The P e d i a t r i c Trauma Score as a Predictor of Injury Severity
in the Injured Child
By Joseph J. Tepas, III, Daniel L. Mollitt, James L. Talbert, and Michael Bryant
Jacksonville, Florida
Q T h e ability of the Pediatric T r a u m a Score (PTS) to
accurately predict the degree of injury severity of the
injured child was assessed by comparing t w o separate
groups of pediatric trauma victims. T h e first group con-
sisted of 110 patients evaluated at a regional pediatric
trauma center whose data was collected and assessed by a
single investigator. The second group consisted of a similar
matched cohort of 120 patients from the National Pediatric
T r a u m a Registry whose data was collated from multiple
participating institutions. In both cases, a linear relation-
ship between PTS and Injury Severity Score (ISS) was
documented that was statistically significant to P < .001.
The linear regression coefficients of each group w e r e
similar as was the distribution of PTS and ISS. This study
documents the validity of the PTS as an initial assessment
tool and confirms its reliability as a predictor of injury
severity.
9 1 9 8 7 Grune & S t r a t t o n . Inc.
INDEX W O R D S : Pediatric trauma; injury severity.
R A U M A C O N T I N U E S to be the most common
T cause of death in the American pediatric popula-
tion. ~ This staggering fact becomes even more so when
considered in light of the consistent finding that
approximately 25% of non-central nervous system
(CNS) traumatic deaths are potentially preventable)
Because of this, trauma care has evolved into regional
systems in which designated centers of expertise are
available for the severely injured patient on an around
the clock basis. An obvious factor in the proper func-
tion of these systems is a means wherein correct field
assessment and triage can ensure that the appropriate
patient is referred to the appropriate facility. Thus, the
most severely injured patients will be afforded the
highest degree of trauma care expertise. Conversely,
minimally injured patients will not overwhelm the
resources of the more sophisticated trauma centers?
Field trauma scoring is, therefore, a major compo-
nent in proper function of a regional trauma care
From the Department of Surgery, Division of Pediatric Surgery,
University of Florida, Jacksonvi[le.
Supported in part by US Department of Education Grant No.
G-008300042.
Presented before the 17th Annual Meeting of the American
Pediatric Surgical Association, Toronto, Ontario, May 14-17,
1986.
Address reprint requests to Joseph J. Tepas, III, MD, Division of
Pediatric Surgery, University Hospital of Jacksonville, 655 W
Eighth St, Jacksonville, FL 32209.
9 1987 by Grune & Stratton, Inc.
0022-3468/87/2201-0005503.00/0
14
system. Many field scoring systems have been devel-
oped over the past few years, none of which have been
consistently reliable, accurate, and easily employ-
able. 4~ Moreover, there have been no trauma scoring
systems specifically developed for use in triage of the
injured child. Because of this, the Pediatric Trauma
Score (PTS) was developed as a means of providing
rapid accurate assessment of the injured child in a
manner that would insure comprehensive initial evalu-
ation. It is a scoring system that includes six common
determinants of clinical condition in the injured child.
Each of the six determinants is assigned a grade
consisting of either + 2 (minimal or no injury), + 1
(minor or potentially major injury), or - 1 (major or
immediate life-threatening injury). The scoring system
is arranged in a manner compatible with standard
advanced trauma life support protocol and thereby also
provides a quick assessment scheme (Table 1).7
As increased clinical data concerning trauma care
has become available, the Injury Severity Score (ISS)
was developed as a retrospective method for numeri-
cally categorizing the overall severity of injury? Previ-
ous reports have documented the direct correlation
between ISS and mortality. This study was designed to
assess the ability of the PTS to predict ISS in the
injured child.
MATERIALS AND METHODS
Two groups of injured children were assessed. For both groups,
the admission PTS was plotted against the ISS calculated at
discharge or autopsy. The regression coefficient was calculated for
the distribution of points and then analyzed for significance.
Group I consisted of 110 multiply injured encountered in the
University of Florida Jacksonville Pediatric Trauma Unit during the
6 months extending from April 1, 1985 through Septembe 30, 1985.
There were 78 males and 32 females with a mean age of 9.8 years.
Mean PTS was 9.5 points. Mean ISS was 9.6. Mean number of
diagnoses per patient utilized for calculation of the ISS was 2.8.
Mortality for this group was 3%.
Group II consists of the first 120 patients (80 male, 40 female)
entered into the National Pediatric Trauma Registry. The National
Pediatric Trauma Registry is a multiinstitutional study begun on
April 1, 1985 and consisting of 33 participating institutions distrib-
uted throughout the United States and Canada. Each institution
submits blinded data to a central computer office located at Tufts
New England Medical Center. This data, submitted on a standard
form enables blinded calculation of admission PTS as well as
analysis of ISS. In this manner, both the PTS and the ISS of each of
these children are derived in an objective manner with no foreknowl-
edge of possible mitigating circumstances. This particular group of
120 children represents the first group of records completed ade-
quately to allow analysis. For this group, mean age was 8.6 years,
Journal of Pediatric Surgery, Vo122, No 1 (January), 1987: pp 14-18
THE PEDIATRIC TRAUMA SCORE AND INJURY SEVERITY 15

