a score of 25. Nonetheless, the ISS is a valid predictor of mortality, length
of stay in the hospital or intensive care unit, and cost of trauma care.

Anatomic profile — The anatomic profile was developed as an alternative to the ISS and gives equal
weight to injuries regardless of body region. The AP uses the AIS descriptors of severity but uses only four
body regions: head/brain/spinal cord, thorax/neck, all other serious injuries, and all non­serious injuries [10].

Mechanism of injury — Mechanism of injury is used for field classification of severity of injury and need for
transportation to a designated trauma center (algorithm 1). In an observational study of 35,097 pediatric
trauma patients (age 2 to 18 years), the mechanism of injury was also associated with mortality and functional
outcomes with the greatest likelihood of mortality occurring in victims of penetrating trauma when compared
with blunt mechanisms (eg, falls, motor vehicle collisions [MVCs], bicycle crashes, pedestrians struck by a
motor vehicle) and the greatest functional morbidity occurring in pedestrians struck by a motor vehicle [30].

Combination systems — Outcome analysis systems use both physiologic and anatomic data to estimate
morbidity and mortality for an individual patient or for trauma populations [10]. Examples of trauma outcome
analysis systems include the Trauma Injury Severity Score (TRISS), a severity characterization of trauma,
and pediatric risk of mortality.

Trauma injury severity score — TRISS analysis combines TS or RTS (physiologic) and ISS (anatomic)
data and age to estimate the probability of patient survival [31,32].

Pediatric age­adjusted trauma injury severity score (PAAT) — The PAAT combines the age­specific
pediatric trauma score with the injury severity score [33]. This score was shown to better predict survival than
the trauma injury severity score (TRISS) and the "a severity characterization of trauma score" (ASCOT) in a
retrospective analysis of 7138 pediatric patients from a regional trauma database.

A severity characterization of trauma (ASCOT) — ASCOT combines RTS (physiologic) and Anatomic
Profile (anatomic) data to calculate probability of survival [34].

Pediatric Risk of Mortality (PRISM III) — The PRISM III score is a scoring system used in Pediatric ICUs
to control for severity of illness or injury when comparing patients within and between ICUs but is not designed
to compare individual patients. It is the only validated predictor of critical care outcome in pediatrics and
incorporates information regarding cardiovascular and neurologic parameters, as well as acid­base,
electrolyte, and hematologic values [35]. In a retrospective study of 125 pediatric trauma patients, PRISM was
a better predictor of resource utilization than was ISS, but underestimated mortality [36]. PRISM III is
proprietary and available only through membership.

Pediatric Index of Mortality 3 (PIM3) — The PIM3 is an updated version of the Pediatric Index of
Mortality 2 (PIM2) score [37]. These scores have been shown to predict mortality with high discrimination
using a limited number of variables. The PIM2 score has been shown to have comparable performance to
PRISM III in certain countries and was found to be easier to use [38,39]. The PIM3 score requires only one
hour of information while a PRISM III score needs 12 to 24 hours of data. Of note, both the PRISM III and
PIM3 scores were developed using general Pediatric ICU patients, rather than a trauma­specific subset, and
have not yet been validated for pediatric trauma patients outside of an ICU setting.

International classification injury severity score (ICISS) — The ICISS is based on the anatomic injury
diagnosis from the international classification of disease, ninth revision (ICD­9) and thus uses objective criteria
rather than more subjective physiologic metrics. A survival risk ratio is calculated for a population based on the

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 4/15
18/10/2016 Classification of trauma in children ­ UpToDate

proportion of fatalities for each diagnosis. The probability of survival is then derived by the product of survival
risk ratios from the three most severe injuries in an individual patient. Large observational studies using data
derived from large registries indicate that the ICISS has shown good validity for prediction of mortality and
resource use in adult [40] and pediatric [41] trauma patients.

However, in a single center observational study of almost 2,000 pediatric trauma patients, the expert
consensus­derived Trauma Injury Severity Score (TRISS) was superior to the ICISS in predicting mortality,
possibly due to a loss of discrimination from the lack of physiologic parameters in the ICISS [42].

