Cohort Of Trauma Patients Research Articles

An Economic Evaluation of Venous Thromboembolism Prophylaxis Strategies in Critically Ill Trauma Patients at Risk of Bleeding

Critically ill trauma patients with severe injuries are at high risk for venous thromboembolism (VTE) and bleeding simultaneously. Currently, the optimal VTE prophylaxis strategy is unknown for trauma patients with a contraindication to pharmacological prophylaxis because of a risk of bleeding. Using decision analysis, we estimated the cost effectiveness of three VTE prophylaxis strategies-pneumatic compression devices (PCDs) and expectant management alone, serial Doppler ultrasound (SDU) screening, and prophylactic insertion of a vena cava filter (VCF) -- in trauma patients admitted to an intensive care unit (ICU) with severe injuries who were believed to have a contraindication to pharmacological prophylaxis for up to two weeks because of a risk of major bleeding. Data on the probability of deep vein thrombosis (DVT) and pulmonary embolism (PE), and on the effectiveness of the prophylactic strategies, were taken from observational and randomized controlled studies. The probabilities of in-hospital death, ICU and hospital discharge rates, and resource use were taken from a population-based cohort of trauma patients with severe injuries (injury severity scores >12) admitted to the ICU of a regional trauma centre. The incidence of DVT at 12 weeks was similar for the PCD (14.9%) and SDU (15.0%) strategies, but higher for the VCF (25.7%) strategy. Conversely, the incidence of PE at 12 weeks was highest in the PCD strategy (2.9%), followed by the SDU (1.5%) and VCF (0.3%) strategies. Expected mortality and quality-adjusted life years were nearly identical for all three management strategies. Expected health care costs at 12 weeks were Can$55,831 for the PCD strategy, Can$55,334 for the SDU screening strategy, and Can$57,377 for the VCF strategy, with similar trends noted over a lifetime analysis. The attributable mortality due to PE in trauma patients with severe injuries is low relative to other causes of mortality. Prophylactic placement of VCF in patients at high risk of VTE who cannot receive pharmacological prophylaxis is expensive and associated with an increased risk of DVT. Compared to the other strategies, SDU screening was associated with better clinical outcomes and lower costs.

WITHDRAWN: The Effects of Cirrhosis on Trauma Outcomes: An Analysis of the National Trauma Data Bank

Introduction A number of small retrospective studies have shown that cirrhosis is associated with increased mortality and poor outcomes in trauma. While these studies have provided useful insight into the management of this unique group of patients, their clinical utility has been limited by very small sample size. The purpose of this study was to examine the relationship between cirrhosis and clinical outcomes using a much larger cohort of trauma patients than has previously been reported. Methods Data were obtained from the National Trauma Data Bank from 1994 to 2005. Of the 884,700 patients who met inclusion criteria, 0.11% had a known diagnosis of cirrhosis ( n = 956). Information regarding demographics, injury severity, preexisting comorbidities, and presence or absence of laparotomy was collected. Primary outcome measures were mortality and pulmonary, hematologic, infectious, and cardiac complications. Age, injury severity, comorbidities, and laparotomy status were analyzed as independent variables using logistic regression. Results The overall mortality rate for patients with cirrhosis was more than four times higher than patients without cirrhosis (17.7% versus 4.4%, P P P Discussion Cirrhosis is a strong predictor of poor outcome in trauma patients, regardless of age, injury severity, or number of comorbidities, especially among those requiring trauma-related laparotomies. Furthermore, TRISS fails to accurately predict survival in this group of patients. This study is the largest of its kind and is powered to detect statistically significant differences for a wide variety of outcomes while controlling for potential confounders. We have confirmed many trends previously seen in smaller studies and provided new information regarding the frequency and proportions of complications seen in this unique population.

Prevalence of Pain in Patients 1 Year After Major Trauma

To describe the prevalence of pain in a large cohort of trauma patients 1 year after injury and to examine personal, injury, and treatment factors that predict the presence of chronic pain in these patients. Sixty-nine hospitals in 14 states in the United States. There were 3047 patients (10 371 weighted) aged 18 to 84 years who were admitted to the hospital because of acute trauma and survived to 12 months after injury. Pain 12 months after injury measured with the Chronic Pain Grade Scale. At 12 months after injury, 62.7% of patients reported injury-related pain. Most patients had pain in more than 1 body region, and the mean (SD) severity of pain in the last month was 5.5 (4.8) on a 10-point scale. The reported presence of pain varied with age and was more common in women and those who had untreated depression before injury. Pain at 3 months was predictive of both the presence and higher severity of pain at 12 months. Lower pain severity was reported by patients with a college education and those with no previous functional limitations. Most trauma patients have moderately severe pain from their injuries 1 year later. Earlier and more intensive interventions to treat pain in trauma patients may be needed.