SO-
Table 1. Pediatric Trauma Score
70-
Category

Component + 2 + 1 - 1 60-

Size >-20 kg 10-20 kg <10 kg

SO-
Airway Normal Maintainable Unmaintainable
Systolic BP --<-90 mmHg 9 0 - 5 0 mmHg < 5 0 mmHg A0-
CNS Awake Obtunded/LOC Coma/decerebrate
Open wound None Minor Major/penetrating
Skeletal None Closed fracture Open/multiple
fractures
Sum total points

o , n , q p r~ r ~ , ~r?q . . . . . .
mean PTS was 9.0 points, mean ISS was 12.7, and mean number of -e-5--4--3-2--1 0 1 2 3 4 S 6 7 S g 10 11 12
diagnoses used to calculated ISS was 2.4. The mortality rate for this P E D I A T R I C T R A U M A& S CC O R E
Jacklonvllle ~ Notional
group was 7%. Figures 1, 2, and 3 illustrate the distribution of age,
PTS, and ISS of both groups.
Fig 2. Pediatric Trauma Score Distribution.
RESULTS

The regression coefficients calculated from the dis- and potentially limited physiologic reserve, represents
tribution of plots of PTS v ISS in groups I and II were a greater threat of morbidity and mortality for a given
- 3 . 5 0 and - 3 . 7 7 , respectively (Figs 4 and 5). There injury than older and larger counterparts.
was no statistically significant difference in this rela- Airway status is another differentiating factor, pri-
tionship between the groups. (T test P > .5). A marily because of its central importance to survival as
decreasing PTS was directly associated with an well as the need for adequate management as correct
increasing ISS (P < .001). Within this distribution was initial treatment for other organ system injuries. The
an obvious threshold occurring at a PTS of six, below assessment system considers not so much the status of
which injury severity increased precipitously as did the airway on initial evaluation as much as a composite
potential for mortality. The mean ISS for children of the airway status and initial management required
whose PTS was > 6 was 6 points, while that for those to protect it. Specifically, a child whose airway is
with a PTS <6 rose to 30 points. completely within normal limits and requires no addi-
tional supportive measures is categorized as a +2. A
DISCUSSION
child whose airway is partially obstructed and who
Appropriate triage of the multiply injured child requires simple measures for protection such as head
mandates not only accurate initial assessment, but also positioning, oral airway, or mask oxygen delivery is
an appreciation of those differences in pediatric physi- categorized as a + 1. The child whose airway requires
ology affecting potential morbidity. The first obvious more definitive management and demands a degree of
differentiating feature in the pediatric trauma patient expertise that will allow intubation, cricothyroidosto-
is size. The primary purpose of the size categorization my, or other invasive procedures, is categorized as an
in the PTS is the selection of the very small child who, unmaintainable or - 1 category.
by nature of his increased body surface to volume ratio
SO
20
19
70
18
17
t6 S0-
15
14
50-
13

I I!I!
12
11 40-
10 N
9 %
.50
8-
7-
6- 20,
5-
4
10 1
3-
2-
1 -
0
o ~
5 10 lS 20 25 ..~0 35 40 45 50 S5 60 SS 70 75
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18
SLrVERITY ORE:
J . c k . . . . 111NJURY r~ Nat, ....
JacklonvHle AGE: ( y r ~ ) [ ~ National

Fig 1. Age distribution. Fig 3. Injury Severity Distribution.