Pediatric trauma BIG score — The BIG score is calculated from the admission base deficit, international
normalized ratio (INR), and Glasgow coma scale (GCS) as follows [43]:

BIG score = (base deficit) + [2.5 x INR] + [15 – GCS]

It was derived and validated in children and appears to predict mortality well regardless of whether the victims
have blunt or penetrating mechanism of trauma. When retrospectively applied to a sample of 707 children, of
whom most had penetrating or blast injury, the BIG score was more accurate in predicting mortality than the
revised trauma score, injury severity score, age­specific pediatric trauma score, or pediatric age­adjusted
TRISS [43]. In a separate, retrospective validation study in 621 children (mortality 8 percent), the BIG score
predicted fatality after blunt trauma with high discrimination independent of prehospital interventions, presence
of head injury, or hypotension [44,45]. In this study, a BIG score <16 was associated with a high likelihood of
survival.

PREDICTIVE VALUE — The abilities of 11 trauma severity scoring systems to predict survival, duration of
intensive and overall care, and persistent disability were compared in a retrospective study of 261 children
with multiple injuries; the mortality rate was 26 percent [7]. The major findings are summarized below:

● Physiologic scores were better able to predict survival than were anatomic scores (79 to 86 percent
versus 73 to 79 percent); combined scores offered no additional benefit to predicting survival (75 to 80
percent).

● The combination of physiologic systems and the ISS (TRISS) increase the ability to predict morbidity.

● Trauma scores designed for pediatric use (eg, PTS) were no better than trauma scores in general (eg,
TS, RTS).

SUMMARY — The introduction and spread of statewide trauma systems, the adoption of the American
College of Surgeons' (ACS) Trauma Center verification for hospitals (table 2) and resulting development of
trauma registries and databases has allowed for more accurate categorization of pediatric trauma patients
and system evaluation.

● Triage decision support classification systems are often used in the pre­hospital setting to guide transport
disposition. By necessity, they are based upon rapidly obtainable clinical findings. They are designed to
identify patients that have a high likelihood of critical injury that requires trauma center care for optimal
outcomes. (See 'Triage decision support' above and 'Physiologic systems' above.)

Examples include:

• Glasgow coma scale (table 4)

• Trauma score

• Revised trauma score (table 3)

• Pediatric trauma score (table 3)

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 5/15
18/10/2016 Classification of trauma in children ­ UpToDate

● Severity of illness (SOI) or mortality prediction classification systems are often used retrospectively to
standardize outcomes for research purposes. They may also serve as a prognostic indicator in individual
patients. However, they usually are not used to guide early resuscitation. These scores are based upon
anatomic site of injury with or without other clinical data. (See 'Severity of illness or mortality prediction'
above.)

● Anatomic systems are calculated once all diagnoses are known. These scores remain constant over time.
They are used primarily for comparisons of injury severity among trauma populations, but they may
accurately predict risk for adverse outcome. Examples include the Abbreviated Injury Scale and the Injury
Severity Score. (See 'Anatomic systems' above.)

● Combination systems use both physiologic and anatomic data to estimate morbidity and mortality for an
individual patient or for trauma populations. (See 'Combination systems' above.)

Examples include:

• International classification injury severity score (ICISS)

• Trauma score and injury severity score (TRISS)

• A severity characterization of trauma (ASCOT)

• Pediatric risk of mortality (PRISM III)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES

1. Krug EG, Sharma GK, Lozano R. The global burden of injuries. Am J Public Health 2000; 90:523.
2. CDC. Web­based Injury Statistics Query and Reporting Ssytem (WISQARS). Atlanta, GA: US
Department of Health and Human Services, CDC; 2009. http://www.cdc.gov/injury/wisqars/index.html
(Accessed on August 13, 2013).
3. Baldwin G, Sleet D, Gilchrist J, Degutis L. Fulfilling a promise: the national action plan for child injury
prevention. Inj Prev 2012; 18:207.
4. Engum SA, Mitchell MK, Scherer LR, et al. Prehospital triage in the injured pediatric patient. J Pediatr
Surg 2000; 35:82.
5. Sasser SM, Hunt RC, Sullivent EE, et al. Guidelines for field triage of injured patients.
Recommendations of the National Expert Panel on Field Triage. MMWR Recomm Rep 2009; 58:1.
6. Tepas JJ 3rd, Ramenofsky ML, Barlow B, et al. National Pediatric Trauma Registry. J Pediatr Surg 1989;
24:156.
7. Champion HR, Copes WS, Sacco WJ, et al. The Major Trauma Outcome Study: establishing national
norms for trauma care. J Trauma 1990; 30:1356.
8. Marcin JP, Pollack MM. Triage scoring systems, severity of illness measures, and mortality prediction
models in pediatric trauma. Crit Care Med 2002; 30:S457.
9. Ruddy RM, Fleisher GR. An approach to the injured child. In: Textbook of Pediatric Emergency
Medicine, 5th, Fleisher GR, Ludwig S, Henretig FM. (Eds), Lippincott Williams & Wilkins, Philadelphia
2006. p.1339.
10. Furnival RA, Schunk JE. ABCs of scoring systems for pediatric trauma. Pediatr Emerg Care 1999;
15:215.