Hyperkalemia After Packed Red Blood Cell Transfusion in Trauma Patients

Published analyses of clinical outcomes for patients requiring large-volume blood transfusion conflict with respect to the impact upon plasma potassium levels. We analyzed a cohort of trauma patients to ascertain the impact of component product transfusion upon plasma potassium values. We performed an observational analysis of previously, prospectively collected clinical data on 131 noncrush trauma patients undergoing resuscitation during the initial 12 hours after admission to a combat support hospital. Comparisons were made between those who received packed red blood cell (PRBC) transfusion and those who did not. Primary outcome was hyperkalemia (plasma potassium level >5.5 mmol/L). Ninety-six of one hundred thirty-one patients (73.3%) received PRBCs (mean number of PRBC units 11.2, range, 0-55.0). For transfusion versus nontransfusion patients, baseline plasma potassium value (3.7 +/- 0.57 mmol/L vs. 3.6 +/- 0.36 mmol/L, p = 0.22) rose significantly after transfusion (5.3 +/- 1.2 mmol/L, vs. 4.0 +/- 0.78 mmol/L, p < 0.001). During the study period, 38.5% of transfusion patients developed hyperkalemia, versus 2.9% of those who did not (p = 0.003). In multivariate logistic regression analysis, transfusion of greater than 7 units of PRBCs was independently associated with the development of hyperkalemia (RR 4.72, 95% CI 1.01-21.97, p = 0.048). Transfusion of other cell-based products, baseline base deficits, and plasma bicarbonate levels were not. Spearman's rank correlation coefficient for the relationship of number of transfused PRBC units to the highest recorded potassium value was 0.554 (p < 0.001). The predictive accuracy of the logistic regression model for hyperkalemia was 0.824 (95% CI 0.747-0.901, p < 0.001). Hyperkalemia is common after PRBC transfusion, and often severe. PRBC transfusion is independently associated with the development of hyperkalemia. The findings suggest the need for interventional studies examining the impact of alternative resuscitative approaches after severe trauma.

Reticulocyte counts and their relation to hemoglobin levels in trauma patients

In many trauma patients, blood loss is the major cause of anaemia. Subsequent increased production of red blood cells is reflected by increased reticulocyte numbers (R). Measurement of the R might be useful in predicting the recovery of hemoglobin (Hb), especially since current transfusion guidelines accept lower Hb levels. The value of the modern fully automated measurement of R in assessing recovery of Hb after blood loss has not been investigated in this context. We therefore investigated the temporal relation of Hb and R in a cohort of trauma patients.

Traumatismos torácicos graves. Revisión de 39 casos

To study the incidence and types of severe thoracic trauma in a cohort of pediatric polytrauma patients, compare cardiac contractility between patients with elevated troponin T levels and those with abnormal electrocardiogram (EKG) findings, and to analyze the value of thoracic computed tomography (CT) scan as a first investigation in patients with suspected thoracic trauma. We performed a 5-year retrospective study in a cohort of trauma patients with an injury severity score of >or=25. Thoracic trauma included pulmonary contusion, hemopneumothorax, large-vessel injury, myocardial contusion, and rib fracture. In all patients, EKG and determination of troponin T were performed at admission. Echocardiogram was performed in patients with troponin T levels>0.035 U/L (except in two patients, because the technique was not available) and abnormal EKG findings. A thoracic CT scan was performed in unconscious patients or when thoracic trauma was clinically suspected, as well as a simple thorax X-ray in the following 24 hours. Among 209 multiple-trauma patients, thoracic injuries where detected in 39 patients. The most frequent injury was pulmonary contusion. Echocardiogram was performed in 10 patients with high troponin levels, with abnormal findings in eight patients. The six patients with EKG alterations also had high troponin levels and pathological findings on echocardiogram. Thoracic CT scan was performed in 81 patients, with abnormal findings in 36 patients. Thoracic lesions were observed in simple X-ray in three patients who had not undergone CT scan. The most frequent thoracic trauma was pulmonary contusion. The results of echocardiogram were abnormal in 80 % of the patients with high troponin levels who underwent this examination. Thoracic CT scan was highly useful in suspected thoracic trauma.