16 TEPAS ET AL

110 Children the most important factor in determining initial neuro-

80
70-
60
50
40
30 o o
20
lO
o , i, ' -'2 J J F , , ,
-6 -4 2 4
PEDIATRIC TRAUMA SCORE
Fig 4. Jacksonville Pediatric Trauma Registry.
The child's systolic blood pressure is assessed to
provide an initial evaluation of cardiovascular status.
A systolic blood pressure of 90 m m H g or greater
suggests that adequate circulating volume is present at
that time. Likewise, a child whose systolic blood pres-
sure is 50 m m H g or less, regardless of size, is accu-
rately considered to be in immediate jeopardy for
evolving hemorrhagic shock. A child whose blood
pressure falls between 90 and 50 m m H g may be in
early stages of hypotension or hemorrhage, or may
have a blood pressure appropriate for age. This group
obviously represents a high risk group and, as such, is
designated as a + 1 category. In the absence of ade-
quate sized blood pressure cuffs, the blood pressure
assessment can be substituted by scoring palpation of
the pulse at the wrist as + 2, palpation of the pulse in
the neck or groin as + 1, and absence of a palpable
pulse as a - 1.
The field evaluation of the child's C N S orients itself
specifically to level of consciousness. While the Glas-
gow Coma Score is an effective initial neurologic
assessment tool, in reality, the level of consciousness is
logic status. 9'1~The child who has sustained no loss of
consciousness and is fully awake is graded as + 2, while
a child who is totally nonresponsive is graded as - 1 .
Any child who has any degree of obtundation or who
has sustained a loss of consciousness no matter how
transient, is graded + 1 indicating potential risk.
o
Because of the frequency of associated skeletal
o 8
injuries with blunt pediatric trauma and their additive
o"~,,., fl o o effect on overall morbidity, an assessment of both the
skeletal and cutaneous systems is included in this
p , , , i i ,
scoring scheme. The child who has no evidence of a
6 8 10 12
fracture is graded as + 2. A child with a single closed
fracture or a suspicion thereof is graded as + 1. A child
who has multiple closed fractures or any open fracture
is categorized as - 1. In regards to cutaneous injuries,
the child who presents with absolutely no evidence of
external trauma is graded as + 2, while the child who
presents with abrasions or minor cutaneous injuries is
graded as +1. Any child who presents with any
penetrating injury regardless of location or a major
avulsion or laceration is graded as - 1.
The PTS is then the arithmetic sum of the grade
assigned to each of the above six categories. It can
range between a - 6 and + 12 and, when utilized in the
manner described in Table 1, can provide a compre-
hensive assessment protocol modeled after the Ameri-
can College of Surgeons' Advanced T r a u m a Life Sup-
port Course assessment scheme. 7
Once appropriately assessed, proper management of
the severely injured child mandates referral to a center
that has the necessary capabilities to handle many of
the special requirements of pediatric care. 11 While
each individual injury may not cause significant
increase in potential mortality, the combination of
them, especially if inadequately or incorrectly handled,
can provide a significant increase in morbidity, hospi-
talization, and long-term rehabilitative needs. 12 Effec-

80-
120 Children
80-
70
79"
SO
60- MEANl.s.s.
50 o ,0
50-
~( 4O +-
+. ~l],s.s.
6

30-
o o
g
20- o o
o o o
1 I
8 o o
a
10-
a

0 6
P I -4 2 o ' ~ ' ~ ' ~ ' -' ' ~'o 12
--4 --2 2 4 6 8 I0 12
PEDIATRIC TRAUMA SCORE
P[OIATRIC TRAUMA SCORE o Notlonol + Jk~:klmnvllle

Fig 5. National Pediatric Trauma Registry. Fig 6. Comparison of PTS vlSS.