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 6/15
18/10/2016 Classification of trauma in children ­ UpToDate

11. Eichelberger MR, Gotschall CS, Sacco WJ, et al. A comparison of the trauma score, the revised trauma
score, and the pediatric trauma score. Ann Emerg Med 1989; 18:1053.
12. Tepas JJ 3rd, Ramenofsky ML, Mollitt DL, et al. The Pediatric Trauma Score as a predictor of injury
severity: an objective assessment. J Trauma 1988; 28:425.
13. Aprahamian C, Cattey RP, Walker AP, et al. Pediatric Trauma Score. Predictor of hospital resource use?
Arch Surg 1990; 125:1128.
14. Beskind DL, Keim SM, Spaite DW, et al. Risk adjustment measures and outcome measures for
prehospital trauma research: recommendations from the emergency medical services outcomes project
(EMSOP). Acad Emerg Med 2011; 18:988.
15. Bruce, DA, Raphaely, RC, Goldbert, AI, et al. Pathophysiology, treatment and outcome following severe
head injury in children. Child's Brain 1979; 5:175.
16. Young B, Rapp RP, Norton JA, et al. Early prediction of outcome in head­injured patients. J Neurosurg
1981; 54:300.
17. Hannan EL, Farrell LS, Meaker PS, Cooper A. Predicting inpatient mortality for pediatric trauma patients
with blunt injuries: a better alternative. J Pediatr Surg 2000; 35:155.
18. Ross SE, Leipold C, Terregino C, O'Malley KF. Efficacy of the motor component of the Glasgow Coma
Scale in trauma triage. J Trauma 1998; 45:42.
19. Acker SN, Ross JT, Partrick DA, et al. Glasgow motor scale alone is equivalent to Glasgow Coma Scale
at identifying children at risk for serious traumatic brain injury. J Trauma Acute Care Surg 2014; 77:304.
20. Borgialli DA, Mahajan P, Hoyle JD Jr, et al. Performance of the Pediatric Glasgow Coma Scale Score in
the Evaluation of Children With Blunt Head Trauma. Acad Emerg Med 2016; 23:878.
21. Champion HR, Sacco WJ, Copes WS, et al. A revision of the Trauma Score. J Trauma 1989; 29:623.
22. Kaufmann CR, Maier RV, Rivara FP, Carrico CJ. Evaluation of the Pediatric Trauma Score. JAMA 1990;
263:69.
23. Saladino R, Lund D, Fleisher G. The spectrum of liver and spleen injuries in children: failure of the
pediatric trauma score and clinical signs to predict isolated injuries. Ann Emerg Med 1991; 20:636.
24. Potoka DA, Schall LC, Ford HR. Development of a novel age­specific pediatric trauma score. J Pediatr
Surg 2001; 36:106.
25. Rating the severity of tissue damage. I. The abbreviated scale. JAMA 1971; 215:277.
26. Baker SP, O'Neill B. The injury severity score: an update. J Trauma 1976; 16:882.
27. Injury severity score. www.trauma.org/archive/scores/iss.html (Accessed on August 21, 2013).
28. Copes WS, Champion HR, Sacco WJ, et al. The Injury Severity Score revisited. J Trauma 1988; 28:69.
29. Karmy­Jones R, Copes WS, Champion HR, et al. Results of a multi­institutional outcome assessment:
results of a structured peer review of TRISS­designated unexpected outcomes. J Trauma 1992; 32:196.
30. Haider AH, Crompton JG, Oyetunji T, et al. Mechanism of injury predicts case fatality and functional
outcomes in pediatric trauma patients: the case for its use in trauma outcomes studies. J Pediatr Surg
2011; 46:1557.
31. Trauma­injury severity score. www.trauma.org/index.php/main/article/387/ (Accessed on August 21,
2013).
32. Schluter PJ, Nathens A, Neal ML, et al. Trauma and Injury Severity Score (TRISS) coefficients 2009
revision. J Trauma 2010; 68:761.
33. Schall LC, Potoka DA, Ford HR. A new method for estimating probability of survival in pediatric patients
using revised TRISS methodology based on age­adjusted weights. J Trauma 2002; 52:235.
34. Champion HR, Copes WS, Sacco WJ, et al. A new characterization of injury severity. J Trauma 1990;
30:539.
https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 7/15
18/10/2016 Classification of trauma in children ­ UpToDate

35. Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care
Med 1996; 24:743.
36. Castello FV, Cassano A, Gregory P, Hammond J. The Pediatric Risk of Mortality (PRISM) Score and
Injury Severity Score (ISS) for predicting resource utilization and outcome of intensive care in pediatric
trauma. Crit Care Med 1999; 27:985.
37. Straney L, Clements A, Parslow RC, et al. Paediatric index of mortality 3: an updated model for
predicting mortality in pediatric intensive care*. Pediatr Crit Care Med 2013; 14:673.
38. Slater A, Shann F, Pearson G, Paediatric Index of Mortality (PIM) Study Group. PIM2: a revised version
of the Paediatric Index of Mortality. Intensive Care Med 2003; 29:278.
39. Brady AR, Harrison D, Black S, et al. Assessment and optimization of mortality prediction tools for
admissions to pediatric intensive care in the United kingdom. Pediatrics 2006; 117:e733.
40. Rutledge R, Osler T, Emery S, Kromhout­Schiro S. The end of the Injury Severity Score (ISS) and the
Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth
revision­based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival,
hospital charges, and hospital length of stay. J Trauma 1998; 44:41.
41. Tepas JJ 3rd, Leaphart CL, Celso BG, et al. Risk stratification simplified: the worst injury predicts
mortality for the injured children. J Trauma 2008; 65:1258.
42. Allen CJ, Wagenaar AE, Horkan DB, et al. Predictors of mortality in pediatric trauma: experiences of a
level 1 trauma center and an assessment of the International Classification Injury Severity Score
(ICISS). Pediatr Surg Int 2016; 32:657.
43. Borgman MA, Maegele M, Wade CE, et al. Pediatric trauma BIG score: predicting mortality in children
after military and civilian trauma. Pediatrics 2011; 127:e892.
44. Davis AL, Wales PW, Malik T, et al. The BIG Score and Prediction of Mortality in Pediatric Blunt Trauma.
J Pediatr 2015; 167:593.
45. Borgman MA, Spinella PC. What is the Big Deal about the BIG Score? J Pediatr 2015; 167:513.

Topic 6459 Version 16.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 8/15
18/10/2016 Classification of trauma in children ­ UpToDate

GRAPHICS

10 leading causes of death, United States (<1 to 24 years) 2013, all races, both
sexes

Age groups (years)

Rank
<1 1­4 5­9 10­14 15­19 20­24

1 Congenital Unintentional Unintentional Unintentional Unintentional Unintentional

anomalies injury injury injury injury injury
4758 1316* 746* 775* 3652* 7967*

2 Short Congenital Malignant Malignant Suicide Suicide

gestation anomalies neoplasms neoplasms 1748 ¶
3130 ¶
4202 476 447 448

3 Maternal Homicide Congenital Suicide Homicide Homicide

pregnancy 337 Δ anomalies 386 ¶
1407 Δ
2922 Δ
complications 179
1595

4 SIDS Malignant Homicide Congenital Malignant Malignant

1563 neoplasms 125 Δ anomalies neoplasms neoplasms
328 161 627 869

5 Unintentional Heart disease Chronic lower Homicide Heart disease Heart disease
injury 169 respiratory 152 Δ
297 644
1156* disease
75

6 Placenta cord Influenza & Heart disease Heart disease Congenital Congenital
membranes pneumonia 73 100 anomalies anomalies
953 102 166 196