Two Cohorts of Severely Injured Trauma Patients, Nearly Two Decades Apart: Unchanged Mortality But Improved Quality of Life Despite Higher Age

The care for trauma patients has undergone major changes during the last decades. Additionally, many injury prevention measures have been established. The objective of these efforts was to reduce the number of traumatic incidents and to reduce mortality and morbidity in injured patients. The aim of our study was to assess how these measures and improved care have altered trauma mechanisms, occurrence of injuries, treatment, and outcome in the trauma population treated at our trauma center. Two cohorts of trauma patients with an Injury Severity Score >15, treated at the University Medical Center Groningen were compared. The first cohort was treated from 1985 to 1990, the second cohort from September 2002 to January 2005. The annual mean number of severely injured patients increased by 76%. Fourteen percent more patients had sustained an injury at home. The mean age increased from 33 +/- 22 years to 41 +/- 23 years. The presence of severe head and neck injuries in the patients increased from 62% to 73%. Inhospital mortality remained unchanged at 25%. The outcome of survivors improved; 67% of patients made a moderate or good recovery versus 40% almost 20 years ago. Striking are the consequences of the aging of the Dutch population: an almost 10-year increase in mean age and a rise in severe head and neck injuries in the population treated at our trauma center. The unchanged mortality and improved outcome of survivors represented the enhanced trauma care.

The Impact of Prehospital Ventilation on Outcome After Severe Traumatic Brain Injury

Prehospital intubation has been challenged on the grounds that it predisposes to hyperventilation, which is detrimental after traumatic brain injury (TBI), and impairs venous return in patients with hypovolemia. We sought to determine the incidence of hyperventilation among a cohort of trauma patients undergoing prehospital intubation and the impact of ventilation on outcome after severe TBI. Data were prospectively collected for all intubated trauma patients transported directly from the field for a period of 14 months (n = 574). An arrival Pco2 <30 mm Hg was termed severe hypocapnea and considered a marker of hyperventilation. Patients with a Pco2 >45 mm Hg were considered severely hypercapneic. Targeted ventilation was defined as a Pco2 between 30 and 35 mm Hg based on the Brain Trauma Foundation guidelines. The rate of severe hypocapnea was 18% and women were more likely to be hyperventilated (p < 0.05). Patients with severe hypercapnia had higher Injury Severity Scores and were more likely hypotensive, hypoxic, and acidodic (p < 0.05). Patients in the targeted ventilation range were less likely to die than were those outside the range even after excluding the severe hypercapnea group (odds ratio, 0.57; 95% confidence interval, 0.33-0.99). This effect was even greater among patients with isolated TBI (odds ratio, 0.31; 95% confidence interval, 0.10-0.96). Targeted prehospital ventilation is associated with lower mortality after severe TBI.

Beta-Blocker Use is Associated With Improved Outcomes in Adult Trauma Patients

Beta-adrenoreceptor blocker (beta-blocker) therapy may improve outcomes in surgical patients by decreasing cardiac oxygen consumption and hypermetabolism. Because beta-blockers can lower the systemic blood pressure and cerebral perfusion pressure, there is concern regarding their use in patients with head injury. However, beta-blockers may protect beta-receptor rich brain cells by attenuating cerebral oxygen consumption and metabolism. We hypothesized that beta-blockers are safe in trauma patients, even if they have suffered a significant head injury. Using pharmacy and trauma registry data of a Level I trauma center, we identified a cohort of trauma patients who received beta-blockers during their hospital stay (beta-cohort). Trauma admissions who did not receive beta-blockers were in the control cohort. beta-blocker status, in combination with other variables associated with mortality, were placed in a stepwise multivariate logistic regression to identify independent predictors of fatal outcome. In all, 303 (7%) of 4,117 trauma patients received beta-blockers. In the beta-cohort, 45% of patients were on beta-blockers preinjury. The most common reason to initiate beta-blocker therapy was blood pressure (60%) and heart rate (20%) control. The overall mortality rate was 5.6% and head injury was considered to be the major cause of death. After adjusting for age, Injury Severity Scale score, blood pressure, Glasgow Coma Scale score, respiratory status, and mechanism of injury, the odds ratio for fatal outcome was 0.3 (p < 0.001) for beta-cohort as compared with control. Decreased risk of fatal outcome was more pronounced in patients with a significant head injury. beta-blocker therapy is safe and may be beneficial in selected trauma patients with or without head injury. Further studies looking at beta-blocker therapy in trauma patients and their effect on cerebral metabolism are warranted.

