It has been shown that the presence of prehospital care providers with advanced life support training lowers pediatric trauma deaths.⁶⁰ In contrast, several studies have shown that paramedics often have difficulty with procedural intervention in the field. Successful pediatric intubation by paramedics varies widely from 41% to 89%.^61-63 In a prospective trial, children less than 12 years of age requiring field airway management were randomized to endotracheal versus bag-valve-mask ventilation.⁶⁴ Survival and neurological outcome were not affected by the type of airway procedure used, although children undergoing endotracheal intubation had significantly longer scene duration. Paramedics also have difficulty with venous access, with success rates less than 50% in critically ill children who were less than six years of age.⁶⁵

Controversy has arisen regarding the administration of intravenous fluids to patients with uncontrolled
hemorrhage.⁶⁶ Several animal studies found that administration of intravenous fluids prior to controlling hemorrhage increased mortality.^67,68 Postulated mechanisms include hydraulic acceleration
of ongoing hemorrhage owing to elevated systemic blood pressure, disruption of thrombus at the bleeding site, and dilution of clotting factors.⁶⁶ Prehospital intravenous (IV) fluid administration in hypotensive adults with penetrating torso trauma injuries resulted in increased mortality despite improved blood pressure, compared with victims who did not receive prehospital IV fluids.⁶⁹ Administration of fluids was only effective after bleeding was controlled in the operating room. Despite these findings, no studies have evaluated adults with blunt trauma or children with any trauma to determine if prehospital fluid administration can be detrimental. Until this is established, fluid administration remains an accepted standard component of prehospital care.

The Pediatric Trauma Score (PTS) was developed as a prehospital tool to rapidly determine the need for children to be transported to a trauma center (Table 1).⁶⁷  Initial studies found that children with a PTS less than 0 had 100% mortality, a PTS of 1-4 had 40% mortality, a PTS of 5-8 had 7% mortality, and a PTS greater than 8 virtually no mortality following trauma.^68,70 Based on these data, a PTS less than or equal to 8 is the recommended threshold for diverting children to a designated pediatric trauma center. Another score, the Revised Trauma Score (RTS) (Table 2) is as accurate as the PTS for determining injury severity, with improved ability to predict overall outcome, although the PTS is slightly better at determining appropriate emergency department (ED) and hospital disposition.^71-73 Proponents of the RTS believe that this score is easier to calculate and allows for a single score to be used at all ages.^71-73 An RTS less than 12 is the recommended threshold for diverting a child to a trauma center.⁷¹ While the RTS and the PTS can stratify the risk of deterioration following trauma, it is important to note that children with isolated abdominal injuries may manifest initial vital sign stability and relatively normal trauma scores. In fact, 86% of children with isolated spleen or liver injuries will have normal heart rates, 94% will have normal systolic blood pressure, and most will have a PTS above 10.⁷⁴






Optimal care of pediatric trauma patients requires that the responsible treating physician and institution have specific expertise and resources. Patient care is different among pediatric trauma centers and adult trauma centers.⁷⁵ At pediatric trauma centers it has been shown that treatment outcome for children with blunt trauma is better and there is a higher incidence of nonoperative management of liver and spleen injuries.^75-78 Therefore, children with significant injuries should be transported to a pediatric trauma center by the EMS system if one is available.

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