7 Bacterial Chronic lower Influenza and Chronic lower Influenza and Diabetes
sepsis respiratory pneumonia respiratory pneumonia mellitus
578 disease 67 disease 73 141
64 80

8 Respiratory Septicemia Cerebrovascular Influenza and Chronic lower Complicated

distress 53 41 pneumonia respiratory pregnancy
522 61 disease 137
60

9 Circulatory Benign Septicemia Cerebrovascular Cerebrovascular Influenza and

system disease neoplasms 35 48 56 pneumonia
458 47 124

10 Neonatal Perinatal Benign Benign Diabetes HIV

hemorrhage period neoplasms neoplasms mellitus 106
389 45 34 31 52

SIDS: sudden infant death syndrome.

* Unintentional injury.
¶ Suicide.
Δ Homicide.

Reproduced from: National Center for Health Statistics (NCHS), National Vital Statistics System. Available at:
www.cdc.gov/injury/wisqars/leading_causes_death.html. Accessed on June 30, 2015.

Graphic 67131 Version 9.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 9/15
18/10/2016 Classification of trauma in children ­ UpToDate

US 2011 trauma field triage algorithm

EMS: emergency medical services.

* The upper limit of respiratory rate in infants is >29 breaths per minute to maintain a higher level of overtriage for
infants.
Δ Trauma centers are designated Level I­IV. A Level I center has the greatest amount of resources and personnel for
care of the injured patient and provides regional leadership in education, research, and prevention programs. A Level
II facility offers similar resources to a Level I facility, possibly differing only in continuous availability of certain
subspecialties or sufficient prevention, education, and research activities for Level I designation; Level II facilities are
not required to be resident or fellow education centers. A Level III center is capable of assessment, resuscitation, and

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 10/15
18/10/2016 Classification of trauma in children ­ UpToDate
emergency surgery, with severely injured patients being transferred to a Level I or II facility. A Level IV trauma center
is capable of providing 24­hour physician coverage, resuscitation, and stabilization to injured patients before transfer
to a facility that provides a higher level of trauma care.
◊ Any injury noted in Step two or mechanism identified in Step three triggers a "yes" response.
§ Age <15 years.
￥ Intrusion refers to interior compartment intrusion, as opposed to deformation which refers to exterior damage.
‡ Includes pedestrians or bicyclists thrown or run over by a motor vehicle or those with estimated impact >20 mph
with a motor vehicle.
† Local or regional protocols should be used to determine the most appropriate level of trauma center within the
defined trauma system; need not be the highest­level trauma center.
** Age >55 years.
ΔΔ Patients with both burns and concomitant trauma for whom the burn injury poses the greatest risk for morbidity
and mortality should be transferred to a burn center. If the nonburn trauma presents a greater immediate risk, the
patient may be stabilized in a trauma center and then transferred to a burn center.
◊◊ Patients who do not meet any of the triage criteria in Steps one through four should be transported to the most
appropriate medical facility as outlined in local EMS protocols.

Reproduced from: Sasser SM, Hunt RC, Faul M, et al. Guidelines for field triage of injured patients: Recommendations
of the National Expert Panel on Field Triage, 2011. MMWR 2012; 61:1.

Graphic 81002 Version 3.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 11/15
18/10/2016 Classification of trauma in children ­ UpToDate

Trauma center verification level: setting and capability for children

Freestanding children's hospital or comprehensive pediatric

Peds LI Peds LII
care unit within general hospital organization

Pediatric trauma service E E

Pediatric surgeon as pediatric medical director E D

Pediatric surgeon E (At least 2) E– (At least 1)

Pediatric emergency medicine physicians E E

Pediatric critical care medicine physicians E E

Other surgical specialists with pediatric specialty experience E E

Pediatric­specific trauma continuing medical education for pediatric medical E E

director and liaisons

Pediatric emergency department area E E

Pediatric intensive care unit E E

Pediatric acute care unit E E

Pediatric rehabilitation E E

Pediatric resuscitation equipment in all appropriate patient care areas E E

Pediatric trauma program manager E E

Pediatric trauma registrar E E

Child life and family support programs E E

Pediatric social work child protective services E E

Child maltreatment assessment capability E E

Injury prevention and community outreach programs (pediatric trauma E E

education programs)

Pediatric trauma research E D

Minimum number of annual trauma admissions of children younger than 15 200 100
years

Pediatric trauma performance improvement program E E

E: expected; D: desired.

