An Activation Failure: Factors Associated With Undertriage of Pediatric Major Trauma Victims

Abstract

Introduction: Undertriage of children contributes to poorer clinical outcomes. The objective of this study was to determine factors associated with undertriage of pediatric major trauma victims.

Methods: We performed a retrospective cross-sectional study of children (aged < 16 ys) using the 2021 American College of Surgeons National Trauma Data Bank. We identified children who met the definition of major trauma defined by the Standard Triage Assessment Tool. We performed multivariable logistic regression to determine factors associated with undertriage, defined as encounters which met criteria, but did not receive highest-level activation.

Results: Of 97,812 included children, 5.3% met major trauma criteria. Undertriage occurred in 34.4% of encounters with major trauma. Factors associated with undertriage included fall and striking mechanisms, missing blood pressure, private vehicle arrival, and incoming interfacility transfers. Hypotension, decreased level of consciousness, prehospital and in-hospital intubation, tachycardia, hypothermia, penetrating mechanism, presentation to a pediatric level 2 or adult level 1 trauma center relative to pediatric level 1 center, and arrival by flight were associated with lower odds of undertriage.

Conclusions: Many children with major trauma were undertriaged, particularly those presenting with lower-risk histories, such as private vehicle arrivals and fall mechanisms. Future work should seek to develop risk-stratification systems that can better identify children with major trauma, with an emphasis on those with blunt traumatic mechanisms.

Keywords: Major trauma; Pediatric trauma; Trauma activation; Undertriage.