THE PEDIATRIC TRAUMA SCORE AND INJURY SEVERITY
tive triage of the injured child thus requires consider-
ation of both morbidity and mortality.
Accurate determination of the prognostic value of
the PTS necessitates an accepted standard for compar-
ison. The ISS is an established effective tool in the
analysis of trauma care. The documented relationship
between ISS and mortality provides the valid basis for
evaluating the utility of the PTS as a method of
predicting not only injury severity, but subsequent
outcome in the pediatric trauma victim.
This study documents the inverse linear relationship
between the PTS and the ISS. This relationship was
constant in both groups evaluated (Fig 6). In group I,
all patients were treated at the same facility, and the
data concerning each patient collected and calculated
by a single investigator (J.J.T.). In group II, all of the
components utilized in the determination of the PTS
and the ISS were provided from objective assessment
by a variety of observers. The constancy of the rela-
tionship of the PTS to ISS in both groups further
confirms the effectiveness and utility of the PTS as a
predictor of pediatric injury severity. Of perhaps
greater importance is the threshold value of 6 in the
PTS scoring system, below which the mean ISS was 30
REFERENCES
1. Gallagher SS, Finison K, Guyer B, et al: The incidence of
injuries among 87,000 Massachusetts children and adolescents.
AJPH 74:1340-1347, 1984
2. Cales RH, Trunkey DD: Preventable trauma deaths. JAMA
254:1059-1063, 1985
3. Champion HR, Sacco W J, Lepper RL, et al: An anatomic
index of injury severity. J Trauma 20:197-202, 1980
4. Champion HR, Sacco W J, Hannan DS, et al: Assessment of
injury severity: The triage index. Crit Care Med 8:201-208, 1980
5. Kirkpatrick J, Youmaris R: Trauma index: An aid in the
evaluation of injury victims. J Trauma 11:711, 1971
6. Gormican SP: CRAMS scale field triage of trauma victims.
Ann Emerg Med 11:132-135, 1982
Discussion
M.L. Ramenofsky (Mobile, AL): In Dale Johnson's
Presidential Address yesterday, he exorted this organi-
zation to provide data and information that when
looked at over time will significantly improve the
health care provided and survival of children. I think
that this particular paper, which Dr Tepas has worked
so hard on and provided such good data on, is just such
an entity. The fact that the pediatric trauma score is
now being used on a nationwide basis is extremely
helpful, will provide us with specific accurate informa-
tion in terms of severity of injury, but it will also do one
other major thing for those of you who are interested in
trauma. It gives you a method to have the most
17
points (Fig 6). When the mortality rate for each PTS
cohort was evaluated, it likewise demonstrated that
children with a PTS of 6 and below have an increased
potential for mortality as well as morbidity. Moreover,
the mortality rate for children whose PTS fell below 2
was 100%.
By providing guidelines for rapid assessment and an
arithmetic number that is predictive of injury severity,
the PTS can be used for triage and referral of the
patient to the appropriate center. It is also a common
descriptor that will allow accurate transmission of
information concerning degree of injury from one
element to another in the typical regional trauma
referral system. Finally, it may provide a means of
objective quality assurance. On periodic review of the
scores obtained on injured children in regard to mortal-
ity experienced, it is easy to identify deaths that seem
inappropriate or potentially preventable.
In summary, the PTS is a quick and simple mecha-
nism wherein the child can be rapidly assessed and
accurately evaluated. In this regard, it serves as an
efficient rescue tool that will hopefully help ensure that
the injured child receives appropriate comprehensive
therapy as expeditiously as possible.
7. American College of Surgeons Committee on Trauma Instruc-
tor Syllabus of Advanced Trauma Life Support. Copyright 1984
8. Baker SP, O'Neill B: The injury severity score: An update. J
Trauma 16:882-885, 1976
9. Young B, Rapp RP, Norton RN, et al: Early prediction of
outcome in head-injured patients. J Neurosurg 54:300-303, 1981
10. Stablein DM, Miller JD, Choi SC, et al: Statistical methods
for determining prognosis in severe head injuries. J Neurosurg
6:243-248, 1980
11. Seidel JS, Horbein M, Yoshiyama K, et al: Emergency
medical services in the pediatric patient: Are the needs being met?
Pediatrics 73:769-772, 1984
12. Hailer JA, Shorter N, Miller DM, et al: Organization and
function of a pediatric trauma center. J Trauma 23:691-696, 1983
severely injured children, the children who have the
