[Assessment of prehospital injury severity in children: challenge for emergency physicians].

BACKGROUND: The prognosis of polytraumatized patients is dependent on the quality of emergency room (ER) management and a smooth transition from prehospital to ER therapy is essential. The accurate assessment of prehospital injury severity by emergency physicians influences prehospital therapy and level of care of the destination hospital. It also helps to ensure that medical resources are immediately available. Overestimation of injury severity wastes resources and underestimation puts patients at risk. The assessment of prehospital injury severity in adults is unreliable. In children, the assessment of injury severity seems to be even more challenging.
MATERIALS AND METHODS: For the comparison of the prehospital documented injury severity and injury severity diagnosed after the ER phase, the injury severity score (ISS) and trauma-ISS (TRISS) were calculated. The TRISS consists of the ISS and the revised trauma score (RTS). All diagnoses of the prehospital and admission charts were collected and an injury severity was allocated according to the abbreviated injury scale (AIS). The concordance of the injury severity within different tolerances was evaluated. A tolerance of the prehospital documented injury severity of more than ± 25 % to the injury severity calculated after ER diagnostics was considered as overestimation or underestimation. The concordance of the prehospital documented diagnosed injury severity and the severity diagnosed after the ER phase of different body regions according to the AIS was evaluated. The documented mechanism of injury in the emergency physician protocol was judged as being detailed, satisfactory or poor.
RESULTS: The results showed that 69 % of the children reached the ER during on-call hours. Furthermore 92 % of the children reached the ER during the daytime between 08.00 h and 20.00 h. The transportation of 25 % of the children was on a private basis. The mean ER-ISS was 10 points (range 1-57). In 42 % of cases the ISS of the emergency physician protocol within a tolerance of ± 25 % was concordant with the ER-ISS. According to this criterion in 38 % of cases an overestimation of the assessment of the injury severity of the emergency physician was found and in 20 % an underestimation. Within a tolerance of ± 75 % based on the ER-ISS, the ISS of the emergency physician protocol was concordant in more than half of the cases (52 %). Using the TRISS with a tolerance of ± 25 % a concordance was observed in 46 % of the cases. Within a tolerance of ± 50 % based on the ER-ISS the ISS calculated after ER diagnostics was concordant in 50 % of the cases. A high concordance of the prehospital and hospital injury severity was found in the region of the face (75 %). The concordance in the body regions of the head, thorax, extremities and pelvis and soft tissue ranged between 43 % and 50 % of the cases. Of the children 38 % suffered a traffic accident, 52 % a fall of less than 3 m and 10 % of more than 3 m. The mechanism of injury was documented in detail in 70 % and satisfactory in 8 %.
CONCLUSIONS: The assessment of prehospital injury severity in children is unreliable. In order to evaluate injury severity the use of anatomical trauma scores alone is insufficient. The adequate documentation of the mechanism of injury implies that the mechanism of injury seems to play a relevant role in the assessment of prehospital injury severity. The unreliable assessment of the injury severity, the arrival in the ER in on-call hours and the private transport to the hospital is a challenge to the ER leader in trauma life support for children.