Variability of Trauma Transfer Practices among Non–tertiary Care Hospital Emergency Departments

To assess both the variability of interhospital trauma transfer practices and nonclinical factors associated with the transfer of injured patients from emergency departments (EDs) of non-tertiary care hospitals. The authors analyzed a retrospective cohort of trauma patients initially presenting to one of 42 non-tertiary care hospitals (Level 3 or 4 hospitals) and requiring admission or transfer from January 1998 to December 2003. Twenty-one clinical, demographic, and hospital-level variables were included in multivariable logistic regression models (outcome = ED transfer to a tertiary care hospital), with hospital and year included as fixed effects to adjust for clustering. Classification and regression tree analysis was used to determine the importance of different covariates in predicting whether or not a patient was transferred from the ED. Included in the analysis were 10,176 persons, of whom 3,785 (37%) were transferred to a tertiary care hospital from the ED. The hospital of initial presentation was the factor of greatest importance in predicting transfer, and there was substantial variability in transfer practices between hospitals. Several additional nonclinical variables were independently associated with transfer, including type and level of hospital, patient age, increasing distance from the nearest higher-level hospital (a measure of geographic isolation), and the patient's insurance status (particularly among Level 3 hospitals). The non-tertiary care hospital of initial presentation is the strongest predictor for whether an injured patient is transferred to a tertiary center from the ED. There is substantial variability in transfer practices between hospitals after accounting for important clinical factors, and several nonclinical variables are independently associated with transfer.

Comparison of respiratory rate and peripheral oxygen saturation to assess severity in trauma patients

Physiological variables are important in the assessment of trauma patients. The role of respiratory rate (RR) and peripheral oxygen saturation (SpO(2)) remains a matter of debate. We therefore assessed the role of RR and SpO(2) in predicting death in trauma patients. Prospective analysis of a multicentric cohort of trauma patients in 2002. A cohort of 1,481 trauma patients cared for by a prehospital mobile intensive care unit (mean age 38 +/- 17 years, 91% blunt and 9% penetrating trauma). None. Systolic arterial blood pressure, heart rate, Glasgow coma scale, RR and SpO(2) were recorded and the Injury Severity Score (ISS) and Trauma Related Injury Severity Score (TRISS) calculated. TRISSn was obtained by neutralizing RR. Systolic arterial blood pressure (99.9%), heart rate (99.9%), and Glasgow coma scale (99.3%) were recorded in most patients, but not RR (63%) and SpO(2) (67%). In patients with both RR and SpO(2) recording (n=675), the discrimination and calibration of TRISS was not significantly modified when RR was neutralized. Whatever the manner of expressing RR and SpO(2) (continuous, five classes, dichotomous), none was significant in predicting mortality with TRISSn. Initial SpO(2) was abnormal (< 90%) and recorded again at the hospital in 97 patients, and the proportion of patients with a non-measurable SpO(2) significantly decreased (8 vs. 42%, p < 0.001) and measurable SpO(2) markedly increased (median 99 vs. 85%, p < 0.001). Respiratory rate and SpO(2) do not add significant value to other variables when predicting mortality in severe trauma patients.

Heart Rate Variability and Its Association with Mortality in Prehospital Trauma Patients

