PARAMEDIC JUDGMENT OF THE NEED FOR TRAUMA TEAM ACTIVATION FOR PEDIATRIC-PATIENTS

Objective: To determine the value of paramedic judgment in determining the need for trauma team activation (TTA) for pediatric blunt trauma patients. Methods: A prospective, observational study was conducted at the ED of Children's Hospital Medical Center of Akron between July 12 , 1996, and February 28, 1997, in cooperation with Akron Fire Departme nt emergency medical technician-paramedics (EMT-Ps). The ED provides o n-line and off-line medical control for pediatric transports. Patients with minor or no identifiable injuries are released at the scene with the instructions to see a physician. The remainder are transported to the ED. The decision for TTA is based on ED trauma protocols as well as emergency physician judgment of injury severity in combination with the judgment of the treating paramedic. During the study, EMT-Ps were asked (before physician input) whether, based solely on their judgmen t, a patient needed TTA. Patients 0-14 years old who were involved in motor vehicle crashes, bike crashes, or falls from a height of >10 fee t were included in the study. TTA was defined as necessary if the pati ent was admitted to the intensive care unit (ICU) or operating room (O R) for nonorthopedic surgical procedures. Out-of-hospital, ED, and hos pital records were reviewed. Coroners' records as well as medical reco rds of all trauma admissions during the study period were reviewed to ensure that the patients released at the scene were not mistriaged. Re sults: One hundred ninety-two patients met study criteria. Eighty-five patients (44%) were transported to the ED, of whom 12 had TTA. EMT-Ps requested TTA for 10 of these patients, and 2 patients had TTA per ED trauma protocol. Two of the patients who were judged by EMT-Ps to nee d TTA were admitted to the ICU/OR, and neither of the patients identif ied by ED trauma protocol to require TTA were admitted to the ICU/OR. Two initially stable patients who did not have TTA deteriorated after arrival to the ED. Both were admitted to the ICU. The sensitivity and specificity of paramedic judgment of the need for TTA for pediatric bl unt trauma patients were 50% (95% CI 9.2-90.8) and 87.7% (95% CI 78.0- 93.6), respectively. The positive and negative predictive values were 16.7% (95% CI 2.9-49.1) and 97.3% (95% CI 89.6-99.5). None of the pati ents released at the scene was mistriaged based on the review of the c oroners' and trauma admission records. Conclusion: Results of this inv estigation indicate that a small percentage of pediatric blunt trauma patients require TTA. EMT-P judgment alone of the need for TTA for ped iatric blunt trauma patients is not sufficiently sensitive to be of cl inical use. The low sensitivity is explained by the deterioration in t he clinical condition of 2 initially stable patients. The paramedic di sposition decisions from the scene were always accurate. Nontransport by emergency medical services (EMS) may be acceptable in some uninjure d pediatric trauma patients. Injured pediatric trauma patients who app ear to be stable may deteriorate shortly after injury. However, if a p ediatric patient appears injured, transport from the scene and examina tion by a trauma specialist are needed. Finally, the role of paramedic judgment must be further defined by larger studies with urban, rural, and suburban EMS systems before it can be used as a sole predictor of TTA.