Reproduced with permission from: Committee on Trauma. Resources for optimal care of the injured patient, 6th
edition. American College of Surgeons. Chicago, Illinois, 2014. Copyright © 2014 American College of Surgeons.

Graphic 66042 Version 2.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 12/15
18/10/2016 Classification of trauma in children ­ UpToDate

Trauma triage scoring systems for children

Revised trauma score* Pediatric trauma scoreΔ

Clinical Parameter Clinical Parameter Parameter Category Score

Score
Parameter Category
Weight (kg) ≥20 2
RR 10­24 4
10­20 1
25­35 3
<10 ­1
>35 2
Airway Normal 2
<10 1
Maintainable 1
0 0
Unmaintainable ­1
SBP >90 4
SBP ≥90 2
70­90 3
50­90 1
50­69 2
<50 ­1
<50 1
Central nervous Awake 2
0 0 system
Obtunded/Loss of 1
GCS 14­15 5 consciousness

11­13 4 Coma or decerebrate ­1

8­10 3 Open wound None 2

5­7 2 Minor 1

3­4 1 Major/penetrating ­1

Skeletal None 2

Closed fracture 1

Open/multiple fractures ­1

* The revised trauma score utilizes respiratory rate, systolic blood pressure, and Glasgow coma score. Unlike the trauma
score, it does not include subjective variables such as respiratory effort and capillary refill. The revised trauma score is
the sum of the values given for each parameter. Triage to a trauma center is recommended for patients with a score of
≤11.
Δ The pediatric trauma score is the sum of the values given for each parameter. Triage to a trauma center is
recommended for patients with a score of ≤8.

Adapted with permission from Furnival, RA, Schunk, JE. Pediatr Emerg Care 1999; 15:215.

Graphic 52562 Version 1.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 13/15
18/10/2016 Classification of trauma in children ­ UpToDate

Glasgow Coma Scale and Pediatric Glasgow Coma Scale

Glasgow Coma
Sign Pediatric Glasgow Coma Scale [2] Score
Scale [1]

Eye Spontaneous Spontaneous 4

opening
To command To sound 3

To pain To pain 2

None None 1

Verbal Oriented Age­appropriate vocalization, smile, or orientation to sound, 5

response interacts (coos, babbles), follows objects

Confused, Cries, irritable 4

disoriented

Inappropriate words Cries to pain 3

Incomprehensible Moans to pain 2

sounds

None None 1

Motor Obeys commands Spontaneous movements (obeys verbal command) 6

response
Localizes pain Withdraws to touch (localizes pain) 5

Withdraws Withdraws to pain 4

Abnormal flexion to Abnormal flexion to pain (decorticate posture) 3

pain

Abnormal extension Abnormal extension to pain (decerebrate posture) 2

to pain

None None 1

Best total score 15

The Glasgow Coma Scale (GCS) is scored between 3 and 15, 3 being the worst, and 15 the best. It is composed of
three parameters: best eye response (E), best verbal response (V), and best motor response (M). The components
of the GCS should be recorded individually; for example, E2V3M4 results in a GCS of 9. A score of 13 or higher
correlates with mild brain injury; a score of 9 to 12 correlates with moderate injury; and a score of 8 or less
represents severe brain injury. The pediatric Glasgow coma scale (PGCS) was validated in children two years of
age or younger.

Data from:
1. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet 1974; 2:81.
2. Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the pediatric Glasgow coma scale in
children with blunt head trauma. Acad Emerg Med 2005; 12:814.

Graphic 59662 Version 11.0

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 14/15
18/10/2016 Classification of trauma in children ­ UpToDate

Contributor Disclosures
Tom Brazelton, MD, MPH, FAAP Nothing to disclose Ankush Gosain, MD, PhD, FACS, FAAP Nothing to
disclose Richard G Bachur, MD Nothing to disclose James F Wiley, II, MD, MPH Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy

https://www.uptodate.com/contents/classification­of­trauma­in­children/print?source=search_result&search=trauma%20pediatric&selectedTitle=7~150 15/15