Accurate prehospital triage of trauma patients is difficult, especially in mass casualty situations. Accordingly, the U.S. Military has initiated a program directed toward improving noninvasive prehospital triage algorithms based on available physiologic data. The purpose of this study was to assess heart rate variability and its association with mortality in prehospital trauma patients. Trauma patients without significant head injury requiring helicopter transport were identified from a retrospective research database. An equal number, unmatched sample of patients who lived were compared with those who died (n = 15 per group). All patients were transported to a single Level I urban trauma center. The primary independent variable was mortality. Patients with Abbreviated Injury Scale head scores >2 were excluded from the analysis, so that the effects seen were based on hemorrhagic shock. Age, sex, Glasgow Coma Scale score (GCS), blood pressure, pulse pressure, pulse, intubation rate, SpO2, mechanism of injury, transport time, and time of death after admission were recorded. R-waves from the first available 120 seconds of usable data were detected from normal electrocardiograms and heart rate variability was assessed. Patients who died demonstrated a lower GCS (7.9 +/- 1.4 versus 14.4 +/- 0.2; p = 0.0001) and higher intubation rate (53% of patients who died versus 0% patients who lived). Pulse rate, arterial pressure, and SpO2 were not distinguishable statistically between groups (p = 0.08), but pulse pressure was lower in patients who died (39 +/- 3 versus 50 +/- 2 mm Hg; p = 0.01). Compared with patients who lived, those who died had lower normalized low-frequency (LF) power (42 +/- 6 versus 62 +/- 4 LFnu; p = 0.009), higher high-frequency (HF) power (42 +/- 3 versus 32 +/- 3 HFnu; p = 0.04) and higher HF-to-LF ratio (144 +/- 30 versus 62 +/- 11nu; p = 0.01). With absolute HF/LF adjusted for GCS, the intergroup variance accounted for by HF/LF was reduced to 6% (p = 0.16). Analysis of heart rate variability provides insight into adequacy of autonomic compensation to severe trauma. In our cohort of trauma patients, low pulse pressures coupled with relatively higher parasympathetic than sympathetic modulation characterized and separated patients who died versus patients who survived traumatic injuries when standard physiologic measurements are not different. These data do not suggest advantages of heart rate variability analysis over GCS scores, but suggest future possibilities for remote noninvasive triage of casualties when GCS scores are unattainable.

The Quality of Surgical Resident Interpretation of After-Hour CT Scans of the Head and Abdomen in Trauma

Computed tomography (CT) is an important diagnostic tool in the evaluation of trauma patients. Accurate interpretation of CT scans remains critical in decision-making and the resultant quality of care. In our study, the records of a consecutive cohort of trauma patients who underwent after-hour CT scans of the head and abdomen between January 23 and June 30, 2004, at Kern Medical Center were reviewed. Three hundred thirty-five CT studies were collected in 211 patients. The accuracy of resident interpretation was 92.8 per cent for abdominal and 97.5 per cent for head CT. Resident readings were 93.2 per cent sensitive and 95.4 per cent specific with a positive predictive value of 85.2 per cent and a negative predictive value of 98.0 per cent. There were 16 (4.8%) instances of interpretation discrepancy between the surgical resident and attending radiologist. Most differences occurred in the evaluation of abdominal CT. In no instance was management or outcome for these patients affected. This data demonstrates a low error rate in resident interpretation of after-hour CT scans of the head and abdomen in trauma, but there remains a need for the continued review of the quality of surgical resident radiologic interpretation in situations when an attending radiologist is not immediately available.

The PreTransport Index (PTI): a prospective validation

Many patients injured in rural areas require urgent transport to a regional trauma center. Predicting patients who require rapid transport is difficult. Determining the best mode of transport for trauma patients—fixed wing, rotor, or ground ambulance—can also be a difficult decision. Our institution developed the PreTransport Index (PTI) from a retrospective cohort of trauma patients. The objective of this study is to prospectively validate the sensitivity and specificity of the PTI Score in identifying rural trauma patients requiring rapid transport to a trauma center using a cumulative endpoint of mortality, time to surgery < 4 hours, ICU LOS > 48 hours, and mechanical ventilation > 24 hours.

Improving risk adjustment in critically ill trauma patients: the TRISS-SAPS Score.

To test (a) the prognostic performance of TRISS and SAPS II scoring systems in a large sample of trauma patients admitted to Austrian ICUs, and (b) the hypothesis that the prognostic performance of TRISS could be improved by adding SAPS II. Prospective multicenter cohort study comprising 5,538 trauma patients out of 35,637 patients admitted to 31 ICUs in Austria over a 4-year period. Separately, TRISS and SAPS II showed lack of calibration in the cohort of trauma patients. The database was then split into two equal samples, development and validation. Using the development sample, a new scoring system was developed, with vital status at hospital discharge as the dependent variable and TRISS and SAPS II as independent variables. The prognostic performance of the new TRISS-SAPS system was then assessed in the validation cohort: Both, discrimination (as shown by area under the ROC curve), and calibration (using Hosmer-Lemeshow goodness-of-fit statistics) was excellent. We improved risk adjustment in critically ill trauma patients by combining TRISS and SAPS II. This new scoring system might aid in evaluating and comparing specialized trauma ICUs.