highest propensity for dying, to be sent to your institu-
tion rather than to anywhere else general down the
street which may or may not have pediatric expertise in
their hospital. What methods do you propose to val-
idate this very important study? Can the score be
validated? What is the patient number that we need?
How long before we will have that result?
M. Eichelberger (Washington, DC): I agree with Dr
Tepas and Dr Ramenofsky that this is an important
area, the prehospital triage of patients. Several things I
think have to be addressed. First of all, there are some
questions about the operational definitions that are
18
used to derive the pediatric trauma score. Second, I
think of extreme importance is the score reliability,
meaning that the doctors, paramedics, and E M T s in
different areas of the country will be using the same
weighted values. The operational definitions become
important because if we are going to add to established
methodology, for example the issue of fractures
whether they be epiphyseal or the definition of obtun-
dation, then I think we have got to be very specific
about what we are talking about because it is very easy
to add a bias into this whole concept. The other thing I
think that I would like to know is how many patients
had an injury severity score of 16 or above, which is
accepted presently in the community at large as being
a patient score that requires triage to a trauma center?
Also I would like to know if you have given any thought
to the potential of over or under triage using this
particular methodology?
J.A. Haller (Baltimore, MD): I got two messages
from this paper. One is that it is possible to modify our
scoring system now using your data and observations
into a new type of score that will be helpful to us
specifically for children. We know that the one for
adults has been helpful. The second message is that it
seems possible to do this in the field, and I think
everyone here has been waiting for something like that
because we need to be able to give simplified informa-
tion and a system to our E M T s so that children will be
brought into appropriate centers; and if that can be
done at the site then I think we have an important tool.
A question I have about the score itself is that it looks
to me like those patients who do not have head injuries
could be very nicely served with this score because it
would select them. But for those who have head
injuries, if I read the data correctly, it looks to me like
that is so important and weighted that if there is a head
injury, you do not need to worry about other injury. I
would like to ask you if you have look at it from a
standpoint of those children who have severe head
TEPAS ET AL
injuries and if that is not enough to determine that they
should come into a specific pediatric trauma center?
J.J. Tepas (closing): I thank all the discussants.
Taking your questions in lumps, no trauma score will
be any better than the ability of the individual who first
encounters the patient to use it and use it effectively.
Therefore, I will answer the question about validation
and answer Dr Eichelberger's question about score
utilization by different components. The score is
designed, if you will, as a microapproach similar to the
advanced trauma life support protocols advocated by
the Committee on T r a u m a of the American College of
Surgeons. Paramedics, EMTs, and emergency medical
physicians who are our referring physicians have
accepted this score very well. How are we documenting
that? We presently have a countrywide study going on
right now where we are looking at the score assigned in
the field and the score assigned in the emergency room.
We are relating that to the injury severity score at
discharge or autopsy. Our initial evaluation of this
data, and it is very preliminary, is that the scores
match to a degree of within 1 point. In answer to the
specific question about the distribution of ISS, approx-
imately 30% of the patients had an ISS >16. Specifi-
cally, the group distribution spiked in the 5 to 10
category and then dropped off logrythmically thereaf-
ter. In regard to Dr Haller's question about head
injury, there is no question that it plays a major role,
but there are two factors that we have to keep in mind.
First is the primary head injury that occurs at the
instant of impact, and second there is the morbidity
that occurs because of inadequate initial resuscitation,
inappropriate triage, and improper care. In reality, the
pediatric trauma score, if used correctly, can go no
higher than 7 for a child with a head injury. They get a
- 1 for the head and they should get a - 1 for the
airway. Our experience thus far has been that it has
been extremely effective.