Prospective validation of clinically important changes in pain severity measured on a visual analog scale

Background: In a landmark hypothesis-generating study, Todd et al found that a difference of approximately 13 mm (95% confidence interval [CI] 10 to 17 mm) on a visual analog scale (VAS) represented the minimum change in acute pain that was clinically significant in a cohort of trauma patients. Study Objective: We test the hypothesis that the minimum clinically significant change in pain as measured by the VAS in an independent, more heterogeneous validation cohort is approximately 13 mm. Methods: This was a prospective, observational cohort study of adults presenting to 2 urban emergency departments with pain. At 30-minute intervals during a 2-hour period, patients marked a VAS and were asked if their pain was “much less,” “a little less,” “about the same,” “a little more,” or “much more.” All data were obtained without reference to prior VAS scores. The minimum clinically significant change in pain was defined a priori as the difference in millimeters between the current and immediately preceding VAS scores when “a little more” or “a little less pain” was reported. Results: Ninety-six patients enrolled in the study, providing 332 paired pain measurements. There were 141 paired measurements designated by patients as “a little less” or “a little more” pain. The mean clinically significant difference between consecutive ratings of pain in the combined “little less” or “little more” groups was 13 mm (95% CI 10 to 16 mm). The difference between this finding and that of Todd et al was 0 mm (95% CI –4 to 4 mm). Conclusion: These data are virtually identical to previous findings indicating that a difference of 13 mm on a VAS represents, on average, the minimum change in acute pain that is clinically significant. [Gallagher EJ, Liebman M, Bijur PE. Prospective validation of clinically important changes in pain severity measured on a visual analog scale. Ann Emerg Med. December 2001;38:633-638.]

Cervical spine screening with CT in trauma patients: a cost-effectiveness analysis.

To investigate the cost-effectiveness of computed tomography (CT) relative to radiography for cervical spine screening in trauma patients. A decision analysis model was constructed to compare the incremental cost-effectiveness of radiography and CT as primary cervical spine screening modalities in trauma patients. Analyses were performed from a societal perspective, and probability and cost estimates from the literature and institutional experience were used. In separate cost-effectiveness analyses, hypothetical cohorts of trauma patients from three defined clinical scenarios were considered: high, moderate, and low risk for cervical spine fracture. Outcome measures included cases of paralysis prevented, total cost of screening strategies, and incremental cost-effectiveness ratios. In high-risk patients, screening with CT is a dominant strategy that prevents cases of paralysis and saves money for society. In moderate-risk patients, screening with CT is cost-effective with reference-case assumptions and within the range of most sensitivity analyses. In the low-risk group, CT screening helps prevent cases of paralysis, but the incremental cost-effectiveness ratio is high (> $80,000 per quality-adjusted life year). CT is the preferred cervical spine screening modality in trauma patients at high and moderate risk for cervical spine fracture.

A comparison of pediatric and adult trauma patients transported by helicopter and ground EMS: Managed-care considerations

Introduction: There is a paucity of data comparing injured pediatric patients transported by helicopter emergency medical services (HEMS) with patients transported by ground ambulance. The purpose of this study was to compare HEMS pediatric trauma patients to: 1) pediatric patients transported by ground to an urban level-1 trauma center (TC), and; 2) a similar cohort of adult patients. The managed-care consequences of these comparisons are highlighted. Methods: All trauma patients flown directly from the scene by HEMS from January 1, 1990, to April 30, 1993, were compared to a cohort of trauma patients arriving by ground advanced life support (ALS). All patients were transported to the same level-1 TC. The data collected included the mechanism of injury and the prehospital procedures performed, the injury severity score (ISS), and outcome. Results:There was no difference in the ISS between the HEMS (n = 216) and ground ALS (n = 355) pediatric patients (16.8 vs 17.1; p = 0.55). Adult HEMS patients (n = 202) had significantly higher ISS than did injured adults (n = 1652) transported by ground (18.0 vs 13.6; p <0.0001). Overall, trauma patients transported by air directly from the scene have a higher ISS than patients transported by ground (17.5 vs 13.6; p <0.001). Conclusions: Pediatric patients transported by HEMS were as severely injured as those transported by ground, in contrast to adult patients. We conjecture that since trauma triage schemes classically focus on adults, ground personnel are more selective about which patients are flown to a TC, and less selective for pediatric patients. Trauma centers and HEMS programs should develop pediatric trauma triage protocols that do not overemphasize physiologic parameters.